Crisis Trauma Counseling - Page 2

 

Disaster crisis counseling is a specialized service that involves rapid assignment and temporary deployment of staff who must meet multiple demands and work in marginal conditions and in unfamiliar settings such as shelters, recovery service centers, and mass care facilities. The major objective of disaster mental health operations is to mobilize staff to disaster sites so that they can attend to the emotional needs of survivors. In the past, these responses tended to be generic; little or no effort was made to tailor resources to the characteristics of a specific population. With time and experience, however, service providers and funding organizations have become increasingly aware that race, ethnicity, and culture may have a profound effect on the way in which an individual responds to and copes with disaster. Today, those in the field of disaster mental health recognize that sensitivity to cultural differences is essential in providing mental health services to disaster survivors.

Integrating cultural competence in the temporary structure and high-intensity work environment of a disaster relief operation is a challenge. Increasing cultural competence, not a one-time activity, is a long-term process that requires fundamental changes at the institutional level. Because both culture and the nature of disasters are dynamic, these changes must be followed by ongoing efforts to ensure that the needs of those affected by disaster are met.

Disasters affect hundreds of thousands of people in the United States annually. Between 1993 and 1998, the American Red Cross responded to more than 322,000 disaster incidents in the United States and provided financial assistance to more than 600,000 families (American Red Cross, 2000). In 1997 alone, the Federal Emergency Management Agency (FEMA) responded to 43 major disasters in 27 States and three western Pacific Island territories (FEMA, 2000). In recent years, human-caused disasters have been a major challenge. Such events include the 1992 civil unrest in Los Angeles, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, and the September 2001 terrorist attacks on the World Trade Center in New York and the Pentagon in Arlington.

The primary purpose of this guide is to provide background information, guiding principles, recommendations, and resources for developing culturally competent disaster mental health services. Disaster mental health providers and workers can use and adapt the guidelines set forth in this document to meet the unique characteristics of individuals and communities affected directly or indirectly by a full range of natural and human-made disasters.

Designed to supplement information already available through CMHS, SAMHSA, and other sources, Developing Cultural Competence in Disaster Mental Health Programs highlights important common issues relating to cultural competence and to disaster mental health. It provides guidance for improving cultural competence in support of disaster mental health services.

The following issues are key to the recommendations set forth in this guide:

Cultural competence requires system-wide change. It must be manifested at every level of an organization, including policy making, administration, and direct service provision. Therefore, for disaster mental health services to be effective, cultural competence must be reflected in disaster mental health plans. For additional information on building mental health systems capacity for disaster mental health response and recovery, readers may wish to review Disaster Response and Recovery: A Strategic Guide (DHHS, Rev. ed, in press).

Cultural competence requires an understanding of the historical, social, and political events that affect the physical and mental health of culturally diverse groups. Issues such as racism, discrimination, war, trauma, immigration patterns, and poverty—which reinforce cultural differences and distinguish one cultural group from another—must be considered (Hernandez and Isaacs, 1998). For a descriptive summary of historical background, patterns, and events, as well as detailed demographic and health profiles of individual cultural groups, readers may wish to refer to Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General (DHHS, 2001) and to Cultural Competence Standards in Managed Care Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups (DHHS, 2000b).

Precise definitions of the terms “race,” “ethnicity,” and “culture” are elusive. As social concepts, these terms have many meanings, and those meanings evolve over time (DHHS, 2001). This guide espouses a broad definition of culture that includes not only race and ethnicity but also gender, age, language, socioeconomic status, sexual orientation, disability, literacy level, spiritual and religious practices, individual values and experiences, and other factors. This guide uses the phrases “cultural groups” and “racial and ethnic minority groups”¹ to refer to the Nation’s diverse, multicultural groups and individuals.

The operational definition of cultural competence provided in this guide is based on the principles of cultural competence described in Towards a Culturally Competent System of Care (Cross et al., 1989). Many Federal, State, and local public mental health systems, as well as organizations in the private sector, have adopted the principles presented in this document.

¹The major racial and ethnic minority groups referred to in this publication are African Americans (blacks), American Indians and Alaska Natives, Asian Americans, Native Hawaiian and Other Pacific Islanders, and Hispanic Americans (Latinos). The authors recognize that opinions about which labels are appropriate differ and acknowledge that heterogeneous subpopulations exist within each of these populations. These categories, which were established by the Office of Management and Budget in 1997, are used because they are widely accepted and used by service providers in the public and private sectors.

Culture and Disaster

Since its founding, the United States has been a nation of diversity. In the years to come, fertility and mortality rates, immigration patterns, and age distributions within subgroups of the population will contribute to an increasingly diverse national population (Day, 1996). Data from the 2000 U.S. Census reveal that Hispanics have replaced African Americans as the second largest ethnic group after whites.² Because of higher birth and immigration rates, the Hispanic population is growing faster than any other ethnic minority group (DHHS, 2001). The population of Asian Americans is also growing and is projected to continue growth throughout the first half of the 21st century, primarily because of immigration (DHHS, 2001). As shown in Table 1-1, by 2010, Hispanic Americans will comprise 14.6 percent of the U.S. population, African Americans will comprise 12.5 percent, Asian Americans will comprise 4.8 percent, and Native Americans will comprise less than 1 percent (U.S. Department of Commerce, 2000).

These demographic changes have given the United States the benefits and richness of many cultures, languages, and histories. At the same time, the Nation’s growing diversity has made it more important than ever for health and human service providers—including disaster mental health service providers—to recognize, understand, and respect the diversity found among cultural groups and subgroups. Service providers must find ways to tailor their services to individuals’ and communities’ cultural identities, languages, customs, traditions, beliefs, values, and social support systems. This recognition, understanding, respect, and tailoring of services to various cultures is the foundation of cultural competence.

 This publication uses the term “whites” to denote non-Hispanic white Americans.

TABLE 1 - 1

Percentage Distribution of the Population
By Race and Hispanic Origin
(Includes foreign and native-born populations)

Race

Hispanic/ Latino Origin*

Year

White

Black/ African American

American Indian/ Alaska Native**

Asian and Pacific Islander

 

1995

73.6

12.0

0.7

3.3

10.2

2000

71.4

12.2

0.7

3.9

11.8

2010

67.3

12.5

0.8

4.8

14.6

2050

52.8

13.2

0.8

8.9

24.3

2100

40.3

13.0

0.7

12.6

33.3

* Persons of Hispanic/Latino origin may be of any race. Groups listed under “Race” are not of Hispanic origin.
** Includes American Indians, Alaska Natives, and Aleuts.
Source: U.S. Department of Commerce, Bureau of the Census. (2000). Projections of the resident population by race, Hispanic origin, and nativity: Middle series, 1999 to 2100. Washington, DC: U.S. Department of Commerce.

UNDERSTANDING CULTURE

Culture influences many aspects of our lives—from how we communicate and celebrate to how we perceive the world around us. Culture involves shared customs, values, social rules of behavior, rituals and traditions, and perceptions of human nature and natural events. Elements of culture are learned from others and may be passed down from generation to generation.

Many people equate race and ethnicity with culture; however, the terms “race” and “ethnicity” do not fully define the scope and breadth of culture. Race and ethnicity are indeed prominent elements of culture, but there are important distinctions between these terms. For example, many people think of “race” as a biological category and associate it with visible physical characteristics such as hair and skin color.

Physical features, however, do not reliably differentiate people of different races (DHHS, 2001). For this reason, race is widely used as a social category. Different cultures classify people into racial groups on the basis of a set of characteristics that are socially important (DHHS, 2001). Often, members of certain social or racial groups are treated as inferior or superior or given unequal access to power and other resources (DHHS, 2001).

“Ethnicity” refers to a common heritage of a particular group. Elements of this shared heritage include history, language, rituals, and preferences for music and foods. Ethnicity may overlap with race when race is defined as a social category. For example, because Hispanics are an ethnicity, not a race, ethnic subgroups such as Cubans and Peruvians include people of different races (DHHS, 2001).

“Culture” refers to the shared attributes of a group of people. It is broadly defined as a common heritage or learned set of beliefs, norms, and values (DHHS, 2001). Culture is as applicable to groups of whites, such as Irish Americans or German Americans, as it is to racial and ethnic minorities (DHHS, 2001). People can share a culture, regardless of their race or ethnicity. For example, people who work for a particular organization, people who have a particular physical or mental limitation, or youth in a particular social group may share cultural attributes.

A culture can be defined by characteristics such as:

  • National origin;
  • Customs and traditions;
  • Length of residency in the United States;
  • Language;
  • Age;
  • Generation;
  • Gender;
  • Religious beliefs;
  • Political beliefs;
  • Sexual orientation;
  • Perceptions of family and community;
  • Perceptions of health, well-being, and disability;
  • Physical ability or limitations;
  • Socioeconomic status;
  • Education level;
  • Geographic location; and
  • Family and household composition.

Culture changes continuously. For example, immigrants to the United States bring with them their own beliefs, norms, and values, but through the process of acculturation gradually learn and adopt selected elements of the dominant culture. An immigrant group may develop its own culture while becoming acculturated. At the same time, the dominant culture may change as a result of its interaction with the immigrant group (DHHS, 2001).

Did You Know . . .
Mental Health: Culture, Race, and Ethnicity—
A Supplement to Mental Health:
A Report of the Surgeon General
(DHHS, 2001) notes that:

  • Approximately 12 percent of the U.S. population—34 million individuals—identify themselves as African American.
  • Six percent of all blacks in the United States today are foreign-born. Most of those who are foreign-born come from the Caribbean.
  • Since 1983, more than 100,000 refugees have come to the United States from African nations.
  • The U.S. Census Bureau estimates that 4.1 million American Indians and Alaska Natives (Indians, Eskimos, and Aleuts) lived in the United States in 2000, representing less than 1.5 percent of the total U.S. population.
  • Alaska Natives comprise approximately 4 percent of the combined American Indian and Alaska Native population.
  • By the year 2020, the combined Asian American and Pacific Islander population will reach approximately 20 million, or about 6 percent of the total U.S. population.
  • Approximately 35 percent of Asian Americans and Pacific Islanders live in linguistically isolated households. For some Asian American ethnic groups—including Hmong, Cambodian, Laotian, Vietnamese, Korean, and Chinese American households—the rate is much higher than this percentage.
  • By the year 2050, Latinos will constitute nearly one-fourth of the U.S. population, and nearly one-third of persons under 19 years of age will be Hispanic.
  • Nearly two-thirds of Hispanic Americans were born in the United States.
  • Nearly two-thirds of Latinos are persons of Mexican origin, and the remaining one-third are primarily persons of Puerto Rican, Cuban, or Central American origin.

 

Four racial and ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic Americans—accounted for approximately 30 percent of the U.S. population in the year 2000 and are expected to account for nearly 40 percent of the U.S. population by 2025 (DHHS, 2001). Although there are important differences among these four groups, there also is broad diversity within each group. In other words, people who find themselves in the same racial or ethnic group—either by census category or through self-identification—do not always have the same culture. Examples follow:

  • American Indians and Alaska Natives may belong to more than 500 tribes, each of which has a different cultural tradition, language, and ancestry (DHHS, 2001).
  • Asian Americans and Pacific Islanders may identify with any of 43 subgroups and speak any of 100 languages and dialects (DHHS, 2001).
  • Hispanics may be of Mexican, Puerto Rican, Cuban, Central and South American, or other heritage (DHHS, 2001).

Furthermore, the broad category labels are imprecise (DHHS, 2001). For example, people who are indigenous to the Americas may be called Hispanic if they are from Mexico or American Indian if they are from the United States (DHHS, 2001). In addition, many people in a particular racial or ethnic minority group may identify more closely with other social groups than with the group to which they are assigned by definition (DHHS, 2001). Finally, many people identify with multiple cultures that may be associated with factors such as race, ethnicity, country of origin, primary language, immigration status, age, religion, sexual orientation, employment status, disability, geographic location, or socioeconomic status. Table 1-2 identifies Federal Government categories for race and ethnicity.

Recognizing the limitations of the traditional broad groupings, the U.S. Census Bureau revised the categories used to report race and ethnicity in the 2000 Census. For the first time, individuals could identify with more than one group (U.S. Office of Management and Budget, 2000). The U.S. Census Bureau anticipated that this change would result in approximately 63 categories of racial and ethnic identifications (DHHS, 2001).

Appendix C lists additional resources offering statistical and demographic data on racial and ethnic populations and subpopulations.

TABLE 1 - 2

Federal Government Categories for Race and Ethnicity

The U.S. Office of Management and Budget (1997) announced revised standards for Federal data on race and ethnicity. The new categories for race are:

American Indian or Alaska Native refers to a person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment.

Asian refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American refers to a person having origins in any of the black racial groups of Africa.

Hispanic or Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Native Hawaiian and Other Pacific Islander refers to a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White refers to a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Some Other Race was included for those who identify with one or more races.

Cultural Competence

 

We use many terms to refer to concepts associated with cultural competence and with interactions between and among people of different cultures including “cultural diversity, cultural awareness, cultural sensitivity, multiculturalism, and transcultural services.” Although the differences in the meanings of these terms may be subtle, they are extremely important. For example, the term “cultural awareness” suggests that it may be sufficient for one to be cognizant, observant, and conscious of similarities and differences among cultural groups (Goode et al., 2001).

“Cultural sensitivity,” on the other hand, connotes the ability to empathize with and understand the needs and emotions of persons of one’s own culture as well as those of others and to identify with emotional expressions and the problems, struggles, and joys of someone from another culture (Hernandez and Isaacs, 1998).

The term “cultural competence” suggests a broader concept than “cultural sensitivity” implies. As previously defined in this section, the word “culture” refers to the shared attributes—including beliefs, norms, and values—of a group of people (DHHS, 2001). The word “competence” implies the capacity to function effectively, both at the individual and organizational levels. “Competence” is associated with “culture” to emphasize that being aware of or sensitive to the differences between cultures is not sufficient. Instead, service providers must have the knowledge, skills, attitudes, policies, and structures needed to offer support and care that is responsive and tailored to the needs of culturally diverse population groups.

Many people and organizations have developed definitions of cultural competence. The following definition blends elements of definitions used by SAMHSA (DHHS, 2001), the Health Resources and Services Administration (DHHS), the Office of Minority Health (DHHS, 2000a), and definitions found in the literature (Bazron and Scallet, 1998; Cross et al., 1989; Denboba, 1993; Evans, 1995; Roberts et al.,1990; Taylor et al., 1998):

Cultural competence is a set of values, behaviors, attitudes, and practices within a system, organization, program, or among individuals that enables people to work effectively across cultures. It refers to the ability to honor and respect the beliefs, language, interpersonal styles, and behaviors of individuals and families receiving services, as well as staff who are providing such services. Cultural competence is a dynamic, ongoing, developmental process that requires a long-term commitment and is achieved over time.

Cross and colleagues (1989) note that culturally competent organizations and individuals:

  • Value diversity;
  • Have the capacity for cultural assessment;
  • Are aware of cross-cultural dynamics;
  • Develop cultural knowledge; and
  • Adapt service delivery to reflect an understanding of cultural diversity.

At the individual level, cultural competence requires an understanding of one’s own culture and worldview as well as those of others. It involves an examination of one’s attitudes, values, and beliefs, and the ability to demonstrate values, knowledge, skills, and attributes needed to work sensitively and effectively in cross-cultural situations (Goode et al., 2001).

At the organizational and programmatic levels, cultural competence requires a comprehensive, coordinated plan that cuts across policymaking, infrastructure building, program administration and evaluation, and service delivery. Culturally competent organizations and programs acknowledge and incorporate the importance of culture, assess cross-cultural relations, are aware of dynamics that can result from cultural differences and ethnocentric attitudes, expand cultural knowledge, and adopt services that meet unique cultural needs (DHHS, 2000d).

 

Cultural competence is not a matter of being politically correct or of assigning one person to handle diversity issues, nor does it mean simply translating materials into other languages. Rather, it is an ongoing process of organizational and individual development that includes learning more about our own and other cultures; altering our thinking about culture on the basis of what we learn; and changing the ways in which we interact with others to reflect an awareness and sensitivity to diverse cultures.

The Cultural Competence Continuum was developed by Cross et al. (1989) for mental health professionals. Today, many other public health practitioners and community-based service providers also find it a useful tool. The continuum assumes that cultural competence is a dynamic process with multiple levels of achievement. It can be used to assess an organization’s or individual’s level of cultural competence, to establish benchmarks, and to measure progress.


The continuum includes six stages: cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence, cultural competence, and cultural proficiency (Cross et al., 1989).

Cultural Destructiveness

The negative end of the continuum is characterized by cultural destructiveness. Organizations or individuals in this stage view cultural differences as a problem and participate in activities that purposely attempt to destroy a culture. Examples of destructive actions include denying people of color access to their natural helpers or healers, removing children of color from their families on the basis of race, and risking the well-being of minority individuals by involving them in social or medical experiments without their knowledge or consent. Organizations and individuals at this extreme operate on the assumption that one race is superior and that it should eradicate “lesser” cultures.

Cultural Incapacity

Organizations and individuals in the cultural incapacity stage lack the ability to help cultures from diverse communities. Although they do not intentionally seek to cause harm, they believe in the superiority of their own racial or ethnic group and assume a paternalistic posture toward “lesser” groups. They may act as agents of oppression by enforcing racist policies and maintaining stereotypes. Employment practices of organizations in this stage of the continuum are discriminatory.

Cultural Blindness

Cultural blindness is the midpoint of the continuum. Organizations and individuals at this stage believe that color or culture makes no difference and that all people are the same. Individuals at this stage may view themselves as unbiased and believe that they address cultural needs. In fact, people who are culturally blind do not perceive, and therefore cannot benefit from, the valuable differences among diverse groups. Services or programs created by organizations at this stage are virtually useless to address the needs of diverse groups.

Cultural Pre-competence

Culturally pre-competent organizations and individuals begin to move toward the positive end of the continuum. They realize weaknesses in their attempts to serve various cultures and make some efforts to improve the services offered to diverse populations. Pre-competent organizations hire staff from the cultures they serve, involve people of different cultures on their boards of directors or advisory committees, and provide at least rudimentary training in cultural differences. However, organizations at this stage run the risk of becoming complacent, especially when members believe that the accomplishment of one goal or activity fulfills the obligation to the community. Tokenism is another danger. Organizations sometimes hire one or more workers from a racial or ethnic group and feel that they have done all that is necessary.

Cultural Competence

Culturally competent organizations and individuals accept and respect differences, and they participate in continuing self-assessment regarding culture. Such organizations continuously expand their cultural knowledge and resources and adopt service models that better meet the needs of minority populations. In addition, they strive to hire unbiased employees, and seek advice and consultation from representatives of the cultures served. They also support their staff members’ comfort levels when working in cross-cultural situations and in understanding the interplay between policy and practice.

Cultural Proficiency

Culturally proficient organizations hold diversity of culture in high esteem. They seek to add to the knowledge base of culturally competent practice by conducting research, developing new therapeutic approaches based on culture, and publishing and disseminating the results of demonstration projects. Culturally proficient organizations hire staff members who are specialists in culturally competent practice.

Achieving cultural competence and progressing along the continuum do not happen by chance. Policies and procedures, hiring practices, service delivery, and community outreach must all include the principles of cultural competence. For these reasons, a commitment to cultural competence must permeate an organization before a disaster strikes. If the concepts of cultural competence and proficiency have been integrated into the philosophy, policies, and day-to-day practices of the mental health provider agency, they will be much easier to incorporate into disaster recovery efforts.

Cultural Competence Necessary from Project Initiation

After the Great Flood of 1993 devastated the economy of rural Minnesota, the State developed a program of supportive services, including crisis counseling for rural residents. Ethnic populations affected by the flood included Hispanics, African Americans, Southeast Asians (Vietnamese, Hmong, Laotians), and Somalians. Some of these populations were relatively new to rural Minnesota, and they were not well integrated into the communities. Trust between cultures was tenuous at best, and many of the minority groups were somewhat socially isolated.

The crisis counseling project faced barriers of language, culture, and mistrust that had to be overcome in order to provide services. The challenge was difficult. Virtually all coordinators and outreach workers initially hired were white and middle class. While a concerted effort was made to provide culturally competent services once the program got underway, the final project report, with great candor, concluded that success in providing services to the various ethnic populations was spotty. It stated that the project might have been more effective had a focus on cultural competence been integrated into the program from the beginning.

DISASTER MENTAL HEALTH SERVICES

Culture as a source of knowledge, information, and support provides continuity and a process for healing during times of tragedy (DeVries, 1996). Survivors react to and recover from disaster within the context of their individual racial and ethnic backgrounds, cultural viewpoints, life experiences, and values. Culture offers a protective system that is comfortable and reassuring. It defines appropriate behavior and furnishes social support, identity, and a shared vision for recovery. For example, stories, rituals, and legends that are part of a culture’s fabric help people adjust to catastrophic losses by highlighting the mastery of communal trauma and explaining the relationship of individuals to the spiritual. Despite the strengths that culture can provide, responses to disaster also fall on a continuum. Persons from disadvantaged racial and ethnic communities may be more vulnerable to problems associated with preparing for and recovering from disaster than persons of higher socioeconomic status (Fothergill et al., 1999).

Because of the strong role that culture plays in disaster response, disaster mental health services are most effective when survivors receive assistance that is in accord with their cultural beliefs and consistent with their needs (Hernandez and Isaacs, 1998). As disaster mental health service providers seek to become more culturally competent, they must recognize three important social and historical influences that can affect the success of their efforts. These three influences are the importance of community, racism and discrimination, and social and economic inequality.

The Importance of Community

Disasters affect both individuals and communities. Following a disaster, there may be individual trauma, characterized as “a blow to the psyche that breaks through one’s defenses so suddenly and with such brutal force that one cannot react to it effectively” (DHHS, Rev. ed. in press). There also may be collective trauma—“a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of community” (DHHS, Rev. ed., in press). Cultural and socioeconomic factors contribute to both individual and community responses to the trauma caused by disaster.

The culture of the community provides the lens through which its members view and interpret the disaster, and the community’s degree of cohesion helps determine the level of social support available to survivors. In other words, a community that is disrupted and fragmented will be able to provide less support than a cohesive community.

A classic example is presented by sociologist Kai Erikson, who studied the impact of the devastating 1972 flood in Buffalo Creek, West Virginia (Erikson, 1976). The flood led to relocation of the entire community. Erikson describes a “loss of community,” in which people lost not only their sense of connection with the locale but also the support of people and institutions. Results of this community’s fragmentation included fear, anger, anxiety, and depression.

Other studies have emphasized positive effects that can result from disaster experiences in communities that perform a protective role and cushion the stress of the disaster (Dynes et al., 1994). Compared with nondisaster-related suffering, which is isolating and private, the suffering of disaster survivors can be collective and public (Dynes et al., 1994). However, devastating disasters can have positive outcomes. They can bring a community closer or reorient its members to new priorities or values (Ursano, Fullerton et al., 1994). Individuals may exhibit courage, selflessness, gratitude, and hope that they may not have shown or felt before the disaster.

Community often is extremely important for racial and ethnic minority groups, and it may dramatically affect their ability to recover from disaster. For example, a racial or ethnic minority community may provide especially strong social support functions for its members, particularly when it is surrounded by a hostile society. However, its smaller size may render it more fragile and more subject to dispersion and destruction after a disaster. Members of some racial and ethnic minority groups, such as refugees, previously have experienced destruction of their social support systems, and the destruction of a second support system may be particularly difficult (Beiser, 1990; Van der Veer, 1995).

Racism and Discrimination

Many racial and ethnic minority groups, including African Americans, American Indians, and Chinese and Japanese Americans, have experienced racism, discrimination, or persecution for many years. Both legally sanctioned and more subtle forms of discrimination and racism are an undeniable part of our Nation’s historical fabric. Despite improvements in recent decades, evidence exists that racial discrimination persists in housing rentals and sales, hiring practices, and medical care. Racism also takes the form of demeaning comments, hate crimes, and other violence by institutions or individuals, either intentionally or unintentionally (DHHS, 2001).

As a result of past or present experiences with racism and discrimination, racial and ethnic minority groups may distrust offers of outside assistance at any time, even following a disaster. They may not be accustomed to receiving support and assistance from persons outside of their own group in non-disaster circumstances. Therefore, they may be unfamiliar with the social and cultural mechanisms of receiving assistance and remain outside the network of aid.

Particularly during the “disillusionment phase” of the disaster, when intragroup tensions are typically high, racial and ethnic minority groups can face the brunt of anger and even blame from members of the larger culture. Such psychological assaults and experiences with racism and discrimination can result in increased stress for individuals and groups.

Social and Economic Inequality

Poverty disproportionately affects racial and ethnic minority groups. For example, in 1999, 8 percent of whites, 11 percent of Asian Americans and Pacific Islanders, 23 percent of Hispanic Americans, 24 percent of African Americans, and 26 percent of American Indians and Alaska Natives lived in poverty (DHHS, 2001). Significant socioeconomic differences also exist within racial and ethnic minority groups. For example, although some subgroups of Asian Americans have prospered, others remain at low socioeconomic levels (O’Hare and Felt, 1991).

Social and economic inequality also leads to reduced access to resources, including employment; financial credit; legal rights; and education, health, and mental health services (Blaikie et al., 1994). Poor neighborhoods also have high rates of homelessness, substance abuse, and crime (DHHS, 2001).

Poverty makes people more susceptible than others to harm from disaster and less able to access help (Bolin and Stanford, 1998). Low-income individuals and families typically lose a much larger part of their material assets and suffer more lasting negative effects from disaster than do those with higher incomes (Wisner, 1993). Often, disadvantaged persons live in the least desirable and most hazardous areas of a community, and their homes may be older and not as sound as those in higher income areas. For example, many low-income people live in apartment buildings that contain unreinforced masonry, which is susceptible to damage in a disaster (Bolton et al., 1993).

Although disaster relief activities can help ameliorate some of the damage rendered by a disaster, some groups cannot readily access such services. Negative perceptions derived from pre-disaster experiences may serve as a barrier to seeking care. Lack of familiarity with sources of community support or lack of transportation are common barriers for many immigrants and unwillingness to disclose their immigration status is a major barrier.

Middle-class disaster survivors are more likely than lower-income people—including those from other cultures—to know how to complete forms, communicate adequately, talk to the “right” people, or otherwise maneuver within the system. Thus, they may be more likely to receive aid than survivors with fewer means or those from different cultures (Aptekar, 1990). On the other hand, affluent groups may find it difficult to accept assistance from mental health and social service agencies. They may fear a loss of control and find it humiliating to accept emergency assistance such as clothing, food, loans, and emotional support from disaster workers.

In some instances, people of lower socioeconomic status exhibit strong coping skills in disaster situations because they have seen difficult times before and have survived. In other instances, the loss of what little one had may leave an individual feeling completely hopeless.

DISASTER PHASES

Survivors’ reactions to and recovery from a disaster are influenced by a number of factors, including:

TABLE 1 - 3

Characteristics of Disasters

Researchers have identified several common characteristics of disasters that are particularly important when discussing emotional distress and recovery (Bolin, 1985: DHHS, 2000a, p. 6.). These characteristics are as follows:

  • Intensity of the impact: Disasters that wreak intense destruction within a short period of time are particularly likely to cause emotional distress among survivors than are disasters that work their effect more slowly.
  • Impact ratio (i.e., the proportion of the community sustaining personal losses): When a disaster affects a significant proportion of a community’s population, few individuals may be available to provide material and emotional to support survivors.
  • Potential for recurrence or other hazards: The real or perceived threat of recurrence of the disaster or of associated hazards can lead to anxiety and heightened stress among survivors.
  • Cultural and symbolic aspects: Changes in survivors’ social and cultural lives and routine activities can be profoundly disturbing. Both natural and human-caused disasters can have symbolic implications.
  • Extent and types of loss sustained by survivors: Property damage or loss, deaths of loved ones, injury, and job loss all affect emotional recovery.

Despite the differences in disasters, communities, and individuals, survivors’ emotional responses to disaster tend to follow a pattern of seven “disaster phases” (National Institute of Mental Health, 1983; DHHS, 2000e):

  • Warning or threat;
  • Impact;
  • Rescue or heroic;
  • Remedy or honeymoon;
  • Inventory;
  • Disillusionment; and
  • Reconstruction or recovery.

The characteristics of the disaster, as well as those of the community and its individual residents, affect the duration and nature of the seven phases. The phases do not necessarily move forward in linear fashion; instead, they often overlap and blend together. Furthermore, individuals may experience a given phase in different ways (DHHS, 1999), and different cultural groups may respond differently during these phases. Below are brief descriptions of each phase, including examples of responses of different cultural groups during each phase.

For further information about disaster characteristics and phases, refer to the Training Manual for Mental Health and Human Service Workers in Major Disasters (DHHS, 2000e).

Warning or Threat Phase

The warning or threat phase occurs with hurricanes, floods, and other disasters for which there is warning hours or days in advance. Lack of warning can make survivors feel vulnerable, unsafe, and fearful of future unpredicted tragedies. The perception that they had no control over protecting themselves or their loved ones can be deeply distressing.

Racial and ethnic groups sometimes differ in the ways in which they receive information about risks and in the credence they place on such information. For example, Hispanics are more likely than non-Hispanics to use social networks for disaster information (Blanchard-Boehm, 1997; Perry and Mushkatel, 1986) and to believe information obtained through these networks (Perry and Lindell, 1991) than are members of other groups. Furthermore, some marginalized communities do not have adequate or functioning warning systems. When disaster warning information is not provided in multiple languages or is not closed-captioned, people who do not understand English or who are deaf or hard of hearing may not receive adequate warning.

Impact Phase

The impact phase occurs when the disaster actually strikes. This phase can vary from the slow, low-threat buildup associated with some types of floods to the violent and destructive outcomes associated with tornadoes and explosions. Depending on the characteristics of the disaster, reactions range from confusion, disbelief, and anxiety (particularly if family members are separated) to shock or hysteria.

Rescue or Heroic Phase

In the rescue or heroic phase, individuals’ activity levels are typically high and oriented toward rescue operations, survival, and perhaps evacuation. People generally work together to save lives and property; pre-existing tensions between racial and ethnic or cultural groups are set aside. However, if family members are separated, anxiety may be heightened.

Remedy or Honeymoon Phase

During this phase, optimism may reign as the community pulls together and government and volunteer assistance become available. The interactions between relief workers and survivors from different cultures can be very important and can influence people’s long-term perceptions of the disaster relief effort. Perceptions and beliefs about how healing occurs also may influence recovery. Frequently, however, disaster workers who have had no orientation to local cultures and lack sensitivity to them are brought in to help out during this phase. Such workers may exacerbate, rather than mitigate, cultural differences.

Inventory Phase

During the inventory phase, survivors recognize the limits of help and begin to assess their futures. They become exhausted because of multiple demands, financial pressures, and the stress of relocation or living in a damaged home. Initial optimism may give way to discouragement and fatigue. This also is a time characterized by high levels of grief and loss. Families who lose loved ones will grieve and cope in different ways.

Disillusionment Phase

The disillusionment phase occurs when survivors recognize the reality of loss and the limits of outside relief. This phase is characterized by a high level of stress that may be manifested in personally destructive behavior, family discord, and community fragmentation. Obtaining assistance from relief agencies can be extremely difficult, and survivors may feel helpless and angry. Hostility between neighbors and among groups is common, and tensions may erupt among different cultural, racial, and ethnic groups.

Reconstruction or Recovery Phase

The final phase, reconstruction or recovery, may last for years. This phase involves the structural rebuilding of the community as well as the integration of changes occasioned by the disaster into one’s community and one’s life. A common problem is a lack of housing, particularly if the disaster destroyed much of the low-income housing stock. In such situations, the private market typically hinders rebuilding of low- and moderate-income rental units (Fothergill et al., 1999). Therefore, housing shortages and rent increases disproportionately affect racial and ethnic minority groups (Bolin and Stanford, 1991; Peacock and Girard, 1997). It is not unusual for local political issues to create friction and fragmentation in the impacted community during the disparate reconstruction progress and buyouts between neighboring counties.

DISASTER MENTAL HEALTH PLANNING

Providing culturally competent mental health services to survivors requires action before, during, and after a disaster. The disaster mental health plan, which should be part of a State or community emergency management plan, can help ensure an efficient, coordinated response to the mental health needs of the affected population (DHHS, Rev. ed., in press). These plans specify roles, responsibilities, and relationships among agencies and organizations in responding to a community’s mental health needs following a disaster (DHHS, Rev. ed., in press).

Well-designed disaster mental health plans enhance coordination and minimize chaos, thereby helping to ensure that survivors receive assistance in a timely, helpful, and culturally sensitive manner should a disaster occur. Disaster mental health plans that identify and address diverse needs within a community can save valuable time and avert many problems. In the absence of such planning, disaster relief is disorganized, especially in the immediate aftermath. Confusion and inefficiency can prevail when survivors attempt to gain access to services.

REPORT

Disaster Strikes a Highly Diverse Community

On January 17, 1994, a major earthquake struck Los Angeles and Ventura Counties. The Northridge earthquake was the largest and most violent to hit an urban area in the United States since the 1906 San Francisco quake. The post-disaster recovery effort provided mental health services to 1.9 million persons, representing myriad ethnic groups, special populations, and lifestyles.

The size and scope of the two affected counties, as well as the ethnic diversity of their residents, constituted a challenge to disaster mental health providers. For example, Ventura County is home to many undocumented migrant farm workers, the majority of whom do not speak English and are mistrustful of government at any level. Language and cultural barriers had to be overcome for persons from several Asian cultures as well. The diverse population in the affected areas also included other special populations, such as physically challenged persons and runaway youth, two groups that required special outreach strategies.

The disaster mental health program staff recognized from the beginning of the project the need to develop and provide culturally relevant and linguistically appropriate services, covering a multitude of cultures and languages.

Successful program planners recognize that creating culturally competent environments requires more than recruiting bilingual and bicultural mental health workers, sponsoring a single diversity management class, sending a few employees to a cultural competence workshop, or hiring a “token” racial or ethnic minority group representative. Rather, cultural competence must be a part of the program values; included in the program’s mission statement; and encouraged in attitudes, policies, and practices at every level.

To develop a culturally competent disaster mental health plan, planners must:

  • Assess and understand the community’s composition;
  • Identify culture-related needs of the community;
  • Be knowledgeable about formal and informal community institutions that can help meet diverse mental health needs;
  • Gather information from and establish working relationships with trusted organizations, service providers, and cultural group leaders and gatekeepers; and
  • Anticipate and identify solutions to cultural problems that may arise in the event of a disaster.

Table 1-4 presents questions that should be addressed in the mental health plan. For further information about disaster mental health planning, refer to Disaster Response and Recovery: A Strategic Guide (DHHS, Rev. ed., in press).

Community demographic characteristics

  • Who are the most vulnerable persons in the community? Where do they live?
  • What is the range of family composition (i.e., single-parent households)?
  • How could individuals be identified and reached in a disaster?
  • Are policies and procedures in place to collect, maintain, and review current and emergent demographic data for any area that might be affected by a disaster?

Cultural groups

  • What cultural groups (ethnic, racial, and religious) live in the community?
  • Where do they live, and what are their special needs?
  • What are their values, beliefs, and primary languages?
  • Who are the cultural brokers in the community?

Socioeconomic factors

  • Does the community have any special economic considerations that might affect people’s vulnerability to disaster?
  • Are there recognizable socioeconomic groups with special needs?
  • How many live in rental property? How many own their own homes?

Mental health resources

  • What mental health service providers serve the community?
  • What skills and services does each provider offer?
  • What gaps, including lack of cultural competence, might affect disaster services?
  • How could the community’s mental health resources be used in the event of different types of disasters?

Government roles and responsibilities in disaster

  • What are the Federal, State, and local roles in disaster response?
  • How do Federal, State, and local agencies relate to one another?
  • Who would lead the response during different phases of a disaster?
  • How can mental health services be integrated into the government agencies’ disaster response?
  • What mutual aid agreements exist?
  • Do any subgroups in the community harbor any historical or political concerns that affect their trust of government?

Nongovernmental organizations’ roles in disaster

  • What are the roles of the American Red Cross, interfaith organizations, and other disaster relief organizations?
  • What resources do nongovernment agencies offer, and how can local mental health services be integrated into their efforts?
  • What mutual aid agreements exist?
  • How can mental health providers collaborate with private disaster relief efforts?

Community partnerships

  • What resources and supports would community and cultural/ethnic groups provide during or following a disaster?
  • Do the groups hold pre-existing mutual aid agreements with any State or county agencies?
  • Who are the key informants/ gatekeepers of the impacted community?
  • Has a directory of cultural resource groups, natural helpers, and community informants who have knowledge about diverse groups been developed?
  • Are the community partners involved in all phases of disaster preparedness, response, and recovery operations?

Guiding Principles and Recommendations

Developing cultural competence requires a concerted effort by disaster mental health planners and front-line workers. Successful programs share common practices that are defined by nine guiding principles. These principles, listed here, have been identified by CMHS.

This section discusses each of the nine guiding principles and suggests ways to integrate them into disaster mental health planning and crisis counseling programs. The guiding principles, in many ways, overlay the Key Concepts of Disaster Mental Health (DHHS, 2000e), presented in Table 2-1. The Cultural Competence Checklist for Disaster Crisis Counseling Programs, presented in Appendix F, summarizes key content in a convenient form for use in program planning.

TABLE 2 - 1

Key Concepts of Disaster Mental Health

The following concepts should be adopted by all disaster mental health providers, including those serving culturally diverse survivors. The concepts can also help administrators and service providers set program priorities. The concepts deviate in some ways from those on which mental health work has traditionally been based. However, their validity has been confirmed again and again in disasters of various types that have affected a broad range of populations (DHHS, 2000a).

  • No one who sees a disaster is untouched by it.
  • There are two types of disaster trauma—individual and community.
  • Most people pull together and function adequately during and after a disaster, but their effectiveness is diminished by the effects of the event.
  • Stress and grief in disasters are normal reactions to abnormal situations.
  • Many emotional reactions of disaster survivors stem from problems of daily living brought about by the disaster.
  • Disaster relief assistance may be confusing to some survivors. They may experience frustration, anger, and feelings of helplessness related to Federal, State, and private-sector disaster assistance programs.
  • Most people do not see themselves as needing mental health services following a disaster and will not seek such services.
  • Survivors may reject disaster assistance of all types.
  • Disaster mental health assistance is often more practical than psychological in nature.
  • Disaster mental health services must be tailored to the culture of communities where they are provided.
  • Mental health workers should set aside traditional methods, avoid mental health labels, and use an active outreach approach to intervene successfully in disaster.
  • Survivors respond to active, genuine interest, and concern.
  • Interventions must be appropriate to the phase of disaster.
  • Social support systems are crucial to recovery.

PRINCIPLE 1: RECOGNIZE THE IMPORTANCE OF CULTURE AND RESPECT DIVERSITY

Culture is one medium through which people develop the resilience that is needed to overcome adversity. Following a disaster, culture provides validation and influences rehabilitation. However, when daily rituals, physical and social environments, and relationships are disrupted, life becomes unpredictable for survivors. Disaster mental health workers can help reestablish customs, rituals, and social relationships and thereby help survivors cope with the impact of a disaster. When doing so, these workers need to recognize that diversity exists within as well as across cultures (Cross et al.,1989). In disasters, individuals within a given cultural group may respond in very different ways; some will be receptive to disaster relief efforts, while others will not. Older adults and young people within a particular culture may react to losses or seek help in different ways, depending on their degree of acculturation. Disaster mental health workers also must be aware of and sensitive to issues stemming from biculturalism; these issues include conflict and ambivalence related to identity and the need to function in cross-cultural environments (Hernandez and Isaacs, 1998).

Recognizing the importance of culture and respecting diversity require an institution-wide commitment. To meet this commitment, disaster mental health workers must understand their own cultures and world views; examine their own attitudes, values, and beliefs about culture; acknowledge cultural differences; and work to understand how cultural differences affect the values, attitudes, and beliefs of others. Table 2-2 examines important considerations mental health workers should keep in mind when dealing with people from other cultures.

TABLE 2 - 2

Important Considerations When Interacting with People of Other Cultures

Giger and Davidhizar’s “transcultural assessment and intervention model” was developed to assist in the provision of transcultural nursing care. It is currently used by several other health and human services professions. The model identifies five issues that can affect the interactions of providers and service recipients. These issues, adapted below to apply to disaster crisis counseling, illustrate the importance of acknowledging culture and of respecting diversity. A complete description of the model can be found in Transcultural Nursing: Assessment and Intervention (Giger and Davidhizar, 1999).

Communication: Both verbal and nonverbal communication can be barriers to providing effective disaster crisis counseling when survivors and workers are from different cultures. Culture influences how people express their feelings as well as what feelings are appropriate to express in a given situation. The inability to communicate can make both parties feel alienated and helpless.

Personal Space: “Personal space” is the area that immediately surrounds a person, including the objects within that space. Although spatial requirements may vary from person to person, they tend to be similar among people in a given cultural group (Watson, 1980). A person from one subculture might touch or move closer to another as a friendly gesture, whereas someone from a different culture might consider such behavior invasive. Disaster crisis counselors must look for clues to a survivor’s need for space. Such clues may include, for example, moving the chair back or stepping closer.

Social Organization: Beliefs, values, and attitudes are learned and reinforced through social organizations, such as family, kinships, tribes, and political, economic, and religious groups. Understanding these influences will enable the disaster crisis counselor to more accurately assess a survivor’s reaction to disaster. A survivor’s answers to seemingly trivial questions about hobbies and social activities can lead to insight into his or her life before the disaster.

Time: An understanding of how people from different cultures view time can help avoid misunderstandings and miscommunication. In addition to having different interpretations of the overall concept of time, members of different cultures view “clock time”—that is, intervals and specific durations—differently. Social time may be measured in terms of “dinner time,” “worship time,” and “harvest time.” Time perceptions may be altered during a disaster. Crisis counselors acting with a sense of urgency may be tempted to set timeframes that are not meaningful or realistic to a survivor. The result may be frustration for both parties.

Environmental Control: A belief that events occur because of some external factor—luck, chance, fate, will of God, or the control of others—may affect the way in which a survivor responds to disaster and the types of assistance needed. Survivors who feel that events and recovery are out of their control may be pessimistic regarding counseling efforts. In contrast, individuals who perceive that their own behavior can affect events may be more willing to act (Rotter, 1966). Disaster crisis counselors need to understand beliefs related to environmental control because such beliefs will affect survivors' behavior.

PRINCIPLE 2: MAINTAIN A CURRENT PROFILE OF THE CULTURAL COMPOSITION OF THE COMMUNITY

No one knows when or where disaster will strike. For this reason, a predisaster assessment of a community’s composition and familiarity with cultural traditions and customs during times of loss, trauma, and grief can provide invaluable knowledge in the event of a disaster. The range of cultural diversity—ethnic, religious, racial, and language differences among subgroups—should be assessed and described in a comprehensive profile of the community. A comprehensive community profile describes the community’s composition in terms of:

  • Race and ethnicity;
  • Age;
  • Gender;
  • Religion;
  • Refugee and immigrant status;
  • Housing status (i.e., number of single-parent households, type of housing, rental versus ownership, number of persons per household);
  • Income and poverty levels;
  • Percentage of residents living in rural versus urban areas;
  • Unemployment rate;
  • Languages and dialects spoken;
  • Literacy level;
  • Number of schools; and
  • Number and types of businesses.
Information about the values, beliefs, social and family norms, traditions, practices, and politics of local cultural groups, as well as the history of racial relations or ethnic issues in the community, should be included in the community profile, because these cultural characteristics may take on additional significance in times of stress (DeVries, 1996). This information should be gathered with the assistance of and in consultation with community cultural leaders (“key informants”) who represent and understand local cultural groups.

Other sources of data incorporated in the community profile include the city hall or the county commissioner’s office, as well as the resources listed in Appendix C. Finally, information included in the community profile should be updated frequently, because such data can change rapidly.

REPORT

Migrant Farm Workers Employed as Outreach Workers

In 1998, El Niño caused a series of storms that devastated many California communities. The storms affected a large number of migrant farm workers, including many in Ventura County. The migrant workers were unwilling to seek help because of cultural proscriptions and language barriers. Some were illiterate.

To improve its ability to assist the migrant workers, Ventura County’s disaster crisis counseling project hired peer farm laborers. These workers, who had contacts and credibility within the migrant community, enabled the project to establish a unique communication model to reach farm laborers. The peer counselors went into labor camps and met with the victims of the rains and their indigenous leaders. Local residents noted that these were the first “government” workers in recent memory to be allowed in the farm workers’ camp.

PRINCIPLE 3: RECRUIT DISASTER WORKERS WHO ARE REPRESENTATIVE OF THE COMMUNITY OR SERVICE AREA

Disaster mental health programs are most effective when individuals from the community and its various cultural groups are involved in service delivery as well as in program planning, policy, and administration and management. Recruiting staff whose cultural, racial, and ethnic backgrounds are similar to those of the survivors helps ensure a better understanding of both the survivors and the community and increases the likelihood that survivors will be willing to accept assistance. For example, if American Indian or Alaska Native populations have experienced a disaster, tribal leaders, elders, medicine persons, or holy persons might be recruited to serve as counselors or in some other capacity. The community profile can be reviewed when recruiting disaster crisis counseling workers to ensure that they are representative of the community or service area.

If indigenous workers are not immediately available, coordinators can attempt to recruit staff with the required racial or ethnic background and language skills from other community agencies or jurisdictions (DHHS, Rev. ed. in press).

Recruitment based solely on race, ethnicity, or language, however, may not be sufficient to ensure an effective response. People who are racially and ethnically representative of the community are not necessarily culturally or linguistically competent. The ability to speak a particular language is not necessarily associated with cultural competence. For example, a well-educated, Spanish-speaking Hispanic professional may not understand the problems and cultural nuances of an immigrant community whose members are living in poverty (DHHS, 2000d).

Table 2-3 highlights the attributes, knowledge, and skills essential to development of cultural competence that should be considered when recruiting disaster mental health staff.

TABLE 2 - 3

Staff Attributes, Knowledge, and Skills Essential to Development of Cultural Competence

Personal Attributes

  • Genuineness, empathy, and a capacity to respond flexibly to a range of possible solutions
  • Acceptance and awareness of cultural differences and cross-cultural dynamics
  • Willingness to work with survivors of different cultures
  • Ability to articulate one's own values, stereotypes, and biases and to identify how they may accommodate or conflict with the needs of culturally diverse disaster survivors
  • Openness to learning about the cultures of diverse groups

Knowledge

  • History, tradition, values, artistic expressions of culturally diverse disaster survivors
  • Help-seeking behaviors, informal helping supports, and natural healing practices of survivors of various cultures
  • Role of language, speech patterns, and communication styles in culturally distinct communities
  • Psychosocial stressors relevant to diverse groups (e.g., migration, acculturation stress, legal and illegal discriminatory patterns, racism, and socioeconomic status)
  • Community resources (agencies, informal helping networks) and their availability for special populations

Skills

  • Ability to discuss cultural issues and to respond to culturally-based cues
  • Ability to assess the meaning of culture for the disaster survivor
  • Ability to interview and assess survivors on the basis of their personal, psychological, social, cultural, political, or spiritual models

PRINCIPLE 4: PROVIDE ONGOING CULTURAL COMPETENCE TRAINING TO DISASTER MENTAL HEALTH STAFF

Cultural competence is an essential component of disaster mental health training programs. Training should be provided to help mental health workers acquire the values, knowledge, skills, and attributes needed to communicate and work in a sensitive, nonjudgmental, and respectful way in cross-cultural situations. Such training should be provided to direct services staff, administrative and management staff, language and sign-language interpreters, and temporary staff.

Cultural competence training programs work particularly well when they are provided in collaboration with community-based groups that offer expertise or technical assistance in cultural competence or in the needs of a particular culture. Involving such groups not only enables program staff to gain firsthand knowledge of various cultures, but also opens the door for long-term partnerships (Hernandez and Isaacs, 1998).

Training should cover basic cultural competence principles, concepts, terminology, and frameworks. For example, training should include discussion of:

  • Cultural values and traditions;
  • Family values;
  • Linguistics and literacy;
  • Immigration experiences and status;
  • Help-seeking behaviors;
  • Cross-cultural outreach techniques and strategies; and
  • Avoidance of stereotypes and labels (DHHS, 2000e).

Even if the initial training period is of limited duration, participants should have an opportunity to examine and assess values, attitudes, and beliefs about their own and other cultures. Self-assessment helps identify areas where skills need to be developed (DHHS, 1998). Training should stress that people of a given cultural group may react quite differently to disaster, depending on their level of acculturation.

Cultural competence training is a developmental process. Ongoing education—through in-service training and regularly scheduled meetings with project staff to discuss cultural competence issues—is essential (Hernandez and Isaacs, 1998).

REPORT

Innovative Program Developed for Seniors

Following civil unrest in Los Angeles in 1993, a crisis counseling program was developed to assist the community. One element of this program was peer counseling with senior adults, including a group of elderly Samoans. No mental health professionals from the Samoan population could be found to help address the needs of these monolingual older adults in South Bay. Project staff worked with the head of the Samoan Council of Chiefs to offer a first-of-its-kind peer counselor training delivered via simultaneous translation. It worked beautifully. Twenty Samoans became deeply committed to counseling seniors in their community.

PRINCIPLE 5: ENSURE THAT SERVICES ARE ACCESSIBLE, APPROPRIATE, AND EQUITABLE

Survivors are not always receptive to offers of support. For example, some members of cultural groups may be reluctant to take advantage of services because of negative past experiences. Undocumented immigrants may not seek services because they fear deportation. Such individuals may be reluctant or refuse to move to temporary shelters, to accept State or Federal assistance, or to discuss information that they think could be used against them.

Inequitable treatment following disasters may reinforce mistrust of the public services and disaster assistance systems. Following the 1989 Loma Prieta earthquake in California, shelter services in the more affluent neighborhoods had more community volunteers than survivors. The mayor visited the disaster site in these areas. Less affluent neighborhoods had fewer volunteers, and some volunteers made remarks that the survivors felt were offensive. The mayor did not visit these areas (Dhesi, 1991). Moreover, food and meal preparation in shelters was not culturally appropriate following the earthquake, and many Latinos reported that they became sick from eating the food prepared by the Anglo relief workers (Phillips, 1993).

In studies of Hurricane Andrew’s aftermath, racial and ethnic minority group survivors were less likely to have insurance than were white survivors because of practices that exclude certain communities from insurance coverage at affordable rates. Survivors from minority groups were also more likely to receive insufficient settlement amounts (Peacock and Girard, 1997). Concerns related to gender also were investigated after Hurricane Andrew. Many non-English-speaking women of color, especially single women, were subjected to dishonest practices of construction contractors (Enarson and Morrow, 1997).

The delivery of appropriate services is a frequent problem. Racial and ethnic discrimination, language barriers, and stigma associated with counseling services have a negative effect on many individuals’ access to and utilization of health and mental health services (Denboba et al.,1998). Families who participated in focus groups reported problems with cultural and ethnic biases and stereotypes, offensive communication and interactions based on such biases and stereotypes, lack of cross-cultural knowledge, and lack of understanding of the values of various cultural groups (Malach et al., 1996).

Disaster mental health programs must take special care to exercise culturally competent practices. They should make efforts to ensure that staff members speak the language and understand the values of the community. Providing food that has cultural significance can be important. Involving cultural group representatives in disaster recovery committees and program decision making (for example, as members of planning boards or other policy-setting bodies) can help ensure that disaster services are accessible, appropriate, and equitable.

REPORT

Hurricane Response Designed to Be Culturally Competent

Hurricane Hortense struck Puerto Rico in 1996 with devastating impact. The disaster crisis counseling program was designed to be particularly sensitive to the Puerto Rican culture. For example, recognizing that this culture encourages strong ties with friends and neighbors, the program provided group debriefing sessions.

The project also used cultural celebrations to advance its goals. For example, the festival of the Three Kings Day, which occurs in early January, was used as an opportunity for special outreach in which project staff went door to door “giving asaltos”—a tradition of singing Christmas carols and giving donated gifts—as a way to identify needs and provide information and social support. The project also used dramatization to inform persons in the community about disaster phases and disaster planning.

Culturally sensitive outreach techniques also can help ensure that services are accessible and appropriate to all survivors. For example, outreach workers should:

  • Allow time for and devote energy to gaining acceptance, take advantage of associations with trusted organizations, and be wary of aligning their efforts with those of agencies and organizations that are mistrusted by cultural groups;
  • Determine the most appropriate ways to introduce themselves;
  • Recognize cultural variations in expression of emotion, manifestation and description of psychological symptoms, and views about counseling; and
  • Assist in eliminating barriers by carefully interpreting facts, policies, and procedures.

TABLE 2 - 4

Special Considerations When Working with Refugees

Refugees may differ from each other and from native populations on several dimensions, including:

Language: Refugees frequently do not speak English well, if at all. This presents communication challenges throughout all phases of a disaster.

Culture: Refugees have their own cultures. Because they are new to the United States, they usually are less well-versed in Western culture than are immigrants, who have had more time to understand it.

Economic marginalization and differences: When they arrive in the United States, many refugees can barely manage economically. Many are supporting relatives left at home. On the other hand, some refugees—especially those with education and highly sought skills—find well-paying jobs quickly. Thus, although poverty is common among refugees, not all refugees are poor.

Fractured social relations: The communities of origin of many refugees have failed to provide needed security. In addition, many refugees have experienced personal attacks by representatives of their community or the larger society. Some become so disillusioned by this experience that they are reluctant to form new community bonds. In addition, refugees often face within-group schisms. Preexisting ethnic, religious, and political divisions of the society of origin are frequently reinstituted in refugee communities formed in the new country.

Some refugees solve the problem by restricting new relationships to the safest ones, for example, by forming or joining small groups of people who emigrated from the same geographic area. When a disaster forces relocation, it can break up this small community and make recovery more problematic (Athey and Ahearn, 1991).

The negative experiences of many refugees also make them suspicious of government. They may be reluctant to seek out or accept assistance following disaster. Undocumented migrants may fear deportation, but even refugees who have achieved legal status may fear that accepting of assistance following a disaster will put them at risk of deportation. Thus, refugees often are the last group to obtain assistance following disaster.

Experience of traumatic stressors and of loss: Refugees often have experienced horrific events that cause symptoms of Post-Traumatic Stress Disorder. They may have lost family members, their homes, and their possessions, and some have been deprived of sufficient food or water, lacked medical care, or lived in inadequate housing for long periods of time. A disaster can lead to the emotional re-experiencing of these events (Van der Veer, 1995). On the other hand, some refugees may have gained strength and resilience from their previous experiences and bring that strength to the new disaster.

Family dynamics and role changes: Another challenge for many refugee families is that of new family dynamics upon resettlement. Children may have seen their parents fearful, helpless, and stressed during the flight and—upon resettlement—anxious, powerless, and exhausted. Children may come to believe that adults are not to be trusted because they have not seen adults playing a protective and nurturing role.

Intergenerational conflict resulting from differing rates of acculturation presents another family problem. Finally, parents may feel deprived of their role as family heads when they find they must depend on children as language translators or navigators within the new culture (de Monchy,1991).

De Monchy (1991) identifies three principles for effective service delivery with refugees:

  1. Trauma experiences need to be acknowledged.
  2. Refugees need to be recognized as successful survivors, and their wisdom and strengths affirmed.
  3. Empowerment and the recovery of control need to be encouraged, especially for refugees who are reestablishing parental roles with their children.

 

Table 2-4 addresses special considerations that should be taken into account when counseling refugees.

PRINCIPLE 6: RECOGNIZE THE ROLE OF HELP-SEEKING BEHAVIORS, CUSTOMS AND TRADITIONS, AND NATURAL SUPPORT NETWORKS

Culturally competent disaster mental health services proactively respond to the culturally defined needs of the community. Disruption of many aspects of life and the need to adapt to difficult circumstances cause stress and anxiety in many survivors. In some cases, these problems can be as difficult as the disaster itself. Effective response requires familiarity with help-seeking behaviors; customs and traditions related to healing, trauma, and loss; and use of natural support networks of various cultural groups.

Help-Seeking Behaviors

Different cultures exhibit different help-seeking behaviors. In many cultures, people turn to family members, friends, or cultural community leaders for help before reaching out to government and private-sector service systems. They may prefer to receive assistance from familiar cultural community leaders or groups rather than unfamiliar service systems. In most communities, churches and other places of worship play a role similar to that of an extended family, and survivors turn to them first for assistance.

Many survivors may be reluctant to seek help or may reject disaster assistance of all types. Some people feel shame in accepting assistance from others, including the government, and equate government assistance with “welfare.” Members of racial and ethnic minority groups, including refugees and immigrants, also may be reluctant or afraid to seek help and information from service systems because of historical mistrust of the health, mental health, and human services systems or because of fear of deportation (Aponte, Rivers, and Wohl, 1995). Other groups may prefer to suffer or even perish rather than seek help from people they mistrust. Therefore, building trusting relationships and rapport with disaster survivors is essential to effective crisis counseling.

Those who do seek help may find relief procedures confusing. Feelings of anger and helplessness and loss of self-esteem can result from survivors’ encounters with relief agencies. These feelings result from the survivors’ lack of understanding of the disaster relief system as well as government and private agencies’ often bureaucratic procedures.

Customs and Traditions in Trauma and Loss

Religious and cultural beliefs are important to survivors as they try to sort through their emotions in the aftermath of traumatic events. Beliefs may influence their perceptions of the causes of traumatic experiences. For example, in many cultures, people believe that traumatic events have spiritual causes. These beliefs can affect their receptivity to assistance and influence the type of assistance that they will find most effective. Different populations may elaborate on the cultural meaning of suffering in different ways, but suffering itself is a defining characteristic of the human condition in all societies. In most major religions, including Christianity, Judaism, Islam, Hinduism, and Buddhism, the experience of human misery—resulting from sickness, natural disasters, accidents, violent death, and atrocity—also is a defining feature of the human condition.

Different cultural groups also handle grief in different ways. Family customs, beliefs, and degree of acculturation affect expressions of grief. Disaster mental health workers must recognize that grief rituals, although diverse in nature, can help people return to a reasonable level of functioning. For example, Western tradition holds that grief should be “worked through.” This process includes acceptance of the loss; extinction of behaviors that are no longer adaptive; acquisition of new ways of dealing with others; and resolution of guilt, anger, and other disruptive emotions.

REPORT

Shamans Counter Bad Luck

In 1995, northern California experienced a series of storms that led to flooding, landslides, and mud debris flow. The State implemented a FEMA-funded crisis counseling program for the victims of the storms. One group affected were Hmong immigrants, persons with a history of war and severe losses. In serving the Hmong population, the program utilized the color red in many printed materials and supplies because Hmong culture includes a belief that red symbolically wards off evil spirits. Another consideration involved the Hmong belief that floods are an omen of doom and that shaman cleansing rituals are needed to counter the bad luck that this omen portends. As a way of acknowledging and respecting this belief, the staff developed and provided a referral list of shamans in the local area.

If a community remains intact after a disaster, cultural norms, traditions, and values determine the strategies that the survivors use to deal with the effects. When the entire community is affected, however, cultural mechanisms may be overwhelmed and unable to fulfill their customary functions of regulating emotions and providing identity, support, and resources (DeVries, 1996). Disaster mental health workers can support the healing process by helping rebuild the community’s cultural support system. Workers will be most effective when they recognize and understand the importance of culture in the lives of disaster survivors and the beliefs, rituals, and level of acculturation of the community in which they work.

Customs and Traditions for Healing

Many cultural groups hold beliefs about illness and healing that differ sharply from those held by Western society. People in every culture share beliefs about the causes of illness and ideas about how suffering can be mitigated. For example, members of some cultures believe that physical and emotional problems result from spiritual wrongdoings in this life or a previous one. They believe that healing requires forgiveness from ancestors or higher spirits. Some people believe that suffering cannot be ameliorated (DeVries, 1996). Others demonstrate stress and emotional conflict through complaints about their physical health.

Traditional healers, such as local herbalists, faith healers, and acupuncturists, play important roles in recovery of mental and physical health within some cultures. In general, the work of healers is based on the principle that the body cannot be isolated from the mind, and the mind cannot be removed from its social context. Disaster mental health workers who interact with cultures in which healers play a key role in health must understand the concepts of integration of body, mind, and spirit when they provide disaster crisis counseling services to diverse populations. They must be able to integrate traditional methods of healing into service delivery (de Monchy, 1991). Although the crisis counselor may not subscribe to certain cultural healing beliefs, he or she must acknowledge their existence and recognize their importance to some disaster survivors. At the same time, the worker must be alert for any use of dangerous healing practices, such as ingestion of harmful mixtures containing lead or other toxic substances, and take corrective measures. Reestablishing rituals in appropriate locations is another way to help survivors in the recovery process. Symbolic gathering places, such as churches, mosques, trees, and safe places for meeting after sundown are important in some cultures and are required for certain rituals. After a disaster, survivors may lose access to symbolic places, and this loss may limit their ability to mobilize healing resources. Identifying new locations for rituals can foster social support and facilitate coping mechanisms following disaster (DeVries, 1996).

Disaster mental health workers also may help organize culturally appropriate anniversary activities and commemorations as a way to help survivors mark a milestone in the healing process. Cultural and religious traditions, including special ways of both celebrating and mourning, can be incorporated into such events and may enrich their symbolic meaning and healing potential. Any attempts to facilitate activities involving customs and traditions must be undertaken carefully and only after consultation with members of the involved cultural groups.

REPORT

Importance of Culturally Competent Ethnic Workers

Flooding in Florida displaced many residents in 1998. One area that was flooded included a community with a high percentage of African Americans, a majority of whom were living in rental property. Unfortunately, the landlords were less than prompt, thorough, or enthusiastic in making repairs.

The disaster crisis counseling program that was developed in response to the flood employed an African American team leader from the county where most of the affected people lived. She was especially important in accessing community leaders and gatekeepers, helping identify needs of the community, and providing services.

Natural Support Networks

In many cultures, the family or kin group is chiefly responsible for its members, and support from kin may be essential in helping individuals overcome grief and trauma. However, when disaster strikes, all members of the extended family may be affected, leaving many people without this customary support network.

Traditions concerning the role of the family, who is included in the family, and who makes decisions vary across cultures (DHHS, 2000e). Elders and extended family play a significant role in some cultures, whereas in other cultures, isolated nuclear families are the decision makers (DHHS, 2000e). Households in racial and ethnic communities are, on average, larger than white households (O’Hare, 1992); they also are more likely to be multigenerational. Asians, for example, are more than twice as likely as whites to live in extended families (O’Hare and Felt, 1991).

Disaster mental health workers must recognize that family support may not be available when entire kin groups are affected. Helping families and friends reunite is one way to ensure mutual support. Likewise, formal support groups can help assure those with limited access to relatives and acquaintances that they are not alone. Individuals who do not relate to support groups because of cultural and linguistic differences may need more individualized services.

Disaster mental health workers also must recognize that in many cultures, the individual cannot be separated from the family and community (Reichenberg and Friedman, 1996). In such cultures, unlike those of Western society, the individual does not exist apart from the group; outreach efforts focused on individuals are, therefore, neither comprehensible nor effective. For example, among some Asian American and Pacific Islander populations, intervention strategies that diffuse the power of family relationships are especially inappropriate. Mental health workers can assess who is significant in a survivor’s family structure by asking the survivor to describe his or her home, family, and community (Managua, 1998).

PRINCIPLE 7: INVOLVE AS “CULTURAL BROKERS” COMMUNITY LEADERS AND ORGANIZATIONS REPRESENTING DIVERSE CULTURAL GROUPS

Involving “cultural brokers”—community leaders and groups that represent diverse groups—is vital to the success of disaster mental health efforts. Collaborating with organizations and leaders who are knowledgeable about the community is the most effective way of gaining information about the community. Collaboration can assist in assessing needs, creating community profiles, making contact with and gaining the trust of survivors, establishing program credibility, integrating cultural competence in training, and ensuring that strategies and services are culturally competent (DHHS, 1998).

In most communities, and in diverse communities in particular, some of the most influential individuals are cultural group leaders who possess “insider” knowledge of the community and are willing and able to articulate that knowledge (Hernandez and Isaacs, 1998). These individuals, who may not be immediately visible, can include spiritual leaders, members of the clergy, teachers, civic leaders, local officials, or long-term residents who have the respect and confidence of their neighbors. They often can provide outsiders with the best insights into a local culture’s values, norms, customs, conventions, traditions, and expectations (Hernandez and Isaacs, 1998).

Organizations representing various cultural groups and other special interest groups in the community should be invited to participate in disaster mental health programs. These organizations can provide valuable insight during the planning process, serve as a point of entry to the survivor community, and enhance cultural relevance of service delivery. Including individuals from various cultures on planning task forces and committees will help ensure that they concur with the selected strategies.

Should a disaster occur, community-based organizations can provide an important communication link with the cultural groups they represent. For example, churches do much more than serve the spiritual needs of the African American community. They are also the center of political, social, educational, and cultural activities. Therefore, African American ministers may play an important part in mental health outreach and recovery efforts.

Informal, culture-specific groups such as sewing circles and youth sports teams can also be sources of support to disaster survivors. The crisis counseling program staff should identify the most effective ways to work with such groups. Community-based organizations that should be involved include:

  • Civic associations;
  • Social clubs;
  • Neighborhood groups;
  • Faith-based organizations;
  • Interfaith groups;
  • Mutual aid societies;
  • Voluntary organizations;
  • Health care and social service providers; and
  • Nonprofit advocacy organizations (Hernandez and Isaacs, 1998).

To ensure effective use of resources, crisis counselors should coordinate their work with that of other public and private agencies responding to the disaster. The coordinating agency should recognize unique jurisdictional situations that may arise when working with various American Indian and Alaska Native cultures. American Indian and Alaska Native tribes are federally recognized sovereign nations. Disaster mental health agencies should acknowledge the need for a partnership that includes various agencies within tribes, different levels of government, and many tribes working together to improve access to disaster assistance. Although under the Stafford Act, a State government must request a Presidential disaster declaration on behalf of a tribe, agencies subsequently can work directly with the tribe and with existing authorities and resources to tailor disaster plans to the tribe’s unique needs and jurisdictional requirements.

PRINCIPLE 8: ENSURE THAT SERVICES AND INFORMATION ARE CULTURALLY AND LINGUISTICALLY COMPETENT

Language can be a major barrier to service delivery. Survivors who are monolingual, limited in their English, or deaf or hard of hearing may be at a particular disadvantage. Emergency response programs generally have few or no staff trained to work with bilingual populations (Phillips and Ephraim,1992). For example, most of the information provided immediately after Hurricane Andrew in Florida was available only in English (Yelvington, 1997). As a result, many Latinos and Haitians did not receive needed food, medical supplies, and disaster mental health assistance information.

“Linguistic competence” ensures accurate communication of information in languages other than English. This capability enables an organization and its personnel to communicate effectively with persons of limited English proficiency, those who are illiterate or have low literacy skills, and individuals who are deaf or hard of hearing (Goode et al., 2001). Elements of linguistic competence include the availability of trained bilingual and bicultural staff, translations of educational materials and documents, and sign-language and language interpretation services. Although linguistic competence and cultural competence involve distinct skills, they are intrinsically connected (DHHS, 1999).

Availability of Trained Bilingual and Bicultural Staff

Ideally, disaster mental health workers should be bilingual, bicultural, and from the affected community. However, in many circumstances, workers who are bilingual but not from the affected culture and community must be hired. In such situations, communication challenges may arise, even though the disaster worker or interpreter speaks the same language as the survivors. Examples or related issues follow.

  • Disaster mental health workers may be responsible for assisting survivors who have a language pattern that is different from their own. Dialects, in addition to colloquialisms and accents, can be difficult to understand and communication barriers can result.
  • Words may have different meanings even among people who share a language. Rogers (1992) noted difficulty in communicating disaster information between members of the United States Army and people in a native Polynesian culture because, although they both spoke English, the two groups did not assign a common meaning to certain words and phrases. The language differences led to frustration and a breakdown of credibility.
  • Bilingual disaster survivors who primarily speak Spanish may be more withdrawn when interviewed in English rather than in Spanish. An individual’s speech pattern may be halting or disrupted and expression of affect may be reduced when the person is required to speak in a language other than his or her primary language. In such situations, the disaster worker’s assessment of the survivor’s issues and needs can be distorted. Ideally, the preferred or primary language of bilingual disaster survivors should be used in delivering outreach and other services (Aponte et al., 1995).

Program managers must be cautious in selecting bilingual staff members and interpreters. Those who are bilingual also must understand nonverbal and cultural patterns to communicate effectively. Bilingual staff members should demonstrate bilingual proficiency and undergo cultural competence training (DHHS, 2000a).

REPORT

Multiple Methods Employed to Communicate with Asian Groups

Hurricane George caused extensive damage in Alabama in 1998, leaving many people homeless and others with major losses to their homes and businesses. Included among the disaster survivors was an Asian population. The disaster crisis counseling program used several methods to reach and serve them. For example, it developed leaflets in the Cambodian, Laotian, and Vietnamese languages and distributed them to churches serving large numbers of Asian immigrants. The crisis counseling project also employed interpreters, a strategy that was viewed as highly effective in disseminating information to these groups. Finally, the project provided screening and information services to Asian adolescents in a church group.

Dissemination of Educational Information

Written information should be translated³ into multiple languages, as appropriate for the community to be served. The literacy level of the target population must be considered when developing written materials. Any written materials should be supplemented with other forms of information (DHHS, 2000a). For example, messages may be conveyed by radio or through announcements at churches and other community centers. Most localities now have television stations that broadcast in the languages of various cultural groups. Although these communications media should be used, it is important to note that some people do not have access to television and may depend on radio broadcasts for information.

Crisis support programs should establish relationships with multicultural television stations, radio stations, and newspapers before a disaster occurs. In addition, program staff should invite television and radio station personnel to participate in the development of a disaster communications plan.

The information needs of people who are deaf or hard of hearing also must be considered. Closed-captioned television, for example, is a critical communication tool for this population. The Federal Communications Commission requires that all emergency information presented on television be accessible to persons who are deaf or hard of hearing.

Interpretation is the oral restating in one language of what has been said in another language. Translation typically refers to the conversion of written materials from one language to another (Goode et al., 2001).

Language and Sign-Language Interpretation

Language interpretation may be used when the language barrier is so great that communication between mental health workers and survivors is not possible or when no bilingual staff can be hired. Sign-language interpretation also must be considered when developing communication strategies.

Although language interpreters may be the only viable option in some situations, hiring bilingual staff members remains the preferred solution. Van der Veer (1995) notes that an interpreter’s behavior may evoke certain feelings in the disaster survivor. Factors such as the interpreter’s gender, age, or level of acculturation may affect the survivor’s willingness to speak openly. Disaster survivors may be ashamed of mental health problems that are considered a sign of madness or a cause for contempt in their cultures. They also may distrust interpreters who are from the same country and speak the same language, but who have different political or religious backgrounds (Van der Veer, 1995).

Interpreters should be trained to accurately convey the tone, level, and meaning of the information presented in the original language. Without adequate training, interpreters may interpret information inaccurately or incompletely. The most common problems include changing open-ended questions into leading questions, altering the content of questions, and adding comments. Problems in interpreting answers include leaving out part of the answer, adding something to the answer, and making mistakes because of limited understanding of English (Van der Veer, 1995).

When working with refugees, mental health workers should be aware that interpreters might have experienced traumatic events similar to those experienced by the refugees. In such situations, the interpreter may want to avoid reliving unhappy or traumatic memories. Thus, the interpreter may present information inaccurately, evade certain topics, change the subject, or tell the mental health worker that the interview is too stressful for the disaster survivor (Westermeyer, 1989). Table 2-5 provides useful guidelines for using interpreters.

TABLE 2 - 5

Guidelines for Using Interpreters

The following guidelines should be considered when using language interpreters (Bamford, 1991; Gaw, 1993; Paniagua, 1998; Westermeyer, 1989):

  • Before hiring interpreters, attempt to identify mental health workers who speak the language spoken by survivors and who identify with the survivors’ culture.
  • Hire certified, qualified interpreters who share the survivor’s racial and ethnic background.
  • Determine the survivor’s dialect before asking for an interpreter.
  • Compare the level of acculturation of the interpreter with that of the survivor. If it is not similar, effective communication may not be possible because Western values may be reflected in the interpreter’s comments.
  • Introduce the interpreter to the disaster survivor, and allow time for them to build trust through informal conversation.
  • Take time for translation. Use a sequential mode of interpretation—that is, the disaster survivor speaks, the interpreter interprets what has been said into English, the disaster mental health worker speaks, and the interpreter speaks again.
  • Do not use survivors’ friends and relatives, including their children, as interpreters. The survivor may not feel comfortable expressing concerns of a personal nature to relatives and friends. Using children can reverse the hierarchical role of parents and place burdens on children. Moreover, such responsibility may require skills beyond the child’s current stage of development and be too stressful for the child (DHHS, 2000c).

 

PRINCIPLE 9: ASSESS AND EVALUATE THE PROGRAM’S LEVEL OF CULTURAL COMPETENCE

Self-assessment and process evaluation are keys to ensuring that disaster mental health services are as effective as possible and to making maximum use of resources. Self-assessment helps programs identify organizational problems that may impede the delivery of culturally competent services. The self-assessment tool presented in Table 2-6 may be used in conjunction with the Cultural Competence Checklist for Disaster Crisis Counseling Programs, presented in Appendix F. The Cultural Competence Continuum (Figure 1-1) is another useful tool for assessing a program’s level of cultural competence.

TABLE 2 - 6
A Cultural Competence Self-Assessment for Disaster Crisis Counseling Programs

Six elements are needed to ensure cultural competence of mental health agencies (Bernard, 1998). Programs can use these elements to assess their level of cultural competence as well.

Leadership

  • Are the leaders of the program committed to cultural competence?
  • Does the project manager hold staff accountable for knowledge of the provision of appropriate services to all disaster survivors?

Understanding of cultural competence

  • Has the program staff developed a common understanding of cultural competence and do they clearly and frequently communicate that understanding to others?

Organizational culture

  • Does the crisis counseling program promote and encourage cultural competence?
  • Is the program administered by an organization with a strong commitment to and history of working toward cultural competence?
  • Are policies, procedures, and systems in place for delivering interpretation, bilingual, or translation services?

Training

  • Have all crisis counseling staff members been trained in cultural competence, and are they familiar with the diverse cultural and ethnic groups in the community?
  • Are training programs ongoing?
  • Are regular meetings convened and educational opportunities offered for staff members to discuss cultural competence issues and concerns, build cross-cultural skills, and develop strategies?

Cultural competence plan

  • Has the program identified goals designed to address the mental health needs of the community in a culturally competent manner?
  • Has the program explored various methods of working with disaster survivors in a way that respects and is sensitive to the needs of all groups in the community?
  • Has the program established partnerships with community-based agencies that serve cultural and ethnic groups for input on needs assessment, program planning, and evaluation?
  • Has the program developed a mechanism to acquire knowledge about the customs, values, and beliefs of special populations?

Managing the plan

  • Has a person or group been identified to evaluate the success of the program in addressing cultural competency issues?
  • Have methods been instituted to recognize innovations in serving culturally distinct groups and implement those innovations project-wide?

Process evaluation helps ensure that the disaster mental health program stays on course. It also can identify problems or gaps in providing culturally competent services. Involving representatives from as many cultural groups as possible in process evaluation ensures that diverse cultural groups or group perspectives are heard and understood.

The program can use a variety of techniques for collecting information for process evaluations. For example, staff might create an evaluation task force or advisory group or a discussion or focus group that includes representatives of different cultural groups. A group that includes a disaster survivor perspective, as well as representatives of partner agencies, can provide qualitative information and innovative ideas that can help the crisis counseling program more effectively address the community’s cultural needs. Evaluation methods should be consistent with the cultural norms of the groups being served. Evaluators should be sensitive to the culture and familiar with the culture whenever possible and practical (DHHS, 2001).

Program staff should regularly communicate process evaluation findings to key informants and cultural groups engaged in the project and in the evaluation in order to ensure their ongoing support.

Developing a culturally competent disaster crisis counseling program requires commitment and diligence. The rewards of such dedication are at the heart of the program—effective and appropriate services to help disaster survivors recover and heal.

REPORT

Bilingual and Bicultural Staff Assist in Assuring Cultural Competence

Late winter storms in California in 1995 affected several ethnic groups in Fresno County. The county crisis counseling project sought to deliver services in a bilingual, bicultural manner. Staff members were assigned to match the ethnic and cultural attributes of each community; for example, Spanish-English speakers primarily concentrated in one area of the county, while Hmong-English speakers were deployed to another area. Brochures and other forms of written information were translated into both Hmong and Spanish. Interpreters were used to reach persons who spoke Punjabi, Armenian, and Chinese. The project also arranged to provide oral translations of handouts for those who were illiterate.

REPORT

Information Dissemination for Deaf and Hard-of-Hearing Populations Improved

In September 1999, Hurricane Floyd arrived in North Carolina, causing the most devastating flooding the State had ever experienced. Outreach efforts organized through the “Hope After Floyd” program helped thousands of residents to deal with the hurricane’s aftermath.

Outreach workers reported particular success in providing crisis counseling services to individuals who were deaf and hard of hearing, many of whom experienced fear and stress associated with the lack of access to information provided through television or radio. Following the disaster, project staff provided in-service training and consultation to emergency management agency officials on the needs of the deaf and hard-of-hearing populations, and worked to ensure that the Federal Communications Commission required broadcast stations to provide closed-captioned emergency information.

 

Training for Mental Health Workers in Major Disasters

Background and Overview

Mental health intervention has become a valued dimension of immediate and long-term disaster response. Psychological recovery is recognized as a focus for relief efforts, along with repairing homes and rebuilding bridges. Emergency responders, disaster workers, and community members now receive mental health support following most large-scale disasters. Mental health professionals have readily stepped into the disaster milieu to provide counseling, debriefing, school interventions, case management, and consultation.

Legislative authority is given to the President under Section 416 of The Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (Public Law 100-707) to provide training and services to alleviate mental health problems caused or exacerbated by major disasters. The Act reads as follows:

Crisis Counseling Assistance and Training. The President is authorized to provide professional counseling services, including financial assistance to State or local agencies or private mental health organizations to provide such services or training of disaster workers, to survivors/victims of major disaster in order to relieve mental health problems caused or aggravated by such major disaster or its aftermath.

The Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) is managed by the Federal Emergency Management Agency (FEMA) in cooperation with the Center for Mental Health Services (CMHS).

Purpose of the Manual

While each disaster and community is unique, States face similar challenges as they mobilize the resources to provide post-disaster mental health services. Disaster mental health providers, program planners, and administrators must quickly acquaint themselves with "the basics" of disaster mental health to be able to design and deliver services that are effective. A primary purpose of this Manual is to present an overview of essential information including: how disasters affect children, adults and older adults, the importance of tailoring the program to fit the community, descriptions of effective disaster mental health interventions, and strategies for preventing and managing worker stress.

Another purpose of the Manual is to efficiently assist mental health administrators, planners, and disaster mental health trainers as they develop the training component of their crisis counseling project. Specific disaster mental health training is critical for all professional and paraprofessional personnel associated with a disaster mental health recovery program. This training can guide crisis counseling project development so that the wisdom gathered from twenty-five years of disaster mental health intervention is reflected in program services. A course outline for comprehensive disaster mental health training complete with overheads and handouts is in Section 6 of this Manual. The overheads and handouts have been prepared for immediate use by the trainer. Additional skill training for paraprofessional staff is described in Section 7. Crisis Counseling Programs typically reach out to human service agencies and organizations in the community. Examples of service provider groups are disaster relief workers, health care professionals, church volunteers, senior center personnel, building permit inspectors, public assistance workers, food bank workers, day care staff, and agricultural extension employees. Crisis counseling staff provide educational presentations and materials on disaster mental health so that local human service workers are better equipped to serve their constituencies following the disaster. The material provided in this Manual, especially the summary tables and handouts, will be useful for human service workers. A description of training options for human service workers is included in Section 7.

Why Special Training?

Specific training is essential because post-disaster mental health services are significantly different from the work activities of most mental health professionals. A supportive conversation or a focused problem-solving session over a cup of coffee, at a feeding van, or at a town meeting are essential activities in disaster work. While a background in crisis intervention or critical incident stress is helpful, it does not prepare a mental health professional for the range of issues encountered in communities during the months following a disaster.

As public funding for mental health services has become primarily limited to serving those with serious and persistent mental illnesses, many mental health workers have become less experienced in dealing with the general population who may be coping with loss, disruption, and, in some cases, tragedy. Many outpatient psychotherapists, accustomed to the fifty-minute session in an office, find providing support services in people's homes or at shelters outside their comfort zone. While case managers for people with mental illness and geriatric specialists are skilled at accessing resources and providing services outside an office, they benefit from training on disaster issues. Disaster mental health training builds on each mental health professional's existing strengths and experiences and provides a framework and specific interventions appropriate to the disaster context.

Newcomers to disaster work are impressed with the "alphabet soup" of agencies, centers, and services (e.g., DFO, EOC, ARC, FEMA, VOAD, SBA). For most, the bureaucratic context of disaster relief work is new, almost like operating in a different culture. Training provides the big organizational picture of disaster recovery, so that mental health workers can navigate in the new environment and utilize available resources.

Crisis Counseling Programs typically find that paraprofessionals from the affected communities can be highly effective community outreach workers. When paraprofessional workers represent the groups they are serving, for example, older adults, people of color, or people from different ethnic or cultural groups, they often readily gain access. Although these individuals may be "natural helpers" or "peer counselors" with other groups, specific training on disaster and mental health issues facilitates their integration into the program. In addition to specific disaster mental health training, paraprofessionals benefit from training and practice with basic counseling skills.

Occasionally, States will provide disaster mental health training for disaster mental health workers only, and not include those who will be providing clinical supervision or program administration. Disaster program experts emphatically concur that when all parties involved with a program have received training in disaster mental health, conflicts and misunderstandings that undermine program effectiveness can be avoided.

Overview of Resources

This Manual is intended as a companion resource to Disaster Response and Recovery: A Handbook for Mental Health Professionals (CMHS, 1994). While the Handbook provides practical information for planning and implementing disaster mental health services, this Manual focuses more on what workers need to know to provide those services. This Manual includes sections on how communities and survivors respond to disaster, potential at-risk groups, and stress management for staff. Recognizing the necessity for service providers to quickly develop competency in a new context, topic presentations are focused and brief. Additional readings are suggested in the text and listed at the end of sections. These have been selected because they provide synthesized research reviews and practical suggestions, and are readily available.

A comprehensive training course outline, which describes the specific skills, knowledge, and attitudes required for disaster mental health, is in Section 6. When the training content is not included in this manual, the trainer is directed, in most instances, to a chapter in the Handbook. Additional resources from the Center for Mental Health Services are extremely useful as well.

Responses to Disaster

A survivor's reactions to and recovery from a disaster are influenced by a number of factors, some inherent and some malleable. These factors are depicted in the diagram below, and, as shown, contribute to recovery outcomes. The disaster event itself has characteristics, such as speed of onset or geographic scope, which generates somewhat predictable survivor responses. Each survivor has a combination of personal assets and vulnerabilities that either mitigate or exacerbate disaster stress. The disaster-affected community may or may not have pre-existing structures for social support and resources for recovery. Disaster relief efforts that effectively engage with survivors and the overall community promote recovery.

This section describes critical variables associated with each factor. The term "psychosocial" is often used to capture the breadth of effects of disaster on survivors. As shown in the diagram below, disasters unavoidably impact survivors both psychologically and socially. Disaster mental health program planners, administrators, and providers can more easily assess their own communities and design effective interventions when they have an appreciation for this "macro" view of interacting factors.

Characteristics of Disasters

Disasters are not uniform events. Each disaster, be it a flood, earthquake, hurricane, or human-caused disaster, has intrinsic unique elements. These elements have psychological implications for survivors and communities. The disaster characteristics discussed in this section are: natural vs. human causation, degree of personal impact, size and scope, visible impact/low point, and the probability of recurrence. Each of these, individually or collectively, has the potential for shaping and influencing the nature, intensity, and duration of post-disaster stress.

Natural vs. Human Causation

While there are divergent findings regarding whether natural or human-caused disasters produce greater overall psychological effects, there are clearly psychological reactions unique to each (Weisaeth,1994; Rubonis & Bickman,1991). In human-caused disasters such as bombings and other acts of terrorism, technological accidents, or airline crashes, survivors grapple with deliberate human violence and human error as causal agents. The perception that the event was preventable, the sense of betrayal by a fellow human(s), the externally focused blame and anger, and the years of prolonged litigation are associated with an extended and often volatile recovery period.

In true natural disasters, the causal agent is seen as beyond human control and without evil intent. For some, accepting mass destruction as "an act of God" is easier, whereas for others it can be more difficult. The world can temporarily seem to become unsafe with its potential for random, uncontrollable and devastating events (Yates, 1998). In reality, there is a continuum between natural and human factors. Many disasters occur or are worsened through an interaction of natural and human elements (Green & Solomon, 1995). For example, damage from the natural event of flooding may be increased due to human factors such as inadequate planning, governmental policies, or faulty warning systems. An aircraft accident may result from an interaction of poor weather conditions and pilot error. Survivors experience reactions consistent with each dimension as they struggle with causal attributions.

Degree of Personal Impact

Researchers have consistently shown that the more personal exposure a survivor has to the disaster's impact, the greater his or her post-disaster reactions (Solomon & Green, 1992). Death of a family member, loss of one's home, and destruction of one's community exemplify high impact factors. In each of these, the intertwining of grief and trauma processes compound the effects and extend the duration of the recovery period for many survivors (Kohn & Levav, 1990). High exposure survivors experience more anxiety, depression, sadness, post-trauma symptoms, somatic symptoms, and, in some studies, alcohol abuse.

Size and Scope of the Disaster

As with the degree of personal impact, a dose-response relationship between community devastation and psychological impact exists. When entire communities are destroyed, everything familiar is gone. Survivors become disoriented at the most basic levels. Researchers have found higher levels of anxiety, depression, post-traumatic stress, somatic symptoms, and generalized distress associated with widespread community destruction (Solomon & Green, 1992). When some fabric of community life is left intact (e.g., schools, churches, commercial areas), there is a foundation from which recovery can occur. Social support occurs more readily when community gathering places remain. Survivors are then more able to continue some of their familiar routines. Family roles of provider, homemaker, or student are more able to be fulfilled when structures and institutions remain.

Visible Impact/Low Point

Most disasters have a clearly defined end point that signals the beginning of the recovery period. After a tornado, hurricane, or wildfire has passed through an area, the community sees the total extent of resulting physical destruction and begins the recovery and rebuilding process. The disaster threat is over and healing can begin.

However, in contrast technological events like nuclear accidents or toxic spills are "silent" disasters and do not show visual damage or have an observable "low point." The health consequences of increased risk for cancer and birth defects continue for decades (Green & Solomon, 1995; Berren et al., 1989). This prolonged impact period with no clear end impedes the recovery process. Survivors suffer the effects of chronic stress and anxiety due to the extended period of anticipation, fear, and threat (Davidson & Baum, 1994).

The end point of the disaster can be ambiguous in some natural disasters as well. Although an earthquake has its major impact, the aftershocks keep survivors worrying that "the big one is yet to come." Slow moving, repeat flooding, and related landslides may continue for months through a period of heavy rains. While there is visual physical damage to be reckoned with, it may be weeks or months before survivors feel that the disaster is truly over.

Probability of Recurrence

When the disaster has a seasonal pattern, such as hurricanes or tornadoes, survivors are concerned they will be hit again before the season ends. During the low-risk portion of the year, communities rebuild. Vegetation grows back and visual reminders of the disaster diminish. At the one-year anniversary, the reminder that the area is potentially at-risk again causes disaster stress and hypervigilance to resurface.

The immediate probability of recurrence is perceived as high following earthquakes and floods. The aftershocks following an earthquake or the increased risk of flooding due to ground saturation and damaged flood control structures following major floods keep many survivors anxious and preoccupied. In flood plain areas prone to repeat flooding, survivors can be kept in limbo regarding governmental buyouts, re-zoning, or the rebuilding of their homes as local, State, and Federal agencies address jurisdictional and legislative issues. This can be especially threatening and anger inducing when the next year's flood season approaches and decisions and/or repairs have not yet been made.

These five characteristics of disasters-natural vs. human causation, degree of personal impact, size and scope, visible impact/low point, and the probability of recurrence-contribute to dynamics that have potential psychosocial implications. These characteristics further define the disaster event portrayed in the diagram at the beginning of this section. Now, the discussion will shift to the survivor's characteristics that can mitigate or elevate disaster stress outcomes.

Survivor/"Person" Characteristics

A major disaster indiscriminately affects all who are in its path. Some disasters, such as a tsunami or landslide, may happen disproportionately to destroy wealthy people's shoreline or cliff-top view properties; whereas, another disaster, such as an earthquake or hurricane, may destroy poor people's structurally unsound housing. The disaster may affect thousands to millions of people in a densely populated urban area, or affect comparatively small numbers of people in a sparsely populated rural area.

Each survivor experiences the disaster through his or her own lens. The meaning the survivor assigns to the disaster, the survivor's inherent personality and defensive style, and the survivor's world view and spiritual beliefs contribute to how that person perceives, copes with, and recovers from the disaster. Experiences with losses or disasters may enhance coping or may compromise coping due to unresolved issues associated with those past events.

Having sufficient financial resources and being able to benefit from a social support network buffer the potentially devastating effects of a disaster and greatly assist the recovery process. An additional resilience factor includes the ability to tolerate and cope with disruption and loss. In contrast, vulnerability factors include preexisting health or emotional problems and additional concurrent stressful life events (McFarlane, 1996). In addition, cultural experience and ethnic background may facilitate or interfere with a survivor's ability to engage with disaster relief efforts.

Research findings are inconsistent with regard to the impact of gender and age on psychological outcomes. There is some indication that those in the forty to sixty age range may be more at risk because of the competing demands of child rearing, jobs, and caring for elderly parents (Green & Solomon, 1995). While single survivors may be more vulnerable than those who are married, increased marital conflict has been demonstrated following disasters. Refer to Section 3 for more information on the disaster reactions of potential risk groups.

Disaster Relief Efforts

When disaster relief efforts "fit" the community being served, survivors' access to assistance is enhanced. Information is available in native languages through print media, radio, and television. Relief workers are respectful of differences and work with trusted community leaders. Barriers are identified and addressed as every effort is made to connect survivors with resources for recovery.

While the above description is a goal, relief efforts may fall short. Disaster mental health workers may identify survivor groups who are not receiving services or recognize incompatibilities between the relief operation and the disaster-affected community. When individual survivors are unable to access services because of their limitations, disaster mental health workers may assist the survivor with overcoming personal or institutional barriers.

The relationships depicted in the Phases of Disaster diagram (page 5) shift over time. The experiences and needs of survivors and the community are different in the first week following the disaster compared with those at three months. Disaster relief efforts, including mental health programs, must maintain awareness of and accommodate to the time-based phases of disaster response (Tassey et al., 1997).

Phases of Disaster

Both community and individual responses to a major disaster tend to progress according to phases. An interaction of psychological processes with external events shapes these phases. Examples of significant time-related external events are the closure of the emergency response phase, the damage assessment of one's personal residence, or receiving financial determinations. The following represents a compilation of phase lists developed by different disaster experts. These particular phases have been selected and described because of their relevance to disaster mental health planners and workers in providing ongoing disaster recovery assistance.

Warning or Threat Phase

Disasters vary in the amount of warning communities receive before they occur. For example, earthquakes typically hit with no warning, whereas, hurricanes and floods typically arrive within hours to days of warning. When there is no warning, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies. The perception that they had no control over protecting themselves or their loved ones can be deeply distressing.

When people do not heed warnings and suffer losses as a result, they may experience guilt and self blame. While they may have specific plans for how they might protect themselves in the future, they can be left with a sense of guilt or responsibility for what has occurred.

Impact Phase

The impact period of a disaster can vary from the slow, low-threat buildup associated with some types of floods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects.

Depending on the characteristics of the incident, people's reactions range from constricted, stunned, shock-like responses to the less common overt expressions of panic or hysteria. Most typically, people respond initially with confusion and disbelief and focus on the survival and physical well-being of themselves and their loved ones. When families are in different geographic locations during the impact of a disaster (e.g., children at school, adults at work), survivors will experience considerable anxiety until they are reunited.

Rescue or Heroic Phase

In the immediate aftermath, survival, rescuing others, and promoting safety are priorities. Evacuation to shelters, motels, or other homes may be necessary. For some, post-impact disorientation gives way to adrenaline induced rescue behavior to save lives and protect property. While activity level may be high, actual productivity is often low. The capacity to assess risk may be impaired and injuries can result. Altruism is prominent among both survivors and emergency responders.

The conditions associated with evacuation and relocation have psychological significance. When there are physical hazards or family separations during the evacuation process, survivors often experience post-trauma reactions. When the family unit is not together due to shelter requirements or other factors, an anxious focus on the welfare of those not present may detract from the attention necessary for immediate problem-solving.

Remedy or Honeymoon Phase

During the week to months following a disaster, formal governmental and volunteer assistance may be readily available. Community bonding occurs as a result of sharing the catastrophic experience and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more readily accepted and have a foundation from which to provide assistance in the difficult phases ahead.

Inventory Phase

Over time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted due to enormous multiple demands, financial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue.

Disillusionment Phase

As disaster assistance agencies and volunteer groups begin to pull out, survivors may feel abandoned and resentful. The reality of losses and the limits and terms of the available assistance becomes apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle. Stressors abound-family discord, financial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of pre-existing conditions emerge due to ongoing, unrelenting stress and fatigue.

The larger community less impacted by the disaster has often returned to business as usual, which is typically discouraging and alienating for survivors. Ill will and resentment may surface in neighborhoods as survivors receive unequal monetary amounts for what they perceive to be equal or similar damage. Divisiveness and hostility among neighbors undermine community cohesion and support.

Reconstruction or Recovery Phase

The reconstruction of physical property and recovery of emotional well-being may continue for years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and have gradually assumed the responsibility for doing so.

With the construction of new residences, buildings, and roads comes another level of recognition of losses. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin.

When people come to see meaning, personal growth, and opportunity from their disaster experience despite their losses and pain, they are well on the road to recovery. While disasters may bring profound life-changing losses, they also bring the opportunity to recognize personal strengths and to reexamine life priorities.

Individuals and communities progress through these phases at different rates depending on the type of disaster and the degree and nature of disaster exposure. This progression may not be linear or sequential, as each person and community brings unique elements to the recovery process. Individual variables such as psychological resilience, social support, and financial resources influence a survivor's capacity to move through the phases. While there is always a risk of aligning expectations too rigidly with a developmental sequence, having an appreciation of the unfolding of psychosocial reactions to disaster is valuable.

Key Concepts of Disaster Mental Health

The following guiding principles form the basis for disaster mental health intervention programs. Not only do these principles describe some departures and deviations from traditional mental health work; they also orient administrators and service providers to priority issues. The truth and wisdom reflected in these principles have been shown over and over again, from disaster to disaster.

No one who sees a disaster is untouched by it.

There are two types of disaster trauma-individual and community.

Most people pull together and function during and after a disaster, but their effectiveness is diminished.

Disaster stress and grief reactions are normal responses to an abnormal situation.

Many emotional reactions of disaster survivors stem from problems of living brought about by the disaster.

Disaster relief assistance may be confusing to disaster survivors. They may experience frustration, anger, and feelings of helplessness related to Federal, State, and non-profit agencies' disaster assistance programs.

Most people do not see themselves as needing mental health services following a disaster and will not seek such services.

Survivors may reject disaster assistance of all types.

Disaster mental health assistance is often more practical than psychological in nature.

Disaster mental health services must be uniquely tailored to the communities they serve.

Mental health workers need to set aside traditional methods, avoid the use of mental health labels, and use an active outreach approach to intervene successfully in disaster.

Survivors respond to active, genuine interest, and concern.

Interventions must be appropriate to the phase of disaster.

Social support systems are crucial to recovery.

(CMHS, 1994; See Chapter 1, page 1, for more information.)

Community Outreach

Outreach approaches that offer practical assistance with problem-solving and accessing resources are key to a successful program. Returning to the diagram at the beginning of this Section, "disaster relief efforts," as shown, include disaster mental health services. It is essential that those services have the flexibility to engage with diverse individual survivors and the varied elements within the community. Programs should establish a vital presence early in recovery, developing creative strategies to meet survivors where they are and bring them forward in their recovery process.

Most people who are coping with the aftermath of a disaster do not see themselves as needing mental health services and are unlikely to request them. People reacting to disasters tend to have little patience with implications that they are in need of psychological treatment. This is why terms like "psychotherapy" or "psychological counseling" are often rejected and terms like "assistance with resources" and "talking about disaster stress" are more acceptable. Survivors who will be using program services are, for the most part, normal, well-functioning people who are under temporary emotional stress.

Disaster mental health workers must go to the survivors and not wait and expect that the survivors will come to them (Cohen, 1990). This means being visible in the disaster-affected neighborhoods, often going door-to-door to check-in with residents to see if they want assistance. Establishing relationships with community gatekeepers like corner store owners, or local cafe staff is important for referrals of survivors in need. Attending community gatherings at churches, schools, or community centers is useful for connecting with local residents and providing disaster mental health information. Besides these outreach approaches, educational materials that describe and emphasize the normalcy of reactions are of great benefit for disaster survivors. Educational outreach through the media-television, newspaper, radio, and community newsletters-reaches survivors whom other means might not contact. Disaster Response and Recovery: A Handbook for Mental Health Professionals provides extremely useful and detailed information about community outreach in a range of settings (CMHS, 1994).

Disaster mental health workers are most likely to find people struggling with the disruption and loss caused by the disaster. Disaster-related psychological symptoms warranting diagnosis are rare (Ursano, et al., 1995). People vary in the ability to recognize their own needs and in comfort level with asking for help. They may, for example, feel that it is personally degrading to request clothing or to seek an emergency loan. This reluctance can usually be overcome by personal contact with a caring person, who has the correct information and encourages the seeking of assistance.

Above all, disaster mental health programs must actively fit the disaster-affected community. Salient dimensions for consideration include: ethnic and cultural groups represented, languages spoken, rural or urban locales, values about giving and receiving help, and who and what the affected groups are most likely to trust. Access and acceptance is gained more quickly when disaster mental health programs coordinate and collaborate with local trusted organizations.

MENTAL HEALTH RESPONSE TO MASS VIOLENCE AND TERRORISM: A FIELD GUIDE

INTRODUCTION

This Field Guide is intended for mental health and disaster workers; first responders; government agency employees; and crime victim assistance, faith-based, healthcare, and other service providers who assist survivors and families during the aftermath of mass violence and terrorism. All who come in contact with victims and families can contribute to restoring their dignity and sense of control by interacting with sensitivity, kindness, and respect. This Field Guide provides the basics of responding to those in crisis.

Human-caused events such as mass shootings, bombings, riots, exposure to biohazards, and acts of terrorism are deliberately planned and perpetrated for political, sociocultural, revengemotivated, or hate-based reasons. Acts of mass violence and terrorism target a building, neighborhood, particular site, or event. Those confronted with life threat, mass casualties, overwhelming terror, and human suffering may experience severe psychological stress and trauma. Survivors, families, and the affected communities cope not only with the resulting deaths, injuries, and destruction but also with the horrific knowledge that their losses were caused by intentional human malevolence. When rescue and recovery efforts extend over weeks and months, family members endure prolonged uncertainty and an ongoing threat of possible future attacks, which contribute to heightened anxiety and a sense of vulnerability. These traumatic realities also impact first responders, media personnel, government officials, and others whose job-related responsibilities bring them in contact with the disaster's tragic impact.

Because disasters caused by mass violence and acts of terrorism are also crimes, law enforcement and the criminal justice system fill primary roles. When the underlying motivation is terrorism, Federal criminal justice agencies are responsible for the investigation and prosecution. The disaster's impact zone becomes a secured crime scene. Crime victims and their families have the legal right to receive information about criminal justice activities, participate in the criminal justice process, and receive protection from intimidation and harassment. They may apply for benefits and compensation for crime-related expenses. This interplay of emergency response, criminal justice, and disaster relief and recovery systems is a defining feature of the response to mass violence and terrorism.

This Field Guide includes essential information about survivors' and family members' reactions and needs, with specific suggestions for assisting children, adolescents, adults, and older adults. It describes basic "helping" skills with indicators for when to refer someone to a licensed mental health professional. The last section presents strategies for worker* stress prevention and management.

This Field Guide draws from material contained in Mental Health Response to Mass Violence and Terrorism: A Training Manual and highlights practical approaches. The Training Manual provides indepth and comprehensive information, and references for additional reading.

*In this Field Guide, the term "worker" refers to service providers and others who assist survivors and families.

Mental Health Intervention

Workers assisting survivors and family members may find the following key principles helpful, as they frequently are used by seasoned crime victim assistance and disaster mental health professionals:

  • No one who witnesses the consequences of mass criminal violence is unaffected by it.
  • Mass violence and terrorism result in two types of human impact-individual and community.
  • Mental health, crime victim assistance and other human services must be uniquely and individually tailored to the communities they serve. Cultural competence is essential.
  • While most traumatic stress and grief reactions are normal responses to extraordinary circumstances, a significant minority of survivors experience serious, longterm psychological difficulties.
  • Most survivors and families respond to active, genuine interest and concern. However, some will reject services of all kinds.
  • Mental health assistance is practical, flexible, empowering, and respectful of survivors' needs to pace their exposure to harsh realities resulting from the event. First and foremost, providers must do no harm when intervening.
  • Procedures and protocols used by emergency services, law enforcement, medical examiners' offices, and the criminal justice system can confuse and distress survivors. Clear, sensitive explanations are helpful.
  • Support from family, friends, and the community helps survivors and families cope with trauma and loss.

When mass violence occurs, innocent and unsuspecting people are caught by surprise in the course of their daily routines. These people usually are well-functioning and resilient. They have the capacity to cope with the profound psychological demands and losses they experience. Communities, families, and social support systems pull together to comfort and support those most impacted.

Workers providing emotional support take a practical, down-toearth approach. They reach out to survivors and respectfully offer reassurance, a listening ear, a warm beverage, concrete information about what will happen next, and practical assistance with immediate tasks. Survivors and families may gather at designated sites such as community centers, schools, employment settings, local places of worship, and disaster relief centers. They may not think they need "psychological counseling" or "mental health services" but may welcome genuine concern and help to cope with the stress. "Mental health support" can even take place over a cup of coffee.

Communities vary in their cultural, racial, and ethnic compositions including: the presence of refugee or immigrant groups, the primary languages spoken, and demographic and socioeconomic characteristics. A particular group may have been the target of violence due to prejudice or hate. If the alleged perpetrators are from a particular country or group, U.S. citizens and residents with similar physical characteristics or origins may be at risk for harassment and retaliatory violence. Crisis mental health support must help each affected group in the community.

Tailor Support to Community Needs

  • Be culturally sensitive.
  • Provide information and services in the appropriate language.
  • Understand the disaster's specific impact on affected cultural groups.
  • Collaborate and consult with trusted organizations and community leaders to serve all members of the community.

Survivors' and Families' Immediate Needs

Experiencing an act of terrorism or mass violence involving exposure to mass casualties, extreme trauma, and threats causes predictable human reactions. Most survivors and families have the same initial concerns and needs. They accept relief efforts more readily when first responders, emergency managers, law enforcement personnel, human services workers, and government officials consider the following:

  • Physical need for warmth, safety, rest, fluids, and food.
  • Emotional need for protection, comfort, control, reassurance, and a "listening ear."
  • Fear and anxiety about the safety and well-being of loved ones, friends, and coworkers.
  • Need for connection with loved ones and support systems.
  • Desire for frequent updates regarding the status of rescue and recovery efforts, criminal investigations, potential threats, and what is going to happen next.
  • Need for clear, sensitive explanations of: emergency medical procedures; medical examiner's office procedures and protocols; the criminal justice process; the rationale for highimpact operational decisions; and immediately available services, benefits, grants, and assistance.
  • Need for death notification conducted in a straightforward, clear, and compassionate manner.
  • Normal trauma reactions such as fearfulness, numbness, jumpiness, sleep and concentration problems, and replaying traumatic images and sounds.

In the days and weeks following mass violent victimization, initial shock gives way to the realization of personal losses. The lifechanging implications of death, the destruction of home and community, serious injuries, and the loss of a sense of safety and security in the world become increasingly apparent. Other consequences such as loss of employment, and relocation of home, school, or place of worship exacerbate disruption and grieving. Survivors and families psychologically pace themselves according to individual timeframes and personal coping styles.

Survivors and families often face numerous logistical and practical issues that can seem overwhelming. Workers may facilitate assistance with transportation, child care, locating a missing loved one or pet, funeral arrangements, finding temporary housing, filling prescriptions, replacing eyeglasses, and providing healthy foods and beverages. They also may help facilitate filling out the necessary paperwork for obtaining crime victim compensation and benefits, a death certificate, disasterrelated unemployment, insurance benefits, and financial assistance. Through helping with practical tasks, workers often earn survivors' trust and the privilege to support them when they express their pain, fear, sorrow, and anger.

Workers should approach survivors and family members with compassion and regard for their humanity and dignity. This includes honoring families' and survivors' wishes to be left alone or deal privately with their suffering. Workers enhance survivors' sense of control over their situation through recognizing and reinforcing their coping strengths, providing clear information, and offering choices when appropriate. When survivors feel more secure and in control, they can better address immediate challenges. Crisis support involves guiding, listening, reassuring, and providing practical assistance. The following section provides "nuts-and-bolts" suggestions.

Establishing Rapport

When making initial contact, workers should introduce themselves and briefly explain their roles. They may ask permission to sit down, since standing over people when they are seated may seem intimidating. Workers convey genuine interest and concern through eye contact, the assurance of safety, offering a warm beverage, and a calm presence. They provide comfort, support, and nonjudgmental response to expressed immediate needs. Trust and safety are enhanced when workers listen to what distressed survivors and family members choose to discuss and avoid asking intrusive questions.

Active Listening

Workers listen most effectively when they absorb information through their ears, eyes, and hearts. Some tips for effective listening are:

  • Support personal "pacing"—Many survivors and family members want to talk about their traumatic experiences. Putting terrifying and tragic experiences into words and having them heard while receiving emotional support can contribute to the healing process. Others may choose to focus on concrete tasks or seemingly inconsequential matters, temporarily avoiding direct discussion of their trauma and loss. Workers should look for cues regarding comfort levels, coping style, and appropriate pacing, and allow survivors and family members to take the lead with personal sharing.
  • Allow silence—Silence can give a person time to reflect and become aware of feelings. Silence may help survivors identify what is most important to them at the moment, or be a prompt for elaboration on thoughts and reactions. Simply "being with" the survivor or family member can be supportive.
  • Attend nonverbally—Eye contact, head nodding, caring facial expressions, and being at the same physical level (e.g., sitting, standing) let the person know that the worker is listening. Observing and heeding cultural differences with regard to nonverbal communication conveys cultural sensitivity and can enhance acceptance of help.
  • Paraphrase—The worker conveys understanding, interest, and empathy by repeating portions of what the person has said. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the person know that he or she is being heard. Good lead-ins are: "So you are saying that...," "It sounds like you...," or "I have heard you say that...." Paraphrasing may seem awkward at first, but is an effective tool for building trust.
  • Reflect feelings—The worker may notice that the person's tone of voice or nonverbal gestures suggest emotions such as anger, sadness, or fear. Possible responses are, "You seem afraid of spending the night at home alone. Is that true?" This helps the person to identify and articulate emotions and needs.
  • Allow expression of emotions—Communicating intense emotions through tears or venting is an important part of healing. It often helps the survivor or family member work through feelings so that he/she can better address the immediate tasks at hand. Workers should stay relaxed and let the person know that it is okay to feel and express emotions. [Suggestions in the "Stress Prevention, Management, and Intervention" section may be helpful.]

Some Possible Do's and Definite Don'ts

Do say:

  • You have temporarily lost your sense of safety and security. You will feel better over time.
  • It is understandable that you feel this way.
  • This is your body's and mind's way of dealing with what has happened to you. Your reactions are normal.
  • Feeling intense emotions and having thoughts that you have never had before is normal. You are not going crazy.
  • You didn't do anything wrong. It wasn't your fault. You did the best you could.
  • Things will never be the same as they were, but you will gradually feel better.

Don't say:

  • It could have been worse. You're lucky that….
  • It's best if you just stay busy.
  • You should count your blessings, it will make you feel better.
  • I know just how you feel.
  • He/she is in a better place now.
  • You need to get on with your life.

While the human desire is to try to "fix" the survivor's or family member's painful situation or to make them feel better, hearing comments in the preceding "Don't Say," however, can make a person feel discounted, judged, misunderstood, or more alone. Workers may find it difficult not to overidentify with survivors and families. They should allow survivors and families the space for their own experiences, feelings, and perspectives—whatever they are. Simply listening with respect, concern, and calmness can comfort them.

Psychological First Aid

During and immediately after an act of mass violence or terrorism, those most affected may experience shock, confusion, fear, numbness, panic, and anxiety. They may "shut down."

Witnessing or suspecting the death of loved ones or friends can be emotionally overwhelming. Some people may be locked in disbelief. When the perpetrators have not been apprehended or the event is considered terrorism, all may experience a sense of continued threat and danger. Workers have seven immediate tasks and purposes:

  1. Identify those in need of medical attention for intense stress reactions.
  2. Provide protection from further harm, and assistance to a safe environment.
  3. Ensure that survivors are warm/cool enough and are being given fluids and food.
  4. Promote a sense of security through orienting and reassurance.
  5. Connect survivors with family, friends, and loved ones.
  6. Provide information about the crime scene and perpetrators, status of rescue efforts, and what will happen next.
  7. Connect survivors and family members with resources for immediate help (e.g., voluntary agencies, crime victim assistance, systems for locating missing persons, emergency shelter and food, faith-based resources, and disaster mental health and psychiatry).

Problem Solving

Stress resulting from trauma, crime victimization, and sudden bereavement often causes disorganized thinking, concentration problems, and difficulty planning and making decisions. Some people react by feeling overwhelmed and may become either immobilized or unproductively overactive. Workers can encourage survivors and family members to participate in simple concrete tasks to help them focus and assume a more active role in coping. Also, workers can guide individuals through the following problem-solving steps to help prioritize and address immediate issues.

  • Identify current priority needs and problems and possible solutions

    "Describe the problems/challenges that you are facing right now."

    Selecting one solvable problem and then successfully addressing it can help restore a sense of control and capability. Avoid picking a complex problem first. Support the person in identifying a task that is easily completed.
  • Assess functioning and coping

    "How are you doing? How do you feel about how you are coping?"

    "How have you handled stressful life events in the past?"

    Through observation, gently asking questions, and reviewing the magnitude of the person's problems and loss, the worker develops an impression of the person's capacity to address current challenges. Based on this assessment, the worker may point out coping strengths, facilitate the person's engagement with social supports, or make referrals. The worker may also seek consultation from a medical or mental health professional.
  • Evaluate available resources

    "Who might be able to help you with this task/problem?"

    "What resources and options might be helpful?"

    Explore existing sources of assistance and support such as immediate and extended family, loved ones, friends, neighbors, coworkers, religious leaders, and healthcare providers. Connect the survivor or family member with the appropriate community, crime victim assistance, and disaster relief resources and assess if he/she is able to make the calls and complete the required paperwork. Assist with accessing resources when necessary.
  • Develop and implement a plan

    "What steps will you take to address this problem?"

    Encourage the survivor or family member to say out loud what they plan to do and how. Offer to check in for support and to see how he/she is doing. If the worker has agreed to perform a task or get information, it is very important to follow through. A plan may focus on a very short timeframe or limited actions. For example, a plan could be to make two phone calls. Being reliable and following up, even when there is no new information, helps survivors gain control. Workers should promise only what they can do, not what they would like to do.

A Word of Caution

When confronted with a survivor's or family member's seemingly overwhelming and heart-wrenching needs, workers can feel the understandable impulse to help in every way possible. Workers may become over-involved and do too much for the survivor or grieving family, which is usually not in the survivor's or family's best interest. While being helpful and available, workers should also convey their confidence in the individual's coping abilities and resilience. When survivors and families are empowered to address their own problems, they feel more capable to tackle the next challenge.

Confidentiality

The privilege of helping others carries ethical responsibilities. Helping people in need involves learning their problems, concerns, fears, and anxieties-sometimes with very personal details. This sharing must be done with a sense of trust, built upon mutual respect, and the understanding that all discussions are confidential. No person's situation or "case" should be discussed elsewhere without the consent of the person being helped, except in extreme situations when the worker believes the person might harm him/herself or others. Under those circumstances, workers should report concerns to their supervisors so that the appropriate authorities may be contacted.

Workers should avoid discussing information in public places, such as restaurants, that might give the impression that privacy is not being protected. Only by maintaining the trust and respect of the survivor or family member can the privilege of helping continue.

Workers should make referrals to mental health and other healthcare professionals when they encounter survivors and family members with severe physical or emotional reactions. Some may have preexisting physical or psychiatric conditions that have worsened because of traumatic stress. The following reactions, behaviors, and symptoms signal a need for the worker to consult with his or her supervisor and, in most cases, refer the person for assessment and more specialized assistance. In all instances, when in doubt, consult.

  • Disorientation: The person is dazed and unable to give date or time, location, and events of the past 24 hours, or understand what is happening.
  • Anxiety and Hyperarousal: The person is highly agitated, restless, jumpy, and on edge; is unable to sleep; has frequent disturbing nightmares, flashbacks, and intrusive thoughts; or broods over circumstances surrounding the event.
  • Dissociation: The person exhibits pronounced emotional disconnection, an incomplete awareness of the traumatic experience, a sense of seeing him/herself from another perspective, a perception that the environment is unreal or that time is distorted.
  • Depression: The person exhibits pervasive feelings of hopelessness and despair; unshakeable feelings of worthlessness, guilt, or self-blame; frequent crying for no apparent reason; withdrawal from others; or inability to engage in productive activity.
  • Mental Illness: Symptoms include hearing voices, seeing things or people that are not there, delusional thinking, appearing out of touch with reality, and excessive preoccupation with an idea or thought.
  • Inability to Care for Self: The person does not eat, bathe, or change clothes; is apathetic, isolated from others, and unable to manage activities of daily living.
  • Suicidal or Homicidal Thoughts or Plans: The person makes statements like "I can't go on," "I just want to end this terrible pain I'm feeling," "I wish that I had died," "I want to join my husband in heaven," or "I'm going to get even." The person feels pervasive self-blame or sense of responsibility for another person's death.
  • Problematic Use of Alcohol or Drugs: The person makes references to getting drunk, getting high, or not being able to stop drinking; blocks out pain with mood-altering substances; relapses from previous abstinence; misses work or other obligations due to alcohol or drug use; or expresses concern about a family member's substance use.
  • Domestic Violence, Child Abuse, or Elder Abuse: The person mentions instances of inappropriate anger or violence toward family members.

Terrorism and mass violence inevitably touch all who are in their zone of impact. This zone may include people of different ages and economic means; people of various cultural, racial, and ethnic backgrounds; people with different sexual orientations and family configurations; people who speak foreign languages; people from many occupational groups; and people who have roles in emergency response and recovery efforts.

The basic human need for survival, safety, protection, connection with loved ones, and accurate information are shared, while additional needs may be more specific to a particular group.

Workers are most effective when they are informed about, respectful of, and responsive to the various groups in the affected community. Special consideration should be given to the following groups as well as others with special needs:

  • Age groups (e.g., children, teenagers, older adults);
  • Highly impacted survivors and families;
  • Cultural, ethnic, and racial groups;
  • People with serious and persistent mental illness;
  • Human service, criminal justice, and emergency response workers.

Age Groups

Each age group is vulnerable in unique ways to the stress of trauma, victimization, and sudden bereavement. Some of the reactions listed in Table 1 may be immediate, while others may appear months later. Table 1 describes possible behavioral, physical, and emotional reactions of different age groups and options for helpful intervention.

Highly Impacted Survivors and Families

Research has shown that those who directly experience violent victimization and mass traumatization, witness the serious injury and physical mutilation of others, or suffer the murder of a loved one have a likelihood of intense and prolonged emotional, behavioral, and physical reactions. They are likely to suffer high levels of distress during the immediate response phase and may have periods of difficulty for years to come. Critical events that occur throughout the criminal justice process, such as trials, sentencing hearings, and appeals, are especially significant to this group and are often linked to restimulation of psychological wounds.

Workers support these survivors and family members by providing respectful and practical assistance, making needed information reliably available, and supporting the multiple pathways for coming to terms with overwhelming trauma and loss. Religious and cultural traditions; spiritual practices; community, family, and personal rituals; and symbolic gestures can soothe survivors' anguish and assist them with finding meaning and the courage to continue living. At different points during the process of coming to terms with loss and trauma, activities and interventions such as counseling, support groups, medication, spiritual guidance, social activism, helping others, artistic expression, and symbolic healing rituals may be helpful.

Cultural, Ethnic, and Racial Groups

Workers must respond sensitively and specifically to the various cultural groups affected by mass violence. The death of a loved one, community trauma, and mass victimization are interwoven with cultural overlays. Rituals surrounding death, the appropriate handling of physical remains, funerals, burials, memorials, and belief in an afterlife are all deeply embedded in culture and religion. The serious injury of a family member brings families from different cultures into contact with Western medicine and the healthcare delivery system. The situation may be even more challenging when English is not the family's primary language.

Cultural and ethnic groups with histories of violent oppression, terrorism, or war in their countries of origin may interpret community violence in the United States through their experiences of prior traumatization. Those who have suffered from political oppression and abuses of military power may find the prominent visibility of uniformed personnel highly distressing or even traumatizing. Some survivor groups may live in a context of poverty, discrimination, or marginalization and face high rates of violent crime in their neighborhoods, potentially making them more vulnerable to disaster impact.

Workers convey cultural sensitivity when they provide informational briefings, notifications, and applications for services and benefits in primary spoken languages. Workers must learn about each affected group's cultural norms, practices, and traditions; views regarding mental health, trauma, and grieving; and the group's local history and community politics. Establishing working relationships with trusted organizations, service providers, and community leaders often facilitates increased acceptance.

Workers communicate cultural sensitivity when they:

  • Use culturally accepted courteous behavior (e.g., greetings, physical space, know who is considered "family");
  • Describe their role in culturally relevant terms;
  • Take time to establish rapport;
  • Provide information and services in appropriate languages;
  • Ask about cultural practices when they are unsure;
  • Value diversity and respect differences;
  • Develop and adapt approaches and services to fit special group needs.

People with Serious and Persistent Mental Illness

What is self-inflicted violence?

 

Clinically, SIV has been referred to by many terms, including “self-mutilation,” “delicate skin cutting,” and “parasuicidality.” While commonly used, all of these labels misrepresent the behavior and meanings of SIV. Mutilation is not a goal of someone who self-injures, and some forms of SIV leave no scars. While cutting is one of the most prevalent methods of SIV, other common forms of self-inflicted violence used are punching, hitting, burning, bruising, head-banging, picking, or scalding the body. Each of these serves its own purpose and these different methods are not often interchangeable.

 

Many myths abound regarding SIV. One of the most prevalent is that the behavior is a failed, minimal suicide attempt, known as “parasuicidality.” In fact, the opposite is actually true. SIV is often used to manage the strong emotions that lead one to consider dying, and it often serves to avert suicide attempts. Practices that seek to eliminate SIV (including physical and chemical restraints, seclusion, constant observation, and intervention) actually increase the risk of successful suicide by removing an effective coping strategy that acts as an alternative to ending one’s life.

 

Who self-injures?

 

Currently, attention to SIV by the media and the mental health field has focused on youth, particularly adolescent girls. While use of SIV often begins in childhood or adolescence, it is not uncommon among men and women of all ages. Therefore, while SIV is an important issue in the juvenile justice system, it is equally important that it be understood in the adult system as well. Other assumptions regarding people who live with SIV are that they are white and of middle or higher socioeconomic class. This is inaccurate. SIV is utilized by men and women of all classes, races, and cultures. The common denominator amongst people who live with SIV is a history of some form of trauma. Research shows that the vast majority of incarcerated people have known histories of childhood trauma, especially childhood abuse. For example, a recent study of men incarcerated in a county jail reported that 59% of them acknowledged some form of sexual abuse occurring before the age of 13. A history of abuse, as well as other forms of trauma, is especially likely for people in the criminal justice system who struggle with mental health and/or substance abuse problems. Rates of prior trauma are as high or higher for individuals in the criminal justice system as for individuals in the mental health system.

 

Childhood trauma often has profound repercussions in later life and can greatly impact a person’s physical, emotional, and spiritual being. As reported by NYCASA, a 1999 study of female inmates at Bedford Hills Correctional Facility in New York found that over 80% had a history of childhood physical and sexual abuse, and more than 90% had experienced battering or sexual assault during their lifetime. In a study of inmates on death row, 100% had histories of family violence and more than 87% were victims of severe physical and/or sexual abuse and met criteria for Post Traumatic Stress Disorder.

 

A history of abuse does not excuse criminal behavior, but it may help explain it. For example, the use of alcohol and other substances is an effective method of “self-medicating,” commonly used by traumatized people to “numb-out” or escape from intrusive thoughts and emotional pain. The use of illegal substances, and the behaviors necessary to access such drugs, often results in criminal behavior and incarceration. Similarly, most of the people (male and female) who work in the sex trade are victims of childhood sexual abuse. People who learn as children that sex is the most effective currency for maintaining relationships and feeling valued (not to mention making money) find as adults that sex work still meets these needs. The vast majority of incarcerated women have been arrested on charges of solicitation, drug offenses, or both.

 

Childhood trauma can take many forms, including experiences of:

  • early loss and separation, especially of a parent /caregiver or sibling due to
    •  illness
    • death
    • divorce/separation
    • drug and/or alcohol abuse
    • incarceration
    • neglect
  • poverty and deprivation
  • severe illness, hospitalization, surgery
  • war
  • racism
  • childhood abuses, including
    • sexual assault, including incest
    • physical assault
    • emotional abuse
    • witnessing domestic violence, and
    • neglect.(emotional and/or physical)

 

Acts of SIV often lead to psychiatric interventions. By far, the most common psychiatric label given to those who self-injure, especially women, is Borderline Personality Disorder. This diagnosis, while now acknowledged to be strongly correlated with childhood trauma, often elicits intensely judgmental and punitive treatment from clinical staff, both in psychiatric hospitals and in corrections facilities. While the most common accurate diagnoses given to childhood trauma survivors are Post Traumatic Stress Disorder and any of the Dissociative Disorders (and the recognition that anxiety, depression, extreme mood swings and hearing voices are not uncommon amongst trauma survivors), these are not usually applied to people who live with self-injury. Also, recent research has identified that people with psychiatric diagnoses not previously considered to be related to childhood trauma, such as schizophrenia and obsessive-compulsive disorder, do have a very high prevalence of childhood trauma and that the trauma might be related to the development of those disorders.

 

Why do people deliberately cut, punch, or burn themselves?

 

Just as the substance use and sex work (described above) serve a purpose and solve a problem for survivors of childhood trauma, so too does SIV (and most other trauma-related behaviors) serve a functional purpose for those who do it. Typically, SIV is driven by the underlying need for self-regulation and serves as a means of grounding, a way of managing highly dissociative states that impinge and impair functioning. It helps the person manage intense, seemingly overwhelming feelings, memories, and experiences. It is best understood as an act of self-defense, defending oneself from being consumed by the overwhelming distress of despair, numbness, or the re-experiencing of abuse. When asked how SIV helps, those who live with it say it helps them to:

  • feel real, get a sense of their physical boundaries
  • diminish intense emotions such as despair, terror, grief, self-hate, rage, shame, or helplessness
  • facilitate dissociation, to disconnect from their sense of self when overwhelmed
  • diminish dissociation, when the sense of disconnection is unwanted; SIV serves as “grounding”
  • symbolize internal pain through an external expression
  • remember without consciously knowing; re-enacting of previous abuse as an attempt to gain mastery
  • communicate what cannot be said verbally
  • express anger at someone else by directing it at their own body; i.e. punching themselves to avoid violence towards another
  • stop or diminish flashbacks of abuse
  • communicate between personalities in those with Dissociative Identity Disorder (formerly known as Multiple Personality Disorder)
  • symbolize spiritual beliefs

 

Many people who self-injure feel no physical pain at the time of the acts of SIV. While some clinicians believe that this is a result of certain naturally produced brain chemicals (endogenous opioids known as endorphins), this theory is flawed. The wounds of SIV are often minimal. Many require little or no medical attention. They are no different from many minor wounds that are the results of accidents, and these do not cause any sort of chemically induced relief. The absence of pain from self-injury is much more likely related to the depth of the psychological disconnection (or dissociation) the self-injuring person is experiencing at the time. Also, as SIV is often used as a release for profound emotional pain, persons who self-injure report that the emotional pain is so overwhelming it makes the less intense physical pain from the self-injury irrelevant. Many people who cut themselves do so as an act of expression and release of deep and very difficult emotions. As a poet once wrote: “I hurt so much, I bleed.” People who have survived traumatic childhoods often struggle with dissociation, which is the sense of having one’s thoughts, feelings, and identity separate from one’s body. Dissociation is often described as a sense of “extreme spaciness.” While an effective form of self-preservation, dissociation leads to feelings of disconnection and/or unreality and thus interferes with learning new ways of being in, and interacting with, the world. For some people it may be a preferable state of being when overwhelmed; at other times dissociation is unwanted or frightening. SIV is often used as a tool to manage dissociation, either to increase it or to decrease it. As a result, SIV serves as an “all-purpose tool” for many institutionalized or incarcerated people.

 

Persons with histories of severe abuse who experience emotional numbness often turn to SIV to “feel something.” This is particularly poignant for those who are kept in isolation most of the time. Inmates in highly restrictive environments who have no hope for change in their situations not only tend to self-injure, but often do so with escalating severity as their helplessness and hopelessness increase. For these people the SIV serves as a way of feeling “something” in the midst of continued intolerable emotional and experiential numbness.

 

Many survivors with mental illness function fairly well following a community disaster, especially if essential services and support networks have not been interrupted. Most have the same capacity as the general population to "rise to the occasion" and perform heroically during the immediate response period. However, those who are directly involved and traumatized by the event may need additional mental health support services, medications, or hospitalization to regain stability. For survivors previously diagnosed with posttraumatic stress disorder (PTSD), emergency response stimuli (e.g., sirens, helicopters, mass casualties) may trigger an exacerbation due to associations with prior traumatic events.

The range of support services designed for the general population is equally beneficial for survivors and family members with mental illness. As with all special population groups, workers need to be aware of how people with mental illness perceive disaster assistance and services, and build bridges that facilitate access.

Human Service, Criminal Justice, and Emergency Response Workers

Workers in all aspects of emergency response and disaster relief experience considerable demands to meet the needs of survivors, families, and the community. Depending on their role, workers may be exposed to human suffering, fatalities, people with serious physical injuries, family demands and anguish, community anger, and other difficulties. They may experience physical stress symptoms or show signs of stress overload. Indicators include irritability, over-involvement with and inability to leave the operation, difficulty focusing, being unproductive, feeling depressed, or feeling emotionally overwhelmed. Workers may intervene by suggesting or using the strategies described in the next section.

Workers must cope with a range of challenging stressors. The devastating losses, casualties, destruction of property, and emotional pain of survivors and bereaved loved ones touch providers in powerful and personal ways. The emergency response working environment often involves physical hardship, unclear roles and responsibilities, limited resources, rapidly changing priorities, intrusive media attention, and long work hours.

Despite the inevitable stress associated with community crisis response, workers experience personal gratification using their skills to assist fellow humans in need. Active engagement in the disaster response can be an antidote to feelings of vulnerability, powerlessness, and outrage commonly experienced by the community.

A proactive stress management plan focuses on two critical contexts: the organizational and the individual. Adopting a preventive approach allows managers and workers to anticipate stressors and manage potential crises rather than simply reacting to them after they occur.

Psychosocial Issues for Children
and Adolescents in Disasters

Following a disaster of such magnitude that the President has declared it as eligible for Federal assistance, communities are often in chaos and individual survivors are undergoing their own feelings of disbelief and shock. It is within this context communities must respond to the emotional needs of their residents: adults and children. Adults living in the impacted area must balance their roles as survivors, responders and caregivers during this time of turmoil. They are often overwhelmed with the responsibility and immediate tasks of crisis response and recovery and must take time to meet the physical and emotional needs of themselves and family members and respond to the needs of the larger community. Consequently, children may be left in the care of unfamiliar persons or provided with limited explanations of what has actually happened.

Disaster response workers, who are providing crisis counseling and emotional recovery assistance, need to be sensitive to the emotional vulnerability of children. The materials discussed herein will give crisis response workers essential information about the impact of disasters on individuals, how the trauma associated with such events impacts children, the unique world of children, and the diversity of family structures in which children reside.

A special emphasis is placed on assisting child health workers to understand children as uniquely different from adults, and childhood as distinct from adulthood. Child health workers must engage children in the ever changing and qualitatively distinct world of emotional and cognitive stages of development in which children find themselves. The purpose of the manual is to achieve a better understanding of the world of children and the nature of disaster response.

The manual also provides information and guidance for the broader group of individuals concerned with the mental health needs of children who experience major disasters, and may include the following:

Experienced mental health professionals who specialize in working with families and their children who experience serious emotional disorders;

Other health professionals such as physicians, physician assistants, nurses, and rehabilitation specialists who are experienced in working with children;

Professional and paraprofessional workers who provide crisis and suicide intervention services, case managers, and other public health and social service personnel who work with children on a regular basis;

School and licensed day care center personnel, including teachers, teachers' aides, guidance counselors, school social workers and psychologists, and administrators;

Nonprofessional volunteers from the community who have little or no training, but who have had personal experience with their own and neighbors' children; and,

Adults who routinely work with children either as volunteers, or as paid service providers or caregivers who have a strong commitment to helping children in times of crisis.

THE WORLD OF CHILDHOOD AND THE DEVELOPING CHILD

Children are one of the most vulnerable groups during and following a disaster. A disaster is a strange event that is not easily understood. It is emotionally confusing and frightening and results in children needing significant instrumental and emotional support from adults. Children, parents, and whole families in need of assistance are found at shelters, recovery centers, and other locations. A review of some basic principles and reminders from child developmental theory show how a child's current stage of development influences their behavior and their understanding of traumatic events associated with the disaster. Below is a list of basic principles that may be helpful as we, the helpers, are rapidly trying to determine the best strategy for providing assistance to children in both the early stages of crisis response and the later stages of emotional recovery from the disaster:

Be a supportive listener. Be sensitive to the child's cultural, ethnic, and racial experiences.

Respond in a way that is consistent with the child's level of development.

Be aware of the child's emotional status. Is the child actively afraid or withdrawn?

Determine if the child is comfortable/secure about his/her current surroundings and those of his or
her parents, and other significant persons/pets,

Assist the child in normalizing his/her experiences.

Seek assistance from a child specialist or mental health professional, if necessary. Assistance is needed when the helper does not know what to do or think or if he or she is making things worse.


THEORIES OF CHILD DEVELOPMENT

An abundance of popular press is available on the subject of children. Topical areas of interest include how to raise, parent, educate, and discipline children. It is important, especially when one is in a period of stress and turmoil, to step back from the issues at hand and assess the current situation from the perspective of life during non-crisis routine times. This is especially true when engaging children.

The most important concept to remember is that children are different from adults; childhood is different from adulthood. As trained child health workers or disaster mental health outreach workers who encounter children as survivors of a disaster, the preceding statement seems with a moment's reflection as obvious. In fact, the reality is so obvious that it is often overlooked.

Jean Piaget, renowned for his elegant theory of child development, formulated much of his theory from simply observing how his own children responded to their environment. Piaget, the scientist-observer, systematically confronted his children at different chronological ages with various mental challenges and recorded his observations of their responses. Classic examples from his work illustrate how children perceive the world differently at various chronological ages.

Piaget (Flavell, 1963) noted young children have difficulty observing objects from more than one perspective. For example, a seven-year-old is shown two glass containers: one is short, wide, and filled with water; the other is empty, tall, and slim in shape. The child is convinced that when the liquid from the short container is transferred to the tall one, the volume of the contents actually changes as well. Similarly, when a child of ten or eleven is asked to solve a problem that requires abstract reasoning, such as a problem of logical inference (i.e., a>b and b>c; therefore, a>c), the child is often baffled by the solution. However, when the same problem is presented with solid objects, it is easily solved. Because the objects are concrete and readily visible, he or she easily recognizes the relationship. An adolescent, on the other hand, can solve this problem in the "abstract" by creating mental images of a, b, and c and then solving the problem in his or her head.

Piaget was trained as a biologist and based much of his theory of development on the notion that organisms seek homeostasis or a steady state of balance or equilibrium. With respect to humans, he postulated that as we grow we change internally and thus, our capacity to engage the environment changes as well. Throughout our development we experience states of disequilibrium and seek to return to a state of equilibrium. The mechanisms he proposed are two active processes of assimilation and accommodation. Simply put, assimilation is the process of interpreting new information within the context of our existing cognitive structure, while simultaneously accommodating to the new information or demands of our environment. Through the tension of these two ongoing processes we develop our cognitive knowledge and capacities. Thus, we develop from an infant who responds primarily to sensations to an adult who is capable of complex abstract reasoning.

All of us can recall conversations with friends who related their frustration as parents, complaining that their children are disobedient and refuse to do their chores. Is this refusal to behave and do the chores simply because the child is disobedient? Or is it because the parent is issuing commands in a manner that requires the child to translate the "abstract" orders into concrete actions, when they have not yet developed the necessary cognitive skills? While a comprehensive discussion of cognitive developmental theories is beyond the scope of the subject at hand, it is important to recognize that children think and construct their responses to the world in different ways depending on their current level or stage of cognitive development.

In summary, we should be aware when we meet a child that they are operating in the world with a different set of cognitive structures than adults and are interpreting information from the environment in a different fashion. In the next chapter, there are a number of illustrations of how this actually works.

Cosario (1997) recently reasserted that when trying to understand children, we must remember that childhood is not simply an apprenticeship to the "real" world of adulthood, but is the current world in which children operate. It is the environment in which cognitive, social, and emotional development occur for individual children. "Children create and participate in their own unique peer cultures by creatively taking or appropriating information from the adult world to address their own peer concerns" (p.18). Hartup (1979) suggests that children really experience two worlds: the world of adult-child interactions, such as with teachers and parents, and the world of peer interactions with children of similar age. We must be aware of the simultaneous presence of both these environments to understand and relate to children as developing individuals.

The emotional development of children parallels, complements, and interacts with their cognitive development. Kagan (1982) has shown in studies of normal infant development that when confronted with new and different information infants may smile if the information is successfully integrated, and they show fear by crying or withdrawing if they cannot make sense of the information. The study of emotional development affirms that emotions are central to survival. Through emotional expression the infant expresses distress (a soiled diaper or hunger), pleasure (being comfortable and having a full stomach), and fear of strangers. As children in middle school and high school, we learn to respect the social standard of non-aggression toward peers and acquire the skills necessary to problem solve conflicts and modulate emotional expression accordingly. By adolescence we are well skilled in expressing empathy, pride, shame, guilt, and other emotions. Thus, throughout normal development we learn more sophisticated strategies of emotional expression.

Closely tied to emotional development is the development of attachment. Attachment theory as originally developed by John Bowlby (1982) integrates psychoanalytic concepts of child development with parts of cognitive psychology, ethnology, and human information processing. He defines attachment theory as a way of conceptualizing ". . . the propensity of human beings to make strong affectional bonds to particular others, and of explaining the many forms of emotional distress and personality disturbance including anxiety, anger, depression, and emotional detachment to which unwilling separation and loss give rise" (Bowlby, 1982, p. 39). Attachment refers to the affectional bond that forms between a nurturing figure, usually the mother, and her child in the course of time and in response to consistent care. Bowlby states that there is an innate tendency within the human baby to seek and maintain proximity to the attachment figure. This behavior has the function of protecting children from the risk of harm.

Mary Main (1996) recently reviewed the field of attachment research. In the years since Bowlby's original formulation, the concept of attachment has been extended beyond infancy to account for behavior throughout the life span. Main has affirmed that the development of the attachment relationship is based on social interaction. In the overwhelming majority of instances children become securely attached to a nurturing caregiver. Children also become attached to maltreating parents and the resulting attachment bond is expressed as an insecure attachment. The quality of the attachment bond is usually established by seven to eight months of age and is characterized as secure or insecure. Secure attachment is the result of an infant being able to rely on the caregiver as consistently available and nurturing. Infants who have incompetent, uncaring, or inconsistent caregivers express insecure attachment behavior. Insecure attachment behaviors related to separation and reunion with the caregiver range from ignoring the caregiver to excessive and disquieting expressions of distress.

Being securely attached to a nurturing caregiver is further expressed by using the caregiver as a "secure base" for exploring one's immediate environment. For example, a small child playing in the park will run and play far away from his or her mother as long as he or she is in visual proximity. The child will wander farther and farther away only to spontaneously return to his or her mother and soon wander off again in spirited play. Just as the child displays organized and confident behaviors while in the comforting presence of the caregiver, he or she can also appear disorganized and highly anxious or fearful upon separation or loss of the caregiver. Brief separations from one's parents is a common event in disasters.

Upon separation and loss of proximity to the caregiver, the child will express fear and anxiety until again secure in the knowledge of the availability of the caregiver. As discussed earlier, infants and very young children must be able physically to see objects to keep them psychologically available. However, with time, children can build psychological representations of objects, people, and relationships. Recent research suggests that through maintenance of mental models of caregivers, children are influenced in their formation of relationships with peers and in the development of successful interactions with friends. In a similar vein, adolescents are influenced by models of adult caregivers as they begin developing long-term relationships with significant others.

To better understand normal and abnormal child development, much research has been conducted comparing the behavior of securely attached and insecurely attached children. Carlson and Sroufe (Main, 1996) have reported ". . . in peer and school settings, children who felt secure as infants with their mother exhibit greater ego resilience as well as social and exploratory competence than insecure infants . . . Security with fathers also contributes favorably to outcome" (p. 240).

Disasters are events postulated with separation and loss. Irrespective of the quality of the child's attachment to the caregiver as secure or insecure, unexpected separation and disruption of one's secure environment results in fear, anxiety, and disorganization of one's own behavior. Children who have experienced secure attachment relationships with a nurturing caregiver are the most resilient in reconciling the disruption and recovering from traumatic events. The disruption and loss experienced will most likely be more difficult to resolve for children who have experienced insecure attachment relationships.

Cassidy (1996) summarized some basic findings from the study of attachment relationships: Linkages exist between family and peer systems.

Children's daily experiences with parents affect their concept of self and relationships with others.

Children with more positive relationships with peers express more positive behaviors.

More positive behaviors result in being better liked by peers.

In summary, the quality of parents' caregiving behavior initiates a process linked with the quality of peer relationships throughout childhood and early adolescence.

Erik Erickson's theory of psychosocial development (Santrock and Yussen, 1987) offers a perspective on a child's social development. Erickson proposed that social development is the result of the interaction between internal biological forces and external cultural pressures. As such, he proposed eight stages of development throughout the life span. The conflicts one experiences at each stage can be resolved in either a positive (adaptive) or negative (mal-adaptive) way. For Erickson, the development of a psychologically healthy adult required the successful resolution of conflict at each developmental stage. He accounted for variation of emotional expression and behavior among individuals on their resolution of conflict along a continuum of healthy to unhealthy outcomes. The eight stages of psychosocial development coincide loosely with eight life stages. Five of these stages occur from infancy through adolescence.

Early infancy is the stage of 'trust versus mistrust' in which the infant learns to view the world as a place where one can trust others to be supportive and caring, or a place where the infant cannot consistently rely on the support and nurturing of others. Late infancy is the stage of 'autonomy versus shame and doubt'. In this stage autonomy is the ability to control one's own actions, such as successful toileting. An inability to learn such control may result in feelings of shame and doubt. Early childhood is the stage of 'initiative versus guilt'. The child is confronted with the conflict of relationships with parents and unresolved feelings of love and hate. Taking the initiative and engaging in positive social activities resolves conflict; failure to do so results in unresolved guilt. Middle childhood is the stage of 'industry versus inferiority'. During this stage, the child's cognitive knowledge, physical abilities, and social relationships are expanded. Upon comparison of self with others, the child ultimately measures how he or she compares to peers. If the child feels incompetent and inferior, as opposed to competent and adequate, his or her interactions with others will differ than if the child feels confident in how he or she compares with peers. During the storm and stress of adolescent years, the child is confronted with the universally known stage of Erickson's theory 'identity versus identity confusion'. It is during this period that the child resolves the conflict between "who I am and what I want to be" and struggles to decide the direction of his or her life. Resolution of the conflict associated with identity marks the end of childhood and the emergence of adult role-taking in society. The remaining three stages continue to deal in a similar vein with issues of role performance and development throughout adulthood.

In summary, normative development throughout childhood is generally viewed as an active and complex process. It involves the ongoing maturation of the child and how he or she engages people and events, attachment to significant adults, social relationships with peers, intellectual and emotional development, and the actual world in which he or she lives. Childhood is the culture in which individual development occurs. The quality and characteristics of their environment also directly influence the healthy development of children. Is it a setting where basic needs are a struggle to meet, where danger and fear of personal safety are daily concerns? Or is it a world that is predictable in its organization and resources? Is it a nurturing place with companionship or one of disregard and isolation?

When a natural or human-caused disaster invades the world of the child, the impact disrupts the normalcy of the environment and normative functioning. Fortunately, most children enjoy successful and normal childhoods surrounded by adults and peers who can help them adjust to the impact of the disaster. Traumatic events can be successfully assimilated into their worlds within the context of their own individual development. For those children who are experiencing childhood as a negative environment and are actively developing maladaptive survival strategies, recovery from traumatic events will be a complex and time-consuming process. This can result in sustained and significant alterations in how successfully children are functioning in their world. For example, children may experience a drop in academic performance at school and disruptions in their social interactions with friends, siblings, or parents. Children who are experiencing such significant disruptions in their routine social and cognitive functioning may be at risk for developing Post Traumatic Stress Disorder (PTSD) or another form of emotional disorder.

Most parents recognize when their children's behavior indicates emotional distress. During routine, non-crisis times parents are tuned-in to the nuances of their children's behavior. Most mothers can tell immediately if their young son or teenage daughter had a bad day at school or a fight with their best friend. A very common sign indicating distress is the sudden appearance of a very busy child, who just suddenly decides he or she will watch TV with his or her parents, and is not even particular about what they are watching. For most parents, this is when their antennae go up and somehow they know it is time to give that extra hug and just be available. Typically, a few words eventually pass between the parent and child. The parent smiles, the child looks relieved, and as quickly as the child appeared he or she vanishes back into his or her now somewhat reorganized and normal world. Under normal circumstances in the majority of nurturing families, they play this scene over and over and without really thinking anything of it. It is just a slice of daily life.

Disasters are not normal or routine and therefore, impose a significant abnormality on our daily routines. Everyone is affected. Typical modes of interacting with each other are strained. All of us are trying to get a grip on things and as a result focus less on supporting each other. It is within this context that children experience the aftermath of disasters.

The American Academy of Child and Adolescent Psychiatry (AACAP, 1998) suggests that a child's reaction to a disaster, such as a hurricane, flood, fire, or earthquake, depends upon how much destruction is experienced during or after the event. The death of family members or friends is the most traumatic, followed by loss of the family home, school, special pets, and the extent of damage to the community. The degree of impact on children is also influenced by the destruction they experience second hand through television and other sources of media reports.

Generally, most children recover from the frightening experiences associated with a disaster without professional intervention. Most simply need time to experience their world as a secure place again and their parents as nurturing caregivers who are also again in charge.

Studies of how children have reacted to catastrophic events are limited. However, in the available work done on this topic there emerges a consistent pattern of responses and factors that influence the difficulty children may have in returning to their pre-disaster state. Yule and Canterbury (1994) reviewed a number of studies concerning children exposed to traumatic events. The types of reactions experienced by many children reported include feeling irritable, alone, and having difficulty talking to their parents. Many experience guilt for not being injured or losing their homes. Adolescents are prone to bouts of depression and anxiety, while younger children demonstrate regressive behaviors associated with earlier developmental stages. Many children who have difficulty reconciling their feelings will engage in play involving disaster themes and repetitive drawings of disaster events. It has also been demonstrated that children as young as two or three can recall events associated with disasters. The child's level of cognitive development will influence their interpretation of the stressful events. Some studies reviewed by Yule and Canterbury suggest that the intellectual ability of the child, their sex, age, and family factors influence their recovery. Girls experience greater stress reactions than boys, bright children recover their pre-disaster functioning in school more rapidly, and families who have difficulty sharing their feelings experience greater distress. As expected, there also appears to be a direct relationship between the degree of exposure to frightening events and the difficulty in emotional adjustment and returning to pre-disaster functioning.

Other researchers have attempted to explain what factors influence children's reactions to traumatic or stressful events. In their review of the emotional effects of disaster, Lewis Aptekar and Judith Boore (1990) report that one's belief as to who or what caused the disaster and the degree of destruction are major factors influencing children's reactions. These authors have also identified five additional factors that influence recovery from the traumatic event:

child's developmental level

child's premorbid mental health

community's ability to offer support

parents' presence or absence during the event

significant adults' reaction

A more recent review by Vogel and Vernberg (1993) also suggests the influence of children's developmental level on their ability to comprehend traumatic events, their coping repertoire, and their involvement with other groups of people beyond the immediate family.

In a longitudinal study, Vernberg, LaGreca, Silverman, and Prinstein (1996) provided a thoughtful account of how elementary school children responded to the disastrous impact of Hurricane Andrew in Dade County, Florida. These researchers concluded that many symptoms experienced by these children could be understood using an integrated conceptual model first discussed by Green et al. (1991). Green et al. investigated four factors:

exposure to traumatic events during and after the disaster

pre-existing child characteristics

post-disaster recovery environment (social support)

coping skills of the child

The model suggested by Vernberg, et al. (1996) increased the number of factors from four to five:

exposure to traumatic events during and after the disaster

pre-existing demographic characteristics

occurrence of major life stressors

availability of social support

type of coping strategies used to manage disaster-related stress

The primary focus of this study was to ascertain what factors influence the lingering symptoms and subsequent identification of children experiencing PTSD. The authors conclude that symptoms associated with PTSD could represent normal adaptive reactions and that for many children the effects of a disaster may still be observed beyond one to two years after the event. In trying to determine what made the various symptoms persist in these elementary age children, the researchers found the daily hassles of routine life in the weeks and months following the incident interacted with the severity of the trauma experienced making it difficult to recover. The strains of ongoing life events (e.g., loss of employment by a parent, divorce, or other stressors) also impact the availability of a supportive environment. Other factors identified by the authors were the overall loss of essential support from the community and schools given the respective impact of the disaster on these social systems.

TYPICAL REACTIONS OF CHILDREN

Fears and anxieties

Fear is a normal reaction to disaster, frequently expressed through continuing anxieties about recurrence of the disaster, injury, death, separation, and loss. Because children's fears and anxieties after a disaster often seem strange and unconnected to anything specific in their lives, the child's relationship to the disaster may be difficult to determine. In dealing with children's fears and anxieties, accepting them as very real to the children is generally best. For example, children's fears of returning to the room or school they were in when the disaster struck should be accepted at face value, and interventions should begin with talking about those experiences and reactions.

Before the family can help, however, they must understand the children's needs; this also requires an understanding of the needs of the family. As discussed throughout this manual, families have their own unique pre-disaster profile of beliefs, values, fears, and anxieties. Frequently, dysfunction in the family is mirrored in the child's malfunctioning. The disaster mental health worker may need to talk with the family as a whole to better understand the role the whole family can play in responding to its own set of fears and anxieties that may exacerbate the fears expressed by the children. Sometimes, the pre-disaster level of dysfunction in the family may be so severe that referral for more formal mental health services may be necessary.

A parent's or adult's reaction to children makes a great difference in the children's recovery. The intensity and duration of children's symptoms decrease more rapidly when families can show that they understand their feelings. When children believe their parents do not understand their fears, they feel ashamed, rejected, and unloved. Tolerance of temporary regressive behavior allows children to redevelop those coping patterns that had been functioning before the disaster. Praise offered for positive behavior produces positive change. Routine rules need to be relaxed to allow time for regressive behaviors to run their course and the reintegration process to take place.

When children show excessive clinging and unwillingness to let their parents out of their sight, they are expressing their fears and anxieties of separation or loss. They have experienced the harmful effects of being separated from their parents and in their clinging are trying to prevent a possible recurrence. Generally, the children's fears dissolve when the threat of danger has dissipated and they feel secure again under the parent's protection.

Children are typically most fearful when they do not understand what is happening around them. Every effort should be made to keep them accurately informed, thereby alleviating their anxieties. Adults frequently fail to realize the capacity of children to absorb factual information and do not share what they know. Consequently, children receive only partial or erroneous information.

Most important to resolving disaster related fears and anxieties in children is the quality of safety and security present in the family. The family should make every effort to remain together as much as possible, for a disaster is a time when the children need their caregivers around them. In addition, the model adults present at this time can be growth enhancing. For example, when parents act with strength and calmness, while maintaining control and sharing feelings of being afraid, they serve the purpose of letting the children see that acting courageously even in times of stress and fear is possible.

Sleep Disturbances

Sleep disturbances are among the most common problems for children after a disaster. Behaviors associated with sleep disturbances are likely to take the form of resistance to bedtime, wakefulness, unwillingness to sleep in their own rooms or beds, and refusal to sleep by themselves. Children will also express a desire to be in a parent's bed or to sleep with a light on, insist that the parent stay in the room until they fall asleep, or may begin to rise at excessively early hours. Such behaviors are disruptive to a child's well-being. They also increase stress for parents, who may themselves be experiencing some adult counterpart of their child's disturbed sleep behavior. More persistent bedtime problems such as sleep terrors, nightmares, continued wakening at night, and refusal to fall asleep may point to deep-seated fears and anxieties that may require professional intervention.

In working with families, exploring the family's sleep arrangements may be helpful. Long-term adjustments in sleeping arrangements, such as allowing children to sleep routinely in the parent's bed, will inhibit the child's recovery process. However, temporary changes following a disaster may be in order. For very young children, it may be especially reassuring to have close contact with their parents during those times when disaster fears are most prominent. After a brief period of temporary changes, the parents should move toward the reinstatement of pre-disaster bedtime routines. Thus, the family may need to develop either new or familiar bedtime routines, such as reinstating a specific time for going to bed. The family may find it helpful to plan calming, pre-bedtime activities to reduce chaos in the evening. Teenagers may need special consideration for bedtime privacy. Developing a quiet recreation in which the whole family participates is also helpful.

Besides the above descriptions of fears, anxieties, and sleep disturbances, children's reactions to a disaster can be expressed in many different forms. Below are some more common reactions. (For convenience, the reactions are presented for three age groups: preschool or early childhood, latency age, and pre-adolescence and adolescence.)

Preschool, Five Years Old and Younger

Most of the symptoms appearing in this young age group are nonverbal fears and anxieties expressed as the result of the disruption of the child's secure world. These symptoms include:

crying in various forms, with whimpering, screaming, and explicit cries for help

becoming immobile, with trembling and frightened expressions

running either toward the adult or in aimless motion

excessive clinging

Regressive behavior, that is, behavior considered acceptable at an earlier age and that the parent had regarded as past may reappear. This includes the following:

thumb sucking

bed-wetting

loss of bowel/bladder control

fear of darkness or animals

fear of being left alone or of crowds or strangers

inability to dress or eat without assistance

Symptoms indicative of fears and anxieties include:

sleep terrors (i.e., child abruptly sits up in bed screaming or crying with a frightened expression and autonomic signs of intense anxiety. The child is unresponsive to the efforts of others to awaken or comfort him/her. If awakened, the child is confused and disoriented for several minutes and recounts a vague sense of terror usually without dream content.)

nightmares (i.e., frightening or anxiety producing dreams)

inability to sleep without a light on or someone else present

inability to sleep through the night

marked sensitivity to loud noises

weather fears - lightning, rain, high winds

irritability

confusion

sadness, especially over loss of persons or prized possessions

speech difficulties

eating problems

The symptoms listed above may appear immediately after the disaster or after the passage of days or weeks. Most often they are transient and soon disappear. Parents can help diminish the above symptoms in their children through understanding the basis for the behaviors and giving extra attention and caring. If the symptoms persist for longer than a month, parents should recognize that a more serious emotional problem has developed and seek professional mental health counseling.

Latency Age, Six Years Old Through 11 Years Old

Fears and anxieties continue to predominate in the reactions of children in this age group.

However, the fears demonstrate an increasing awareness of real danger to self and to the children's significant persons, such as family and loved ones. The reactions also begin to include the fear of damage to their environment. Imaginary fears that seem unrelated to the disaster also may appear.

Regressive behaviors may appear in this age group similar to those in the preschool group. Problem behaviors include the following:

bed-wetting

sleep terrors

nightmares

sleep problems (e.g., interrupted sleep, need for night light, or falling asleep)

weather fears

irrational fears (e.g., safety of buildings, or fear of lights in the sky)

Additional behavior and emotional problems include:

irritability

disobedience

depression

excessive clinging

headaches

nausea

visual or hearing problems

The loss of prized possessions, especially pets, is very difficult for children in this age group. As noted in the previous section, the school environment and relationships with peers is central to the life of latency age children. School problems begin to appear and may take the form of:

refusal to go to school

behavior problems in school

poor school performance

fighting

withdrawal of interest

inability to concentrate

distractability

peer problems (e.g., withdrawal from play groups, friends, and previous activities or aggressive behaviors and frequent fighting with friends or siblings)

Preadolescence and Adolescence, 12 Years Old Through 17 Years Old

Adolescents have great need to appear competent to the world around them, especially to their family and friends. Individuals in this age group are struggling to achieve independence from the family and are torn between the desire for increasing responsibility and the ambivalent wish to maintain the more dependent role of childhood. Frequently, struggles occur with the family, because the peer group seems to have become more important than the parental world to the adolescent child. In the normal course of events, this struggle between adolescents and family plays itself out and depending on the basic relationships between the child and his or her parents, they resolve the trials and problems.

The effects of a major disaster on adolescents will vary depending on the extent to which it disrupts the functioning of the family and the community. The impact of the disaster may stimulate fears related to loss of family, peer relationships, school life, and even concern over the intactness of their own bodies. Adolescents struggling to achieve their own identity and independence from the family may be set back in this personal quest with reactivated fears and anxieties from earlier stages of development. The trouble signs to watch for in pre-adolescents and adolescents include:

withdrawal and isolation

physical complaints (e.g., headaches or stomach pain)

depression and sadness

antisocial behavior (e.g., stealing, aggressive behavior, or acting out)

school problems (e.g., disruptive behavior or avoidance)

decline in academic performance

sleep disturbances (e.g., withdrawal into heavy sleep, sleep terrors, or sleeplessness)

confusion

risk taking behavior

alcohol and other drug use

avoidance of developmentally appropriate separations (e.g., going to camp or college)

Most of the above behaviors are transitory and disappear within a short period. When these behaviors persist, they are readily apparent to the family and to teachers who should respond quickly. Teenagers, who appear to be withdrawn and isolate themselves from family and friends, are experiencing emotional difficulties. They may be concealing fears they are afraid to express. Just as many adults do, adolescents often show their emotional distress through physical complaints.

HELPING THE CHILD AND FAMILY

This section of the manual focuses on helping children and their families deal with the emotional aftermath of a disaster. Major disaster events irrespective of their origin impact all persons who experience the event. Evidence from numerous disasters clearly demonstrates that persons who are impacted by the event either directly or indirectly will experience a range of feelings and emotions regarding the effect of the disaster and its consequences.

While everyone interprets life events within the context of their experiences, children interpret their personal experiences within the limited context of their current stage of psychological development. As mentioned in the previous sections, the world of the child is defined by his or her stage of intellectual and emotional development, experiences with siblings and parents and extended family including grandparents, uncles, aunts, and cousins, the child's history and culture, and his or her school, peers, neighborhood, and community within which he or she lives. It is within the structure of these relationships that a child must cope with the impact of the disaster event.

Understanding the definition(s) of family for a child is essential to understanding the complexity of their emotional reaction to the disaster. Family in its most common definition is a group of persons consisting of parents and their children. However, in its broadest interpretation it can be defined as any class or group of related things. Thus given the appropriate context, a child's family can be as broad as their neighborhood, community, or school, or as narrow as their relationship to their parents. Considering the various definitions of family when trying to assess the depth of impact of a disaster on children is important and necessary to determine appropriate crisis counseling and disaster mental health recovery strategies.

Below are examples of some potential relationships that comprise the notion of family for children:

children to natural parent, direct caregiver, or guardian

children to brothers and sisters, living in the same and other households

children to grandparents (maternal and fraternal)

children to uncle, aunts, and cousins, within and distant from the impact area

children to significant non-related adults

children to the world of their school (teachers, staff, and students)

children to school friends and neighborhood friends - from their inner circle of very close confidants to casual acquaintances

children to community of worship (church, synagogue)

children to persons in the communities of reference, (e.g., local neighborhood, village, town, city, county)


GENERAL STEPS IN THE HELPING PROCESS

A basic principle of working with children in disasters is that they are essentially normal children who have experienced great stress. Most of the problems that appear are likely therefore to be directly related to the disaster and transitory in nature.

The process recommended for helping children and families often starts with "crisis intervention," which trained and supervised paraprofessionals and volunteers can provide. The primary goal in crisis intervention is to identify, respond to, and relieve the stresses resulting from the crisis (disaster) and to reestablish normal functioning as quickly as possible. Sometimes the reaction is mild, but other times it is severe. Also, the workers must be trained to recognize when the condition is mild and can be handled by the families (with guidance), when referral to a helper, such as a school counselor is warranted, and when it is severe and requires intervention by a mental health professional.

The general steps in the helping process are:

  1. ESTABLISHING RAPPORT
    • Let the children know you are interested in them and want to help.
    • Check with the children to make sure that they understand what you are saying and that you understand them.
    • Display genuine respect and regard for the children and their families.
    • Communicate trust and promise only what you can do.
    • Convey acceptance of the children and their families.
    • Communicate to the children and their families that you are an informed authority.
  2. IDENTIFYING, DEFINING, AND FOCUSING ON THE PROBLEM
    • Identify and prioritize specific problems with the children, parents, and family.
    • Select a specific problem, define its characteristics, and focus on solving it first.
    • Achieve a quick resolution to the problem so that the members of the family experience a sense of success and control.
    • Evaluate the seriousness of each of the identified problems and the capacity of the family to deal with them.
  3. UNDERSTANDING FEELINGS
    • Demonstrate your ability to see and feel as others do.
    • Display patience in trying to understand children's feelings, for children are frequently unable to express their fears.
    • Respond to the children's stories frequently by commenting on the events and affirming their feelings.
    • Express a nurturing positive regard for the children, to convey an appreciation for the kind and intensity of their feelings.
  4. LISTENING CAREFULLY
    • Understand the disaster concerns from the point of view of the children.
    • Listen to the children's account of the disaster many times, in order to help children "work through" their feelings associated with the disaster.
    • Refrain from interrupting the children as they tell their stories.
    • Affirm children's feelings by giving them time to express themselves.
  5. COMMUNICATING CLEARLY
    • Communicate in a language children understand.
    • Talk with children in groups or with siblings or other family members.
    • Seek the presence of family members to interpret code words used by the children.
    • Communicate with children in their dominant language.


THE ROLE OF THE FAMILY

As discussed earlier, many factors can influence the child's psychological definition of family. However, for purposes of the current discussion, the child's family is defined in terms of significant persons providing caregiving and support, who are also members of the child's nuclear and extended family structure. Since children live in family systems, both the experience of the disaster and recovery from its aftermath are most often mutually experienced. Consequently, children will share common aspects of the disaster event experience. The retelling of these experiences between the adults and children in the family can normalize the overwhelming rush of feelings associated with the disaster. For many families, the role of the outreach worker is simply to give them permission to share their feelings with each other and to communicate that having disaster related feelings is normal and sharing these feelings with each other is appropriate and healthy.

A function of the crisis counseling program is to convey information to parents about the common reactions of families to trauma and loss following a disaster. Often parents deny the need for this type of information for themselves, but will gladly participate in programs or gatherings where this type of information is provided for helping support their children. Typically parents will recognize stress reactions and accompanying behavioral changes in their children, before they recognize them in themselves. The disaster mental health worker helps all members of the family unit by sensitizing parents to the signs of stress in their children and suggesting strategies for helping their children.

Outreach workers can remind parents of these simple facts:

Parents should acknowledge the parts of the disaster that were frightening to them and other adults.

Parents should not falsely minimize the danger as it will not end a child's concerns.

The child's age affects how he or she will respond to the disaster. (A six-year-old may express his or her concerns by refusing to attend school, while an adolescent may express his or her concerns by arguing more with parents.)

The way the child sees and understands his or her parent's response is very important.

Parents should admit their concerns and also stress their abilities to cope with the situation.

Often the role of the family is simply to learn to work together to solve problems and actively recognize the needs and feelings of both the children and the adults. The identification of concrete issues that are problematic for the family unit, as well as for individuals within the family, is often the first step in the emotional recovery of the family. This is followed by crafting solutions to problems, resolving problems by implementing solutions, and celebrating the successes of positively resolving problems. Through this process, family members begin to reestablish mastery over their environment and bring back into equilibrium the role of each of the family members. By routinely repeating this process throughout the various stages of recovery, the family members will become closer as a unit and individually more autonomous, thus helping all members of the family reestablish their identity and proceed with their normal developmental roles.

In working with families of diverse backgrounds, outreach workers must be sensitive to language differences and cultural needs. Children are often thrust into the role of interpreter if their parents and relatives are not fluent in English. This responsibility may require skills beyond the child's current stage of development and be too stressful for the child. The outreach worker can relieve the child of this responsibility by seeking out adult interpreters for the family.


COMMON FEELINGS AND BEHAVIORS

Children and adults express signs and symptoms to stressful events along four dimensions: cognitive, emotional, physical, and behavioral. Common reactions expressed by children along each of these dimensions include the following:

COGNITIVE

  • trouble concentrating
  • preoccupation with the event
  • recurring dreams or nightmares
  • questioning spiritual beliefs
  • inability to process the significance of the event

EMOTIONAL

  • depression or sadness
  • irritability, anger, resentfulness
  • despair, hopelessness, feelings of guilt
  • phobias, health concerns
  • anxiety or fearfulness

BEHAVIORAL

  • isolation from others
  • increased conflicts with family
  • sleep problems
  • avoiding reminders
  • crying easily
  • change in appetite
  • social withdrawal
  • talking repeatedly about the event
  • refusal to go to school
  • arguments with family and friends
  • repetitive play

PHYSICAL

  • exacerbation of medical problems
  • headaches
  • fatigue
  • physical complaints with no physical cause


CASE EXAMPLES

Below are examples of the situations that confront children in the aftermath of a disaster event. These examples are from ice storms in Maine, tornadoes in Texas and Arkansas, and floods in Louisiana and Texas.

  1. Separation Anxiety
    Katy, an eight-year-old girl, and her father were returning home from the video store one Saturday afternoon when a tornado struck. Katy and her father hunched down in the car, when suddenly the windows blew out and a tree fell across the hood. They crawled out of their demolished car shaken but miraculously unhurt. Katy's mom and two older brothers, who were in the home when the tornado struck, survived with only bumps, bruises, and one broken arm, but their two-story home was a pile of rubble.

The next few weeks after the tornado were difficult for Katy. She did not want to go to school and had difficulty sleeping at night. She had dreams about the tornado and feared leaving her mom, dad, and brothers. The teachers at school were supportive and understanding of Katy's needs. The first few weeks after the tornado Katy felt anxious and worried about her parents. School personnel allowed Katy to call and "check-in" with her parents at recess so she was assured that they were okay. Katy's family also held a family meeting and discussed what they should do to be safe at home, school, or work in the event of another disaster. After a few weeks, Katy could sleep in her own room again and go to school without much anxiety.

  1. Acting Out
    Tommy, an eleven-year-old fifth grader, had been receiving mental health treatment for disruptive behavior and defiance in the classroom prior to the tornado. He was responding well to treatment and receiving positive reports from his teacher. Tommy, who had never experienced any kind of disaster, was at a friend's house when the tornado struck and several trees came smashing through the windows. Tommy was not hurt physically by the tornado, but both his teachers and parents reported an increase in his disruptive and defiant behavior even though he continued in treatment. Upon review of Tommy's situation with the school and an interview with his parents, it became clear that no one had offered Tommy any opportunity to deal with his disaster related experience and with the subsequent stress he was trying to manage due to fears associated with the occurrence of another tornado. A series of visits by the disaster outreach workers to Tommy's home and school helped Tommy normalize his experience and feel more open about discussing his fears. Both his parents and teacher reported a lessening of Tommy's disruptive and defiant behavior.
  2. Anxiety
    Jill, a six-year-old, was at home with her mother and father on the afternoon when the tornado struck. The family escaped with no injuries. Jill started having problems within the next few days, scared that another tornado would strike. Jill would frequently question her parents about the weather and often became tearful.

Jill's mother called the 1-800 tornado coping line and asked for advice. The crisis counselor suggested that Jill's parents explain tornadoes to her, discuss the warning signs for a tornado in their community, and develop and practice its own family safety plan. The crisis counselor sent the family some informational materials about tornadoes. The crisis counselor called Jill's parents several days later to see how they were doing. Jill's parents reported that her fears had lessened by learning about tornadoes and knowing how to protect herself.

  1. Disruptive Behavior at School
    Following a major ice storm, Jason, age eight, was displaced from his home to a Red Cross shelter for eleven days waiting for power to be restored to his home. Greg, age eleven, was displaced from his family for thirteen days and spent this time with relatives in a very crowded house. Both children exhibited disruptive behaviors upon returning to school. Jason was constantly talking and appeared very anxious. Greg was inattentive in class and presented an angry and defiant manner. The outreach crisis counselor spoke with the teacher and offered to come to the weekly health class to talk about the ice storm and to tie the conversation with the classroom material about the five senses. The crisis worker first encouraged the children to share their personal experiences with the storm (i.e., What did you see? What did you smell? What did you hear? What did you feel?). This was a creative way of discussing the effects of the storm, providing assurance and information, and for the students to hear from their peers that they shared many of the same feelings. Within a few days both Jason and Greg settled back into their daily routines.
  2. Adolescent Aggression
    Patrick, a sixteen-year-old, became verbally aggressive and threatened other youths after only one night in a large urban shelter following a major flood. Patrick had a history of petty crimes, homelessness, and drug use, and was well known to the local police. Given Patrick's history and current behavior, the shelter manager and local police seriously considered removing him to a juvenile detention center. His mother met with the crisis counselor, the shelter manager, and a law enforcement official to work out an alternative plan. They asked Patrick to assist the National Guard in their duties distributing water and other food supplies. He readily agreed, helped the community, and with this more structured level of adult guidance was able to maintain good behavioral control and remain at the shelter.
  3. Reactions Three to Six Months Post-Disaster
    Several months following the floods, many children remained in temporary living situations. Roger, an eight-year-old third grader, continued to struggle with school work, became increasingly withdrawn from friends, and non-responsive at school. As the school year was nearing the end, his teacher became concerned he would not advance to the fourth grade. Consultation with the school guidance counselor and the crisis counseling outreach workers revealed that many children displaced from the same trailer park as Roger were still feeling anxious and tense and doing poorly in school. In some cases, the pressures of the long disruption had affected the relationships of the parents, and separations and divorces were occurring within the families of his peers.

The crisis counselors became more involved with Roger's class, assisting with field trips and performing skits about floods and the lengthy time it takes to return families to pre-disaster status. The counselors also began encouraging the families in the trailer park to get together with their neighborhood friends over potluck suppers to talk about common issues and plans to get things "back to normal." The school helped Roger's parents find a retired teacher to tutor Roger with his school work, so that he would be ready to advance to the fourth grade.

  1. Anniversary Reactions of Children and Families
    A crisis counseling team assisting the community to recover worked with schools and the local unmet needs committee to arrange a number of commemorative events to assist survivors during the anniversary of the disastrous floods. Some families were still waiting for financial assistance, while others were rebuilding their homes. Since many families had returned to their daily routines, there was some degree of community impatience with those still struggling with the impact of the flood. During the commemorative week of the anniversary, many children expressed lingering fears and a remaining sense of loss. The anniversary events focused on individual and community healing, celebrating their survival, and the accomplishments of the last year. At several schools, outreach workers visited the younger children and distributed coloring books depicting the recovery and return to daily routines experienced by Andy and Allie, two young alligator characters who had lived through the storms. Through human interest stories revealing the ongoing needs of survivors, additional resources were donated to assist in their recovery.
  • GUIDELINES FOR CAREGIVERS,
    MENTAL HEALTH AND HUMAN
    SERVICE WORKERS
  • Disaster work almost always requires training, supervision, and consultation of human service workers, many of whom have little or no training in disaster issues. This section is directed to the various roles professionals, parents and caretakers of children may be called upon to serve during and following a disaster event. Side by side, professionals and paraprofessionals alike can work together to utilize basic skills in responding to the special needs of children who have experienced a disaster.

  • PROVIDING DISASTER
    MENTAL HEALTH SERVICES
  •  
  • The hallmark of a disaster mental health operation is to assist persons in dealing with their emotional response and recovery following the trauma of a major disaster event. The intended outcome is to return persons affected by the disaster to their pre-disaster level of coping. Since most disaster survivors do not perceive themselves as ill or in need of mental health services, crisis counseling programs emphasize outreach to communities, neighborhoods, churches, schools, and existing social networks to help persons who typically would not seek assistance from mental health service agencies. Hundreds of crisis counseling programs across the nation have repeatedly demonstrated that paraprofessionals indigenous to the affected community perform most effectively in the role of providing basic crisis counseling services. In these programs, it has been demonstrated that special services and programs for children have been developed within schools, extended school programs, communities, youth organizations, and summer recreational programs.
  • Children may have an extensive support system, but usually do not have the life experiences or coping skills that would assist them in responding to the dramatic changes in their lives caused by disaster. Knowing what kind of assistance is available in the community, through government, religious and private agencies, is critical in responding to the needs of children and families in disasters. Most services will be found in local government and private agencies. Professionals, paraprofessionals and caretakers such as teachers need to learn as much as practicable about the community resources specifically offering services to children. Examples are family services agenices, child guidance agencies, child care centers and after school programs.
  • However, due to the unpredictable nature of outreach work and the potential for engaging persons who may significantly benefit from professionally delivered mental health services, it is crucial that outreach workers are provided with sufficient levels of supervision from trained mental health professionals.

  • SUPERVISION OF HUMAN
    SERVICE WORKERS
  •  
  • The FEMA/CMHS Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) that follows a Presidentially declared disaster employs intervention models that mobilize a broad spectrum of persons with a great diversity of experience and training. Crisis Counseling Programs emphasize outreach to communities, neighborhoods, schools, and other networks to help persons who typically would not seek assistance from mental health service agencies. Hundreds of Crisis Counseling Programs across the nation have repeatedly demonstrated that paraprofessionals indigenous to the affected community perform most effectively in the role of outreach workers. Outreach workers must have certain communication skills and other attributes necessary for successfully conducting their roles, which are discussed in other CMHS publications. However, due to the unpredictable nature of outreach work and the potential for engaging persons who may significantly benefit from professional mental health services, it is crucial that outreach workers are provided with sufficient levels of supervision from trained mental health professionals. Below are examples of the broad range of supervisory roles mental health professionals provide:
  • Supervision Through Didactic Training - Increasing the knowledge base of workers through brief in-service sessions explaining the basics of human behavior and development, assessing survivor needs, and providing tips on engagement.

    Group Supervision - Team building through weekly review of current events and activities of the outreach workers. This includes discussing recent interactions with disaster survivors, problem-solving unique situations, and stimulating innovative thinking among outreach team members. Individual Supervision - Supporting each individual team member with strategies for managing administrative workload, emotional/professional commitment, personalization of outreach experiences, development of dependency relationships, and issues of transference and counter transference.

  • PROVIDING MENTAL HEALTH TRAINING
  •  
  • Crisis Counseling Programs often engage mental health professionals to provide specific information about working with special populations. After a disaster, persons in a community who would have little reason to meet each other now find they share a bond through the common challenge of post-disaster recovery. Outreach workers, volunteers, unmet needs committee members, emergency operations personnel, clergy, housing specialists, and others may be confronted with situations and persons with special needs with whom they have little or no experience. Children with serious emotional or behavioral disorders and their families are an example of a special population that disaster recovery personnel may encounter in shelters, disaster recovery centers, and other sites. Brief training sessions for operations staff by mental health professionals can alleviate much apprehension of personnel and equip them with information and strategies that will result in successful outcomes for all involved parties. Mental health professionals may be called upon to provide ongoing training on specific topics to crisis counseling staff. Examples include the following: specialized information topics about case finding techniques of in-home intervention, working with children with developmental disabilities, issues related to family interventions, child abuse, and recognizing maladaptive patterns of alcohol and drug use.
  • SYSTEMS CONSULTATION
  • Mental health professionals also play a significant role as consultants to Crisis Counseling Programs. A common role of consultants is to provide orientation and ongoing project development training to the crisis counseling staff. In the context of children and their recovery, the main purpose of the consultant is to sensitize project staff to the mental health needs of children and families in their recovery from the disaster and to assist project staff to integrate their services through interagency collaboration with other child-serving agencies. Many communities throughout the country have developed Child and Adolescent Services System Programs (CASSP). These children oriented systems of care are designed for at-risk children with serious emotional disorders. In a time of a disaster, these agencies may represent significant resources to crisis counseling recovery programs. Often the child mental health professionals in a community play an important role in this network. They can provide consultation on how interagency collaboration is done in a specific community, as well as which combined community and agency resources may be available to disaster survivors. Consultants can also assist staff with issues of organizational boundaries, working with school administrators, referral criteria for various community services, and role clarification.
  • ASSISTING CRISIS COUNSELING STAFF
    TO MANAGE STRESS
  •  
  • Responding to the needs of children and families who are coping with the aftermath of a major disaster is physically demanding and emotionally charged work. This is true even for the seasoned mental health professional who is accustomed to the fast paced, often chaotic environment of mental health crisis intervention work. A distinguishing characteristic of disaster mental health work is that often the worker identifies on a personal level with survivors and cannot find a quick method for establishing psychological distance with the persons seeking assistance. Additionally, the disaster mental health worker may also be a survivor of the disaster and must deal with issues concerning his or her own recovery and that of family members.
  • Acknowledging the high stress load of this work and implementing an array of stress reducing strategies is an important role for mental health professionals. Examples of typical stress management activities linked to Crisis Counseling Programs are: routine defusing and debriefing sessions during all phases of recovery operations, identifying a stress management counselor outside the project's administrative chain of command, offering ongoing stress management training sessions, providing auto-relaxation techniques, and assisting staff to recognize the signs and symptoms of burnout in survivors and staff.
  • Burnout is the normal result of increased demands and overwork after a disaster and may appear as persistent physical and emotional exhaustion, unrelieved feelings of fatigue, marked irritability, and a decrease in the individual's desire and ability to work effectively. With respect to staff working with children and families, burnout is often the result of overwork and over commitment. Burnout among project staff may be very harmful not only to the worker, but also to the disaster survivors who are seeking assistance. Project staff may become irritable with survivors and make promises they cannot possibly keep. CMHS strongly recommends that staff responsible for implementing disaster mental health services seek consultation on the development of a comprehensive stress management program as an integral part of their disaster recovery operations.
  • CONCLUSION
  •  
  • Most parents are capable of assisting their children in overcoming fears and anxiety related to a disaster event. However, when the situation seems beyond their reach, assistance can easily be provided through pediatricians, family physicians, or mental health and school counselors. Understanding and helpful intervention can reduce a child's fears and prevent more serious problems from developing. The manner in which adults, caregivers and mental health professionals help children to resolve their emotional turmoil at uncertain times may have a lasting effect on the child. Knowing the type of assistance that is available in a community is necessary in responding to the needs of children after a disaster.

Introduction to Crisis Counseling Programs and Services to Persons With Serious and Persistent Mental Illness

Tony Speier, Ph.D.

This document provides a brief guide for State and local mental health agency administrators and five detailed chapters for program planners and providers of direct services. The intent is not to suggest that persons with serious and persistent mental illness require separate disaster recovery programs, but that within the scope of such programs people with mental illness may require specialized strategies for accessing the services they need on the journey to recovery. Our goals are:

  • to educate State and local mental health administrators, planners, and providers about the needs of individuals with serious and persistent mental illness who experience a disaster;
  • to present practical suggestions for disaster preparedness, for structuring disaster response and programs that mobilize the strengths of survivors; and
  • to summarize some of the broader issues regarding disaster mental health service delivery to people with mental illness.

Chapter Summaries

These summaries offer a quick reference to the information in the full document.

Chapter 2:
State Mental Health Authority (SMHA)

This chapter gives State mental health program directors an overview of the role of the public mental health system in disaster response operations, with special emphasis on preplanning activities essential to mobilizing agency resources.

State and local mental health program agencies typically function along parallel lines of authority and responsibility. Emergency situations require rapid and integrated agency responses.

SMHAs must plan and organize their disaster response operations before the disaster. Administrative policy development occurring concurrently with direct service responses are ill-advised and often confuse--rather than simplify--the response effort.

Disaster response planning requires the SMHA to understand the structure of State government, the mission and function of social and human agencies, and the responsibilities of local governments.

State emergency operations plans and the mental health response should be organizationally integrated, and direct responses must be well coordinated. The SMHA must assist responders and survivors during all phases of the disaster event and its aftermath.

The rapidly evolving nature of disaster events require a flexible mental health response. Quick implementation of preplanned administrative procedures assures availability of crisis counselors and crisis counseling services.

Chapter 3:
Local Mental Health Authorities

Local mental health authorities, whose missions include providing services and resources to people with serious and persistent mental illnesses and providing mental health assistance to survivors and disaster, will find this chapter useful in assuring that the special needs of those with mental illness are met after a major disaster.

People with mental illness have the same basic needs as the general population following a major disaster--safety, shelter, food, social support--but they may have other special needs.

Programs designed to meet these special needs should not be anymore stigmatized than programs for other special populations, such as children, the frail elderly, or people with special language or cultural needs.

People with mental illness have the same capacity to "rise to the occasion" and perform heroically in the aftermath of a disaster as the general population. Many demonstrate an increased ability to handle this stress without decompensation from their primary illness.

Though the local mental health authority is responsible for reestablishing general mental health services to this population, it is also important to provide special disaster services and interventions for those with special needs, either through crisis counseling services for the general population or those specifically provided at mental health service sites.

Disaster mental health training should be provided to therapists, case managers, and care coordinators as well as to consumers, families, board-and-care home operators, single-room-occupancy hotel managers and consumers who operate satellite housing programs. Preparedness training should be provided to consumers.

Recognition should be given to staff members who continue to provide routine clinical services to people with mental illness as well as to those staff who provide disaster response services.

Chapter 4:
Community Mental Health Centers

This chapter will help CMHC managers, program directors, clinical staff, and consumers prepare for, and recover from, a disaster experience.

Making disaster planning as a part of an ongoing psychiatric rehabilitation program is a way to educate staff and consumers about preparedness, response, and recovery. Consumers can develop the curriculum and train their peers.

Staff must address disaster-related needs of consumers, provide opportunities for group work to share experiences and resolve the painful aspects of the experience, and provide opportunities for consumers to serve the larger community in its recovery.

Chapter 5:
Crisis Counseling Program

This chapter is written for those who design, administer, or work in crisis counseling programs. It describes the crisis counseling programs funded by FEMA and monitored by CMHS. It also addresses how these programs may, within the scope of their intent, respond to the needs of this population.

Establish predisaster plans, agreements, and relationships among State Mental Health Authority, local mental health provider agencies, State emergency management agencies, and FEMA will help ensure rapid, effective disaster mental health response and timely implementation of the Crisis Counseling Program.

CMHS staff may be contacted for help with developing the Crisis Counseling Program and negotiating the bureaucratic maze of State and Federal agencies. States that have recently implemented successful Crisis Counseling Program also can be consulted.

The disaster mental health needs of people with mental illness will be similar to those of the general population; it must be assumed that these needs cannot be met by traditional mental health and psychiatric programs.

The service concepts of "the three A's"--availability, accessibility, and acceptability--should be incorporated into all crisis counseling services. Adjustments may need to be made for survivors with mental illness.

The Crisis Counseling Program function should be broadly applied. It must provide direct services for survivors; training and consultation for disaster workers, CMHC staff, and other providers of services; and crisis counseling and support with CMHC and other staff who are also disaster survivors.

Chapter 6:

Psychosocial Rehabilitation Programs and Consumer Empowerment

This chapter is for providers of mental health services, consumers of those services, and their family members. It outlines the experiences of members of Fellowship House, a clubhouse program that experienced Hurricane Andrew.

Developing and maintaining a community support network is vital to the ability to access needed resources during a disaster. Using social group work as a methodology prepares consumers and staff for the teamwork needed to weather an emergency. The sense of community and ownership of the clubhouse by consumers and staff plays a major role in recovery from a disaster.

Involving consumers in preparing for and recovering from a disaster provides needed human resources and makes good rehabilitative sense. Principles of psychiatric rehabilitation are as effective in a disaster as in normal times.

Crises have a profound ImpaCt on people wIth serIous mental health or emotIonal problems. Adults, children and older adults with a serious mental illness or emotional disorder often lead lives characterized by recurrent, significant crises.These crises are not the inevitable consequences of mental disability, but rather represent the combined impact of a host of additional factors, including lack of access to essential services and supports, poverty, unstable housing, coexisting substance use, other health problems, discrimination and victimization.


Homelessness, police contact, institutionalization and other adverse events are in themselves crises, and may also contribute to further crises.The statistics below paint a sobering picture of how crises affect the lives of people who have mental or emotional disabilities:

  1. From one third to one half of homeless people have a severe psychiatric disorder.1
  2. Approximately 7 percent of all police contacts in urban settings involve a person believed to have a mental illness.2
  3. The likelihood of mental illness among people confined in state prisons and local jails is three to four times higher than in the general population3 and, compared with other inmates, it is at least twice as likely that these individuals will be injured during their incarceration.4
  4. About 6 percent of all hospital emergency department visits reflect mental health emergencies.5
  5. Due to a lack of available alternatives, 79 percent of hospital emergency departments report having to “board” psychiatric patients who are in crisis and in need of inpatient care, sometimes for eight hours or longer.6
  6. Almost one in 10 individuals discharged from a state psychiatric hospital will be readmitted within 30 days; more than one in five will be readmitted within 180 days.7
  7. About 90 percent of adult inpatients in state psychiatric hospitals report histories of trauma. 8
  8. About three quarters of youth in the juvenile justice system report mental health problems and one in five has a serious mental disorder.9
  9. Mothers with serious mental illnesses are more than four times as likely as other mothers to lose custody of their children.10
  10. People with serious mental illnesses die, on average, 25 years earlier than the general population.11

These statistics are incomplete; they reflect just a sampling of scenarios that, while commonplace, constitute significant life crises for individuals with serious mental illnesses.


1 Practice Guidelines: Core Elements for Responding to Mental Health Crises


Many such individuals experience a cascade of crisis events that place them in more than one of these statistical groups. For instance, readmission to a psychiatric institution—a high probability for adults who have been discharged from a state psychiatric hospital, based on these data—may feature a series of crisis events for the individual: the psychiatric emergency itself; forcible removal from one’s home; being taken into police custody, handcuffed and transported in the back of a police car; evaluation in the emergency department of a general hospital; transfer to a psychiatric hospital; a civil commitment hearing; and so on.And at multiple points in this series of interventions, there is a likelihood that physical restraints, seclusion, involuntary medication or other coercion may be used. Intense feelings of disempowerment are definitional of mental health crises, yet as the individual becomes the subject of a “disposition” at each juncture, that person may experience a diminishing sense of control.


In the wake of rare but highly publicized tragedies attributed to people with mental illnesses, there is often a temporary surge in political concern about mental healthcare and expanding crisis interventions. Sadly, the more commonplace crises endured every day by many thousands of adults, older adults and children with serious mental or emotional problems tend to generate neither media attention nor political concern.


While no one with a mental or emotional disorder is immune from crises, people with what are termed serious mental illnesses—defined as schizophrenia, bipolar disorder and major depression—may be most reliant on public systems. They also may be at great risk of recurrent crises and interventions that exacerbate their clinical and social problems. These guidelines focus most specifically on individuals with serious mental or emotional problems who tend to encounter an assortment of governmental or publicly funded interveners when they are in crisis. Nevertheless, the values, principles and strategies embedded in the guidelines that follow are applicable to all individuals with mental healthcare needs, across populations and service settings.


Individuals whose diagnoses do not fit “serious mental illnesses” may be vulnerable to serious mental health crises that can have devastating outcomes. Interventions on their behalf are more likely to occur within the private healthcare sector, which mirrors public mental health systems’ problems in providing early and meaningful access to help.Within these parallel systems, crisis services are provided in a broad array of settings that ultimately will require translation of the guidelines presented here into specific protocols that break cycles of crises and advance the prospects of recovery for people with mental illnesses.


2
what It means to be In a mental health Crisis


Too often, public systems respond as if a mental health crisis and danger to self or others were one and the same. In fact, danger to self or others derives from common legal language defining when involuntary psychiatric hospitalization may occur—at best, this is a blunt measure of an extreme emergency.A narrow focus on dangerousness is not a valid approach to addressing a mental health crisis.To identify crises accurately requires a much more nuanced understanding and a perspective that looks beyond whether an individual is dangerous or immediate psychiatric hospitalization is indicated.


While behaviors that represent an imminent danger certainly indicate the need for some sort of an emergency response, these behaviors may well be the culmination of a crisis episode, rather than the episode in its entirety. Situations involving mental health crises may follow trajectories that include intense feelings of personal distress (e.g., anxiety, depression, anger, panic, hopelessness), obvious changes in functioning (e.g., neglect of personal hygiene, unusual behavior) or catastrophic life events (e.g., disruptions in personal relationships, support systems or living arrangements; loss of autonomy or parental rights; victimization or natural disasters).


Because only a portion of real-life crises may actually result in serious harm to self or others, a response that is activated only when physical safety becomes an issue is often too little, too late or no help at all in addressing the root of the crisis.And a response that does not meaningfully address the actual issues underlying a crisis may do more harm than good.


the need for Crisis standards


Individuals experiencing mental health crises may encounter an array of professionals and non-professionals trying to intervene and help: family members, peers, healthcare personnel, police, advocates, clergy, educators and others.The specific crisis response offered is influenced by a number of variables, among them:

  1. where the intervention occurs,
  2. at what time of day it occurs,
  3. when it occurs within the course of the crisis episode,
  4. the familiarity of the intervener with the individual or with the type of problem experienced by the individual,
  5. interveners’ training relating to crisis services,
  6. resources of the mental health system and the ready availability of services and supports, and
  7. professional, organizational or legal norms that define the nature of the encounter and the assistance offered.

This report of the panel’s findings is not intended to be an exhaustive resource on crisis services and best practices, but rather an explanation of factors essential to any response to mental health emergencies. In organizations that may already have protocols for responding to individuals in mental health crises (for instance, police departments, hospitals and mental health clinics), these guidelines offer an opportunity to assess the adequacy of current practices based on a set of underlying values and principles. In foster care, schools or other settings where protocols may not currently exist, the guidelines can serve as a framework for examining current activities and the need for more explicit standards. In either instance, these crisis guidelines promote two essential goals: 1. Ensuring that mental health crisis interventions are guided by standards consistent with recovery and resilience and 2. Replacing today’s largely reactive and cyclical approach to mental health crises with one that works toward reducing the likelihood of future emergencies and produces better outcomes.

II. respondIng to a mental health CrIsIs ten essentIal values
Ten essential values are inherent in an appropriate crisis response, regardless of the
nature of the crisis, the situations where assistance is offered or the individuals providing
assistance:


1. Avoiding harm. Sometimes mental health crises place the safety of the person, the crisis responders or others in jeopardy.An appropriate response establishes physical safety, but it also establishes the individual’s psychological safety. For instance, restraints are sometimes used in situations where there is an immediate risk of physical harm, yet this intervention has inherent physical and psychological risks that can cause injury and even death. Precipitous responses to individuals in mental health crises—often initiated with the intention of establishing physical safety—sometimes result in harm to the individual. An appropriate response to mental health crises considers the risks and benefits attendant to interventions and whenever possible employs alternative approaches, such as controlling danger sufficiently to allow a period of “watchful waiting.” In circumstances where there is an urgent need to establish physical safety and few viable alternatives to address an immediate risk of significant harm to the individual or others, an appropriate crisis response incorporates measures to minimize the duration and negative impact of interventions used.

6. emergency interventions consider the context of the individual’s overall plan of services. Many individuals with serious mental illnesses go into mental health crises while receiving some sort of services and supports.Appropriate crisis services consider whether the crisis is, wholly or partly attributable to gaps or other problems in the individual’s current plan of care and provide crisis measures in ways that are consistent with services the individual receives (or should receive) in the community. In addition, appropriate crisis services place value on earlier efforts by the individual and his or her service providers to be prepared for emergencies, for instance, by having executed psychiatric advance directives or other crisis plans. Incorporating such measures in a crisis response requires that interveners be knowledgeable about these approaches, their immediate and longer-term value, and how to implement them. Appropriate crisis interventions also include post-event reviews that may produce information that is helpful to the individual and his or her customary service providers in refining ongoing services and crisis plans.

crisis services are provided by individuals with appropriate training and demonstrable competence to evaluate and effectively intervene with the problems being presented. Crisis intervention may be considered a high-end service, that is high-risk and demanding a high level of skill.Within the course of a psychiatric emergency, various types of crisis interventions may occur—some by healthcare professionals, some by peers and some by personnel (such as police) who are outside of healthcare.Throughout, the individual experiencing a mental health crisis should be assured that all interveners have an appropriate level of training and competence.What that means may vary considerably between scenarios. For instance, a significant number of instances of police involvement with individuals in mental health crises result in injuries or even death.15 Accordingly, some police departments have taken special measures to train officers in identifying and de-escalating mental health crises. Many have also established links with mental health professionals who can provide timely on-site assistance. These efforts have required police and health care professionals to connect across traditional bureaucratic boundaries.


8. individuals in a self-defined crisis are not turned away. People who seek crisis services but do not meet the service criteria of an organization should receive meaningful guidance and assistance in accessing alternative resources.This is particularly applicable in organizations or programs that carry out a screening or gatekeeping function. For instance, it is not sufficient, upon determining that an individual fails to meet the criteria for hospitalization, to tell the individual or family members to make contact again if the situation worsens. Such practices tacitly encourage the escalation of crises. Individuals and their families should be assisted in accessing services and supports that resolve issues early on, and an organization providing screening or gatekeeping services should be fluent with alternatives for when service thresholds are not met.When these alternatives are lacking, the organization should consider this a problem in care and take action accordingly. Likewise, an organization providing early intervention that routinely receives referrals from hospital gatekeepers might consider improving its outreach so that individuals seeking help are more likely to access their services directly, without placing demands on programs designed for late-stage emergencies.


9. interveners have a comprehensive understanding of the crisis. Meaningful crisis response requires a thorough understanding of the issues at play.Yet, for people with serious mental illnesses, interventions are commonly based on a superficial set of facts: behaviors are seen to present a safety issue, the individual national resource center on Psychiatric Advance directives Psychiatric advance directives (PADs) are relatively new legal instruments that may be used to document a competent person’s specific instructions or preferences regarding future mental health treatment, in preparation for the possibility that the person may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness. Almost all states permit some form of legal advance directive (AD) for healthcare, which can be used to direct at least some forms of psychiatric treatment. In the past decade, 25 states have adopted specific PAD statutes.


Mobile outreach services, which have the capacity to evaluate and intervene within the individual’s natural environment, have inherent advantages over facility-based crisis intervention, especially when an individual who has personal experience with mental illness and mental health crises is a part of the intervention team. Such mobile outreach capacity is even more meaningful when it is not restricted to a special crisis team, but rather when staff and peers familiar with the individual have the ability to literally meet the individual where he or she is.When intervention within an individual’s normal living environment is not feasible, hospitalization is not the inevitable alternative; for many individuals facing civil commitment, consumer-managed crisis residential programs can represent a viable, more normalized alternative that produces good outcomes.16

  1. helping the individual to regain a sense of control is a priority. Regaining a sense of control over thoughts, feelings and events that seem to be spinning out of control may be paramount for an individual in mental health crisis. Staff interventions that occur without opportunities for the individual to understand what is happening and to make choices among options (including the choice to defer to staff) may reinforce feelings that control is being further wrested away.The individual’s resistance to this may be inaccurately regarded as additional evidence of his or her incapacity to understand the crisis situation. Incorporating personal choice in a crisis response requires not only appropriate training, but also a setting with the flexibility to allow the exercise of options. Informed decision-making in this context is not a matter of simply apprising the individual of the empirically derived risks and benefits associated with various interventions; it also includes an understanding among staff that an ostensibly sub-optimal intervention that is of the individual’s choosing may reinforce personal responsibility, capability and engagement and can ultimately produce better outcomes.The specific choices to be considered are not limited to the use of medications, but also include the individual’s preferences for what other approaches are to be used where crisis assistance takes place, involving whom and with what specific goals.While the urgency of a situation may limit the options available, such limitations may also highlight how earlier interventions failed to expand opportunities to exercise personal control. Post-crisis recovery plans or advance directives developed by the individual with assistance from crisis experts are important vehicles for operationalizing this principle
  2. services are congruent with the culture, gender, race, age, sexual orientation, health literacy and communication needs of the individual being served. Given the importance of understanding how an individual is experiencing a crisis and engaging that individual in the resolution process, being able to effectively connect with the individual is crucial.A host of variables reflecting the person’s identity and means of communicating can impede meaningful engagement at a time when there may be some urgency. Establishing congruence requires more than linguistic proficiency or staff training in cultural sensitivity; it may require that to the extent feasible, an individual be afforded a choice among staff providing crisis services.
  1. rights are respected. An individual who is in crisis is also in a state of heightened vulnerability. It is imperative that those responding to the crisis be versed in the individual’s rights, among them: the right to confidentiality, the right to legal counsel, the right to be free from unwarranted seclusion or restraint, the right to leave, the right for a minor to receive services without parental notification, the right to have one’s advance directive considered, the right to speak with an ombudsman and the right to make informed decisions about medication. It is critical that appropriately trained advocates be available to provide needed assistance. Correctly or not, many individuals with serious mental illnesses have come to regard mental health crisis interventions as episodes where they have no voice and their rights are trampled or ignored. Meaningfully enacting values of shared responsibility and recovery requires that the individual have a clear understanding of his or her rights and access to the services of an advocate. It is also critical that crisis responders not convey the impression that an individual’s exercise of rights is a hostile or defiant act.
  2. services are trauma-informed. Adults, children and older adults with serious mental or emotional problems often have histories of victimization, abuse and neglect, or significant traumatic experiences.Their past trauma may be in some ways similar to the mental health crisis being addressed. It is essential that crisis responses evaluate an individual’s trauma history and the person’s status with respect to recovery from those experiences. Similarly, it is critical to understand how the individual’s response within the current crisis may reflect past traumatic reactions and what interventions may pose particular risks to that individual based on that history. Because of the nature of trauma, appropriately evaluating an individual requires far more sensitivity and expertise than simply asking a series of blunt, potentially embarrassing questions about abuse and checking off some boxes on a form. It requires establishing a safe atmosphere for the individual to discuss these issues and to explore their possible relationship to the crisis event.
  3. recurring crises signal problems in assessment or care. Many organizations providing crisis services—including emergency departments, psychiatric hospitals and police—are familiar with certain individuals who experience recurrent crises.They have come to be regarded as “high-end users.” In some settings, processing these individuals through repeated admissions within relatively short periods of time becomes so routine that full reassessments are not conducted; rather, clinical evaluations simply refer back to assessments and interventions that were conducted in previous (unsuccessful) episodes of care. While staff sometimes assume that these scenarios reflect a patient’s lack of understanding or willful failure to comply with treatment, recurrent crises are more appropriately regarded as a failure in the partnership to achieve the desired outcomes of care.And rather than reverting to expedient clinical evaluations and 15. meaningful measures are taken to reduce the likelihood of future emergencies. Considering the deleterious impact of recurrent crises on the individual, interventions must focus on lowering the risk of future episodes. Crisis intervention must be more than another installment in an ongoing traumatic cycle. Meaningfully improving an individual’s prospects for success requires not only good crisis services and good discharge planning, but also an understanding that the crisis intervener—be it police, hospital emergency department, community mental health program, or protective service agency—is part of a much larger system. Performance-improvement activities that are confined to activities within the walls of a single facility or a specific program are sharply limited if they do not also identify external gaps in services and supports that caused an individual to come into crisis.Although addressing certain unmet needs may be beyond the purview of one facility or program, capturing and III. InfrastruCture

An organization’s infrastructure should support interventions consistent with the values and principles listed above. Given the nature of crises affecting individuals with serious mental or emotional problems, these values and principles are applicable to a very broad array of organizations—hospital emergency departments, psychiatric programs, foster care, education, police, schools, and courts.While needed infrastructure will necessarily vary by setting, population served and the acuteness of crises being addressed, there are some important common denominators:
staff that is appropriately trained and that has demonstrated competence
in understanding the population of individuals served, including not only a clinical perspective, but also their lived experiences.

  1. staff and staff leadership that understands, accepts and promotes the concepts of recovery and resilience, the value of consumer partnerships and consumer choice, and the balance between protection from harm and personal dignity.
  2. staff that has timely access to critical information, such as an individual’s health history, psychiatric advance directive or crisis plan. Such access is, in part, reliant on effective systems for the retrieval of records, whether paper or electronic.
  3. staff that is afforded the flexibility and the resources, including the resource of time, to establish truly individualized person-centered plans to address the immediate crisis and beyond.
  4. staff that is empowered to work in partnership with individuals being served and that is encouraged, with appropriate organizational oversight, to craft and implement novel solutions.
  5. An organizational culture that does not isolate its programs or its staff

from its surrounding community and from the community of individuals being served.This means that the organization does not limit its focus to “specific” patient-level interventions, but also positions itself to play a meaningful role in promoting “indicated” strategies for the high-risk population it serves and “universal” strategies that target prevention within the general population.The intent here is not to dissipate the resources or dilute the focus of an organization, but to assure recognition that its services are a part of a larger spectrum and that it actively contributes to and benefits from overall system refinements.

  1. coordination and collaboration with outside entities that serve as sources of referrals and to which the organization may make referrals. Such engagement should not be limited to service providers within formal networks, but should also include natural networks of support relevant to the individuals being served.
  2. rigorous performance-improvement programs that use data meaningfully to refine individuals’ crisis care and improve program outcomes. Performance improvement programs should also be used to identify and address risk factors or unmet needs that have an impact on referrals to the organization and the vulnerability to continuing crises of individuals served.

making It happen


The need for major improvements in crisis services for adults, children and older adults with serious mental or emotional problems is obvious.The statistics presented in the introduction to these guidelines make a clear case that people with mental illnesses are vulnerable to repeated clinical and life crises that can have deleterious effects on the individual, families and social networks, and communities. Many interventions could have a significant, positive impact on the frequency and severity of mental health crises, but they are not readily available to most of the individuals who need them.


Properly applied, these guidelines should work to improve the quality of services for people who are in or are vulnerable to mental health crises. Embedded in the guidelines is the notion that crisis services should not exist in isolation; crises are a part of an individual’s life experiences and the assistance provided during crisis periods is part of a larger set of services and supports provided to the individual.While the values, principles and infrastructure recommendations presented here focus on crises affecting people with serious mental illnesses, they also have wider application; they reflect generally accepted approaches to working with individuals who have mental or emotional problems, whether or not they are in crisis. Stated differently, these guidelines challenge any disjuncture between responses to mental health crises and routine mental healthcare.They demonstrate how appropriate emergency mental health responses should affirm the principles of recovery and resilience that are the benchmarks for appropriate mental healthcare even though crisis scenarios may test the application of these values.


From a practice standpoint, these guidelines may be most effectively enacted when they are embedded in the various quality-control and performance-improvement mechanisms that operate within an organization.When appropriately conducted, quality control and performance-improvement processes should be data-driven and attuned to demonstrating not only what segments of the service population are prone to mental health crises,but also what factors underlie their vulnerability.An adequate understanding of these factors requires much more than the “encounter” data now routinely collected by both healthcare organizations and police. Data collection should clearly reflect the premise that mental health crises represent problems in care (whether individual or systemic) and should facilitate the root-cause analyses that are required when significant problems in care occur. Similarly, data should be used as tools for identifying gaps, developing remedies and monitoring the impact of these remedies. Providers and provider organizations should have access to these data for purposes of ensuring the quality of care and the appropriate use of resources.To the extent that the causes of mental health crises extend beyond the domains of an emergency department, a hospital, a mental health system, a police department, and/ or a housing authority, data without personal identifiers should be routinely shared across systems. Entities having oversight responsibility should ensure that these performance-improvement activities are being carried out and that opportunities exist for cross-agency/ cross-system analysis of information and the implementation of strategies to reduce mental health crises.And the partnerships between providers and consumers that are appropriate in the context of individual crises should be mirrored at the performance-improvement level.


15 Practice Guidelines: Core Elements for Responding to Mental Health Crises


In addition to the human case for improving crisis services, a strong business case can be made and data should be collected accordingly. Current approaches to crisis services needlessly perpetuate reliance on expensive, late-stage interventions (such as hospital emergency departments) and on settings that have inherent risks for harm for people with mental health needs (for instance, jails and juvenile justice facilities). Resources and personnel that might otherwise be available for more effective, less risky and less expensive interventions are now channeled into these costly and suboptimal settings.The factors that sustain late-stage crisis interventions may be linked to reimbursement practices and political considerations, yet in some ways the service system is itself complicit. Performance-improvement data derived from on-the-ground case experience can paint a compelling story of how “the right services at the right time” would look for individuals who are currently at high risk for future crises. These data can also set the stage for concrete discussions of the costs and the benefits of changes in policies governing the provision and funding of services and supports.


In short, the approach to crisis services must be forward-looking rather than merely reactive, with success seen as the ability of the individual served to return to a stable life in the community. Rather than leading merely to an increase in the number of beds available for mental health care, it must have as its goal a reduction in the number of crises among people with mental illnesses and therefore a reduced need for emergency services.

Executive Summary


Crisis Services are a continuum of services that are provided to individuals experiencing a psychiatric emergency. The primary goal of these services is to stabilize and improve psychological symptoms of distress and to engage individuals in an appropriate treatment service to address the problem that led to the crisis. Core crisis services include: 23-hour crisis stabilization/observation beds, short term crisis residential services and crisis stabilization, mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance directive statements, and peer crisis services.


The research base on the effectiveness of crisis services is growing. There is evidence that crisis stabilization, community-based residential crisis care, and mobile crisis services can divert individuals from unnecessary hospitalizations and ensure the least restrictive treatment option is available to people experiencing behavioral health crises. Additionally, a continuum of crisis services can assist in reducing costs for psychiatric hospitalization, without negatively impacting clinical outcomes.


Our environmental scan revealed that most states provide a continuum of crisis services including residential, mobile crisis, and hotlines. Additional core crisis services are available in some states, including warm lines, crisis respite, and crisis intervention teams, depending upon available funding, state and local infrastructure, and state program and funding polices. In our interviews with states, states reported using several different strategies in the provision of crisis services including co-locating different crisis services in facilities that covered a specific geographic region, including trained mental health consumers (i.e. peers) in the provision of crisis services and collaborating with other partners, such as law enforcement.


Our interviews also revealed states are providing services using different payment mechanisms. Some states such as Massachusetts, Tennessee and Michigan have used Medicaid managed care waivers to expand their crisis services continuum, while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum.


The most frequently reported funding sources for crisis services are state and county general funds and Medicaid. Although states finance crisis services in different ways, many are using multiple funding sources to ensure that a continuum of crisis care can be provided to all who present for services, regardless of insurance status. Each of the states indicated that using funding from multiple sources has been an effective way to support a continuum of crisis care.


States reported opportunities, challenges and lessons learned in implementing and financing crisis services. Opportunities included updating consumer information to streamline identification of payer source, including peers in various roles in the provision of crisis services and collaborating with other partners to improve crisis services. Challenges included difficulties in obtaining reimbursement for crisis services to individuals with dual mental health and substance abuse disorders and difficulties in obtaining crisis services reimbursement from private insurance due to differences in provider qualifications from Medicaid.


Finally, states provided valuable insight into lessons learned regarding providing crisis services. Some states reported that they were able to use the flexibility of Medicaid waivers to increase the provision of crisis services tailored to their specific delivery system while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum. Particularly, states with Medicaid managed care behavioral health carve outs were better able to create a full 6 continuum of crisis services whereas states that operated under the Medicaid fee-for-service model faced challenges in implementing a full complement of crisis services. States also emphasized the value of collecting data on crisis services quality indicators to inform policy decisions around crisis care.


Introduction

Historically, individuals who experienced acute psychiatric or substance abuse symptoms, such as an acute disturbance in thought, mood, behavior, or social relations that required immediate attention, would be treated in a general hospital emergency department or admitted to a hospital. Subsequently, they would receive less intensive outpatient treatment. It has become increasingly apparent that this service mix is frequently inadequate and expensive. Emergency rooms often lack staff with specialized psychiatric training as well as the time and infrastructure to appropriately address the needs of individuals experiencing psychiatric or substance abuse crises. Furthermore, an emphasis on delivering the most appropriate care in the most appropriate setting has led to greater care provided in the community, lessening the reliance on admitting individuals to hospitals. While the move to community-base treatment has led to a reduction in the number of psychiatric beds, in some instances, it has led to an unintended shortage.


This situation has led to the development of a continuum of alternative psychiatric emergency services, or “crisis services” (Allen, M. H., Forster, P., Silver, J., & Currier, G, 2002). The primary goals of these services are to stabilize and improve psychological symptoms of distress and to engage individuals in the most appropriate course of treatment. In contrast to the traditional hospital inpatient-based care settings available to individuals in need of immediate attention for psychiatric or substance abuse symptoms, crisis services include an array of services that are designed to reach individuals in their communities through telephone “hotlines” or “warm lines,” and mobile outreach; and to provide alternatives to costly hospitalizations—such as short-term crisis stabilization units and 23-observation beds.


Like emergency medical services, crisis services are intended to be available to the entire community. Those receiving services may include individuals with a history of severe and persistent mental illness or a substance use disorder (SUD), or those who have never before used behavioral health services. They may be children, adults, or the elderly.


National statistics attest to the significant need for crisis services. In 2010, 2.2 million hospitalizations and 5.3 million emergency department visits involved a diagnosis related to a mental health condition (Agency for Healthcare Research and Quality, 2010). Moreover, in any given year approximately one-fourth of adult Americans will have a mental disorder and about five percent of children aged 4–17 years have serious emotional distress (National Center for Health Statistics, National Health Interview Survey, 2009).
Although not everyone with a mental health or substance use disorder will experience a need for crisis services, some factors may increase the risk of crisis and the need for individuals to access essential services and supports. These factors include poverty, unstable housing, coexisting substance use, and other physical health problems associated with mental illness (SAMHSA, 2009b)

.
The nature of comprehensive crisis systems, with their complex range of programs and services for addressing various individual situations, makes it difficult to finance crisis services within the constraints of one particular funding stream. Although many crisis services are provided from within the behavioral health system, some are hospital-based, and others are cut across the broader community (e.g., schools or the justice system). In many cases, crisis programs that are operated by different agencies or organizations have separate eligibility criteria and funding. In addition, there are multiple categorical funding streams to address specific problems or specific target populations, such as youth in foster care, elders, or individuals with developmental disabilities. For certain individuals, categorical funding results in the receipt of intended and needed services. However, through collaborative funding, funders of categorical dollars could also play a role in addressing the broader fundamental situation that often surrounds a crisis.


Funding that is tied to serving a specifically defined population can limit the financial feasibility of a program, particularly in rural areas or other areas that have a limited population base to draw upon. Also, funding that is tied to delivering units of pre-defined treatment to individuals who are eligible for specific types of insurance make it difficult for communities to build a continuum of crisis services. Due to the nature of behavioral health crises, many communities require a program with a “fire-house” staffing model that needs to respond to individuals immediately, often prior to establishing insurance status. These issues present limitations to states and communities who wish to build a continuum of crisis services.


Overcoming eligible individual limitations imposed by categorical and single-service dedicated funding streams requires mobilizing multiple resources to address the diverse needs of individuals experiencing a behavioral health crisis. Such a collaborative funding approach would create an overall strategy that reconciles the many separate funding strands, and would have greater potential to meet the immediate needs of individuals in crisis, that extends beyond the scope of what a single system could have mobilized on its own (National Gains Center for People with Co-occurring Disorders in the Justice System, 2004).
This report summarizes the evidence base on the clinical effectiveness and cost-effectiveness of different types of crisis services, and then presents case studies of different approaches that states are using to coordinate, consolidate, and blend fund sources in order to provide robust crisis services.


Effectiveness of Crisis Services


The empirical evidence on the effectiveness of crisis services in addressing the needs of individuals with mental or substance use disorders is growing. In this section, we summarize the evidence on the effectiveness of the following types of crisis services:

  1. 23-hour crisis stabilization/observation beds
  2. Short term crisis residential services and crisis stabilization
  3. Mobile crisis services
  4. 24/7 crisis hotlines
  5. Warm lines
  6. Psychiatric advance directive statements
  7. Peer crisis services

The review was based on a systematic search of systematic reviews of the effectiveness of crisis services, which included the Cochrane Collaboration, the Campbell Collaboration, and SAMHSA’s National Registry of Evidence-Based Programs and Practices. In addition, studies were identified through searches of PubMed (U.S. National Library of Medicine and National Institutes of Health), Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, and Google Scholar to identify relevant peer-reviewed studies or review articles. Search terms were specific to each service. To make the review as extensive as possible, the searches were not restricted to randomized controlled trials (RCTs). In addition, the research team manually reviewed references contained in the retrieved literature.


23-Hour Crisis Stabilization/Observation Beds


23-hour crisis observation or stabilization is a direct service that provides individuals in severe distress with up to 23 consecutive hours of supervised care to assist with deescalating the severity of their crisis and/or need for urgent care. The primary objectives of this level of care are prompt assessments, stabilization, and/or a determination of the appropriate level of care. The main outcome of 23-hour observation beds is the avoidance of unnecessary hospitalizations for persons whose crisis may resolve with time and observation (SAMHSA, 2012).


Two studies have evaluated the effectiveness of 23-hour crisis stabilization/observation beds. A quasi-experimental study by Gillig and colleagues (1989) compared two psychiatric emergency services and found that the service with the emergency evaluation unit had a significantly lower rate of hospital admissions (36 percent) compared to the one without the unit (52 percent). Clinicians in the program reported that 65 of the 134 patients admitted to the observation unit would have been admitted to the hospital if the unit had not been available.


An observational study by Francis and colleagues (2000) examined the effectiveness of a 23-hour observation program at a Veterans Affairs medical center. The program was designed to avoid unnecessary hospitalization of patients experiencing acute psychiatric crises. The most frequent psychiatric diagnosis among program participants was substance abuse or dependence (77 percent). During the 6 months before admission to the 23-hour program, 38 percent had been admitted at least once to an inpatient psychiatric unit. Following the program, only 12 percent of the patients were admitted to inpatient care. Reasons for the decrease in inpatient services were not systematically explored as part of the study design. However, participating staff members hypothesized that the short duration of the observation period facilitated rapid decision making and referrals to outpatient programs—such as residential substance abuse treatment and partial hospitalization programs—and capitalized on the fact that a high level of distress often motivates patients to accept treatment programs that are immediately available.


Short-Term Crisis Residential Stabilization Services


Crisis stabilization is defined as “a direct service that assists with deescalating the severity of a person’s level of distress and/or need for urgent care associated with a substance use or mental health disorder. Crisis stabilization services are designed to prevent or ameliorate a behavioral health crisis and/or reduce acute symptoms of mental illness by providing continuous 24-hour observation and supervision for persons who do not require inpatient services” (SAMHSA 2012). Short-term crisis residential stabilization services include a range of community-based resources that can meet the needs of an individual with an acute psychiatric crisis and provide a safe environment for care and recovery. Core attributes of residential crisis services include providing housing during a crisis with services that are short term, serving individuals or small groups of clients, and are used to avoid hospitalization (Stroul, 1988).


The current literature generally supports that crisis residential care is as effective as other longer psychiatric inpatient care at improving symptoms and functioning. It also demonstrates that the satisfaction of these services is strong, and the overall costs for residential crisis services are less than traditional inpatient care.
For the studies examined in this review, the populations range from late adolescence (aged 16-18 years) through adulthood. This review excluded programs in which substance use disorder was the primary diagnosis, as these programs are usually much longer in duration, and complicated by the need for medical detoxification. A substance use condition requiring inpatient care is often preceded by a period of detoxification in an appropriate facility. Studies on crisis residential service generally compare community-based or hospital facility programs with a time-limited intervention focus to traditional hospital care.
Regarding mental health and crisis residential, a recent systematic review examined the effectiveness of residential alternatives to hospital inpatient services for acute psychiatric conditions (Lloyd-Evans, et al., 2009). This review included randomized control trials or studies that provided specific quantitative comparisons of effectiveness of alternatives to standard acute inpatient care. Based on 9 out of the 27 studies reviewed, which were rated as of moderate or high quality methodological rigor, the authors concluded that there is preliminary evidence to suggest that residential alternatives may be as effective and potentially less costly than standard inpatient units. The authors note, however, that more research is needed given the heterogeneity of the services and patients studied to date, and rigor of the study designs.


Mobile Crisis Services


The American Psychiatric Association (APA) Task Force defines mobile crisis services as having the “capacity to go out into the community to begin the process of assessment and definitive treatment outside of a hospital or health care facility,” along with a staff including “a psychiatrist available by phone or for in-person assessment as needed and clinically indicated” (Allen et al., 2002). Mobile crisis teams provide acute mental health crisis stabilization and psychiatric assessment services to individuals within their own homes and in other sites outside of a traditional clinical setting (Scott, 2000).


The main objectives of mobile crisis services are to provide rapid response, assess the individual, and resolve crisis situations that involve children and adults who are presumed or known to have a behavioral health disorder (Allen et al., 2002; Fisher, Geller, and Wirth-Cauchon, 1990; Geller, Fisher, and McDermeit, 1995). Additional objectives may include linking people to needed services and finding hard-to-reach individuals (Gillig, 1995). Although most mobile crisis teams are a link between the community and the emergency department (ED), some are co-located in facilities that have both outpatient and ED services, fewer are co-located in inpatient services and outpatient services, and some operate in more than one of these domains (Allen et al., 2002; Gillig, 1995). The main outcome objective of mobile crisis teams is to reduce psychiatric hospitalizations, including hospitalizations that follow psychiatric ED admission. Some mobile teams are focused on reducing arrests of mentally ill offenders (Lamb, Weinberger, and DeCuir, Jr., 2002). Diversion is also a main goal of police-based teams, which may be staffed by mental health consultants or exclusively by police officers with mental health training (Compton, Bahora, Watson, and Oliva, 2008; Lamb et al., 2002; Steadman, Deane, Borum, and Morrissey, 2000).


Four studies were identified with empirical evidence on the effectiveness of mobile crisis services: one randomized controlled trial (Currier et al., 2010) and three that used quasi-experimental designs (Guo, Biegel, Johnsen, and Dyches, 2001; Hugo, Smout, and Bannister, 2002; Scott, 2000; Dyches, Biegel, Johnsen, Guo, and Min, 2002). The studies suggest that mobile crisis services are effective at diverting people in crisis from psychiatric hospitalization, effective at linking suicidal individuals discharged from 11
the emergency department to services; and better than hospitalization at linking people in crisis to outpatient services.


24/7 Crisis Hotlines


Crisis hotlines are defined as “a direct service delivered via telephone that provides a person who is experiencing distress with immediate support and/or facilitated referrals. This service provides a person with a confidential venue to seek immediate support with the goal of decreasing hopelessness; promotes problem-solving and coping skills; and identifies persons who are in need of facilitated referrals to medical, healthcare, and/or community support services” (SAMHSA, 2012).


The goals of most crisis hotlines are to provide support to callers who are feeling hopeless and overwhelmed and to help the caller find a plan for coping with the situation or other resources that can provide further assistance (Kalafat, Gould, Munfakh, and Kleinman, 2007). Most hotlines are available to entire populations, rather than to individuals with specific characteristics or diagnoses. Insurance is not required to use these services. They are available to individuals with mental illnesses and to those with substance use disorders.


An example of a crisis hotline in the United States is the National Suicide Prevention Lifeline, which is a national, toll-free hotline that combines 24/7 crisis centers into a single network. Calls originating from anywhere in the country are routed to the nearest available crisis center, based on capacity and availability. With few exceptions (for example, services that are created specifically for adolescents), crisis hotlines are available to all callers (Samaritans USA, 2010).


Investigators have been able to demonstrate that the mental status of many callers improves during and after calls to a hotline. Qualitative reports as well as some evaluative studies indicate that hotlines have value for numerous suicidal and troubled people—especially those with depression—and that the hotlines represent an asset in the service continuum.


Studies of crisis hotlines often focus on a reduction in suicide as their outcome. Early studies that aimed to assess the effectiveness of hotline services compared suicide rates in towns with and without suicide prevention facilities (Jennings, Barraclough, and Moss, 1978; Miller, Coombs, Leeper, and Barton, 1984). Miller et al. (1984) studied mortality data from the National Center for Health Statistics for 226 central city counties in the contiguous United States (except for those in New England and Virginia) for the years 1968 through 1973. The investigators found that young, white females demonstrated a significant (p = .005) difference in suicide rate between counties that initiated crisis centers and those that did not. Using 1980 census data, the authors concluded that each year these services saved the lives of 637 white females under the age of 25 years, per year.


A more recent study examined how individuals with serious mental illness and a history of suicidal behavior cope with suicidal thoughts (Alexander, Haughland, Ashenden, Knight, and Brown, 2009). Using the mental health system—including crisis hotlines, emergency services, or speaking to a therapist—was the fourth-most cited coping strategy. The first three coping strategies were: spirituality and religious practices; talking to someone and companionship; and positive thinking.


In 1983, Hoult, Reynolds, Charbonneau-Powis, Weekes, and Briggs found that 24-hour crisis hotlines combined with community treatment provided positive outcomes such as reduction in cost, and 12
patients and their families were satisfied with this combined approach. Participants in this program spent an average of 8.4 days in psychiatric hospitals, compared to an average of 53.5 days for controls.
Although few studies of crisis hotline services discuss individuals with substance use or co-occurring mental and substance use disorders, one review noted that callers who had “drug problems or more serious emotional/behavior disorders rated telephone counselors as significantly less effective” than did callers with other problems (Stein and Lambert, 1984, p. 120).


A rigorous study of crisis hotline outcomes was reported in two parts—one devoted to nonsuicidal callers and one to suicidal callers (Kalafat et al., 2007; Gould, Kalafat, Munfakh, and Kleinman, 2007). These investigators studied 240 counselors who worked at eight telephone crisis services across the United States, seven of which were members of the 1-800-SUICIDE National Suicide Prevention Lifeline network mentioned above. Suicidal and nonsuicidal callers completed baseline and follow-up assessments approximately two weeks following the use of the service. Among nonsuicidal callers, distress was significantly reduced from the beginning to the end of the call, and there was a significant reduction in callers’ distress levels from the end of the call to follow-up (Kalafat et al., 2007). Among suicidal callers, there was a significant reduction in suicide status from the beginning to the end of the call on intent to die, hopelessness, and psychological pain. There were also significant reductions in callers’ psychological pain and hopelessness from the end of the call to follow-up (Gould et al., 2007).


Warm Lines


Warm lines are telephone lines that are run by trained mental health consumers (i.e., peers) and staffed by people who are also in recovery (SAMHSA, 2010). A warm line is “a direct service delivered via telephone by a [peer] that provides a person in distress with a confidential venue to discuss their current status and/or needs SAMHSA, 2012). Unlike hotlines, warm lines are for situations that are not considered emergencies but could potentially escalate if left unaddressed. Peer telephone operators can offer compassion, and support callers on topics such as loneliness, anxiety, and sleeplessness. When individuals use warm lines, they are encouraged to talk through their concerns with operators and, in turn, operators may relate information about their own experiences to help the caller to address their own concerns. Operators can help callers that may feel isolated or “stuck” and, as a result, they may calm or reassure the callers. Operators refrain from offering advice; rather, they give a message of hope and provide resources. As a result of warm lines and their operators, situations that may have resulted in a crisis-related trip to a local ED before the call may be prevented (U.S. Department of Health and Human Services, 2010).


In 2011, Dalgin, Maline, and Driscoll administered telephone surveys to 480 warm line callers over a period of four years. They found that callers saw a reduction in both the use of crisis services and feelings of isolation. They also found that keeping telephone lines open after 5:00 p.m. was especially helpful, as they were available after most office hours.


Psychiatric Advanced Directive Statements


An advanced directive statement is a document that specifies a person’s future preferences for treatment, should he or she lose the mental ability to make treatment decisions. Advanced directives are typically used in end-of-life situations. However, people with mental illness may also benefit from having an advanced directive statement, in the advent of a crisis rendering them unable to make treatment or life decisions (Campbell and Kisely, 2009). Twenty-five states have statutes authorizing psychiatric advanced directive statements (PADs). Minnesota was the first state to legislate for psychiatric advance directives in 1991. None of the statutes allow patients to use directives to avoid emergency involuntary detention (Morrissey, 2010).


A study by Flood and colleagues (2006) found that an advanced directive plan formulated by the patient, coordinator, psychiatrist, and project worker led to lower costs and less service use, but these findings were not statistically significant. A more recent review by Campbell and Kisley (2009) found no differences in hospitalization rates for those with advance directive statements and those without. Our review suggests that more research is needed to determine the impact of these statements on mental health costs or health outcomes.


Henderson and colleagues (2004) investigated the impact of a joint advanced directive plan developed by the patient and his or her outpatient treatment team on hospital admission outcomes. A group of psychiatric patients having the 'joint crisis or advanced directive plan' was compared to a group of psychiatric patients without a plan in place. Among those with severe mental illness, the use of an advanced directive plan reduced compulsory admissions and treatment compared to patients without a plan by 13 percent and 27 percent, respectively. In a similar study by Papageorgiou and colleagues (2002), patients who developed advanced directives (but without assistance from the outpatient mental health team) were compared to patients without an advanced directive plan in place. The study found no difference in the number of psychiatric hospital admissions. Findings from the two studies suggest that the involvement of facilitator and outpatient mental health team in the development of an advanced directive plan may be a critical factor for preventing compulsory hospital admissions.


Peer Crisis Services


An alternative to psychiatric ED or inpatient hospitalization, peer crisis services are operated by people who have experience living with a mental illness (i.e., peers) (Ostrow and Fisher, 2011). Peer crisis programs are designed as calming environments with supports for individuals in crisis. They are delivered in community settings with medical support. Services are intended to last less than 24 hours but may extend up to several days, if needed. Peer crisis services are generally shorter term than crisis residential services.
The number of research studies in this area is limited. However, the positive results from the few studies existing provide support for continued state and county mental health peer crisis services, and highlight the need for a more systematic study of the implementation efforts. Study populations in this review included adults with serious mental illness, as well as peer-run suicide prevention line callers for all ages. No literature was identified that discussed peer crisis services for consumers with substance use disorders.


In a randomized investigation of a five-bed crisis hostel in Tompkins County, New York, Dumont and Jones (2002) evaluated a two-year demonstration. The results of this study were presented at the 2001 meeting of the National Association of State Mental Health Program Directors, and were reported in the Human Services Research Institute Outlook publication. The authors reported that “in nearly all areas, persons who had been assigned access to the crisis hostel were associated with both better outcomes and lower costs.” The program was not published in a peer-reviewed journal and the details of the study are not available.


In a more recent RCT on peer services, researchers found that the average rate of improvement in symptom ratings was greater in the peer services group than in the hospital comparison group (Greenfield, Stoneking, Humphreys, Sundby, and Bond, 2008). The Greenfield et al. study involved random assignment of individuals with serious mental illness to one of two conditions: a consumer-operated, short-term crisis residential program (CRP); or “usual care,” which in this case was a locked inpatient unit. CRP consumers had improved psychiatric symptoms, strengths, and treatment satisfaction. The peer-run alternative group had much greater service satisfaction compared to the usual care group. Findings suggest that short-term peer lead interventions, together with available community outreach, are a viable alternative to standard hospital care.


The Economic Impact of Crisis Services


As with the health care system overall, there is a growing need to control costs associated with the delivery of mental health services while maintaining or improving the quality of care. Several studies have examined the economic impact of various types of crisis services, relative to usual mental health care. As described below, these studies find that significant cost savings can result from crisis services, due to reduced inpatient utilization, emergency department diversion and more appropriate use of community-based behavioral health services.


Crisis Stabilization


In a recent study by Wilder Research (2013), the authors used claims data to calculate a return on investment of mental health crisis stabilization programs in the east metropolitan area of the Minnesota Twin Cities. The authors examined the impact of the program on utilization of health care including ED use, outpatient services, and inpatient psychiatric services. They also investigated the cost of inpatient hospitalization (all-cause and behavioral health only) post-crisis stabilization compared to costs prior to intervention. They compared the value of the resources invested in these programs and the benefits associated with this intervention. Programs served 315 patients at an average cost of mental health crisis stabilization of $1,085. The study found that the net benefit for mental health crisis stabilization services was approximately $0.3 million, with a return of $2.16 dollars for every dollar invested.


Community-Based Residential Crisis Care


A study by Fenton, Hoch, Herrell, Mosher, and Dixon, (2002) found that acute treatment episode costs in residential crisis settings were 44 percent lower than in general hospitals. Hawthorne et al., (2005) found that a Short-Term Acute Residential Care (START) program for veterans aged 18–59 years with a diagnosis of affective disorder, bipolar disorder, or psychosis was 65 percent less costly than regular hospital care; while outcomes where similar to hospital care. As part of an effort in the Texas public mental health system to test certain key components of the peer crisis model in comparison to standard hospitalization (20–26 days length of stay in this usual care condition), Toprac, Sherman, and Holzer, (1996) found no significant differences between the groups in effectiveness. However, as hypothesized, a cost analyses found lower costs (hospital and community) for those who received crisis respite during the crisis period (through three months after initiation of crisis treatment) compared to those with standard hospitalization. Although the difference was not statistically significant, the total costs for those in the brief hospitalization plus respite care groups were also lower than those for the standard hospitalization group. Because there were no significant differences in effectiveness between the types of care, the differences in cost between the interventions suggest that respite care is more cost effective than standard hospitalization. The data also suggest that brief hospitalization plus respite care may also be more cost effective than standard hospitalization.


Mobile Crisis Programs


Scott, (2000) analyzed the effectiveness and efficiency of a mobile crisis program by comparing it to regular police intervention. The average cost per case was $1,520 for mobile crisis program services, which included $455 for program costs and $1,065 for psychiatric hospitalization. For regular police intervention, the average cost per case was $1,963, which consisted of $73 for police services and $1,890 for psychiatric hospitalization. In this study, mobile crisis services resulted in a 23 percent lower average cost per case. In another study analyzing the cost impact of mobile crisis intervention, Bengelsdorf et al., (1993) found that mobile crisis intervention services can reduce costs associated with inpatient hospitalization by approximately 79 percent in a six-month follow-up period after the crisis episode.


Peer Crisis Services


The previously mentioned study conducted by Greenfield and colleagues regarding the comparison of individuals treated in a consumer-operated, short-term crisis residential program (CRP) or a locked inpatient unit showed that in addition to improved psychiatric symptoms and consumer satisfaction, the cost for treatment of consumers in CRP was also significantly less: $211 per day for peer services and $665 per day for hospitalization.


Funding Crisis Services: Overview


In 2009, the United States spent $172 billion on mental health and substance abuse treatment (SAMHSA, 2013). The majority of mental health and substance abuse expenditures were supported by public funding (60 percent of mental health expenditures, 69 percent of substance abuse expenditures) with the remaining portion covered by private sources (Levit et al., 2013).1,2 While no data exists for the proportion of spending on crisis services specifically, as with behavioral health services in general, state and federal governments do provide a critical source of financing for crisis programs. Tables 1 and 2 summarize state use of Medicaid and other federal funding sources to finance crisis services, as compiled from an environmental scan of these services.


Truven Health Analytics examined crisis services covered under Medicaid State Plan benefits and other Medicaid demonstrations and waivers. As mentioned, although these services are sometimes covered by state funds, grant funds or private insurance, the scope of the environmental scan was limited to
1 Public funding sources for mental health, represented as a percentage of total mental health expenditures, were distributed as follows: 27 percent Medicaid, 13 percent Medicare, 15 percent state and local and 5 percent other federal. Public funding for substance abuse expenditures were more heavily distributed towards state and local funding with the following distribution: 31 percent state and local, 21 percent Medicaid, 11 percent federal and 5 percent Medicare. The proportion of behavioral health expenditures for private payers is as follows: private insurance (26 percent of mental health expenditures and 16 percent of substance abuse expenditures), out-of-pocket payments (11 percent for both types of treatment), and other private sources (3 percent and 5 percent, respectively).

2 A significant portion of total behavioral health spending was for treatment in hospital settings. Specifically, in 2009, 26 percent of mental health expenditures and 31 percent of substance abuse expenditures were for services delivered in a hospital setting, including general hospitals and specialty behavioral health hospitals.

Medicaid because, in many cases Medicaid covers these services and information about states’ Medicaid benefit packages are accessible to the public. Data sources (Appendix B) used included Medicaid Provider Manuals; Medicaid Member Handbooks; Medicaid Billing Manuals; Medicaid Waiver manuals; and Medicaid agency websites. When these methods were not sufficient, we conducted internet keyword searches (e.g., state name, crisis type of services, Medicaid).


We found that all 50 states and the District of Columbia indicated that they use Medicaid funds to finance some form of crisis services in 2012. Identifying the specific types of crisis services that states cover under Medicaid proved to be more difficult; however. Many states do not post Medicaid crisis service definitions in one place online. Many states provide different manuals for different provider types; therefore, crisis services are found in many different locations.


Also, Medicaid regulations outline, but do not necessarily or consistently define, the types of services states can provide. Therefore, states vary widely in how they describe their services. Some states may offer a variety of services under a single program name. For example, “crisis intervention” may include mobile crisis. In some instances, services that are covered within a broad category are clearly delineated, and in other instances, there are no narrower definitions of services contained within. The term crisis stabilization was used by many states to describe crisis residential services; however, some other states, further defined crisis residential services, crisis respite services, and stabilization services.


Finally, different states use different mechanisms to publish Medicaid service definitions. While many states publish Medicaid crisis services in various Medicaid manuals, some states have defined services in state legislative code, which can be difficult to identify.


Table 1 provides information on some states that use Medicaid funding to support various types of crisis services. Due to the aforementioned reasons, this list is not exhaustive; however, it does show the variety of states that are funding crisis services through Medicaid.


Our environmental scan shows that many states are funding mobile crisis services through Medicaid. Short term crisis residential services and crisis stabilization are also funded by many states. Of note, 15 states are funding peer crisis services through Medicaid, while additional states are using Medicaid funding to support other types of peer support services.


Table 1. Examples of Medicaid Funded Crisis Services by State Crisis Services

State

23-hour crisis stabilization/observation beds

FL

Short term crisis residential services and crisis stabilization

CA, HI, IL, MI, MN, MS, NM, OR, WI

Mobile crisis services

AZ, CT, DE, FL, HI, MS, NC, NJ, NM, OK, VT, WI

Psychiatric advance directive statements

IA, NC, WA

Peer crisis services

AK, AR, GA, IA, IN, KS, KY, MA, MN, MD, MI, MT, OK, SC, WA

funding for such care. ACS also provides aftercare in order to reduce the reoccurrence of crises.
Wisconsin relies on state policy to ensure a crisis services continuum. Wisconsin’s administrative rule requires counties to provide a minimum of mobile crisis services, a crisis hotline, and a crisis walk-in center for Medicaid funding. Crisis stabilization may also be provided, but it is optional for counties.
Although all states interviewed provide mobile crisis services, geographic accessibility varies from state to state. Many states struggle with provision of mobile crisis services in rural areas. Michigan has mobile crisis teams, but they are available in urban areas only. Tennessee services are structured so that there is mobile crisis team coverage for the entire state. However, in situations in which the individual in crisis is too far away for the mobile crisis team to provide timely services, the individual can go to the regional mental health center for telemedicine or other treatment services. Texas reports having at least one mobile crisis team in each county, and larger counties have more than one team.


Many states are involving peers in the operation of crisis services. Peers are included in a variety of roles, including certified peer specialists who are included on mobile crisis teams in Tennessee, and peers who staff the central crisis call line along with mental health professionals in Maine. Peers also play a central role in the operation of crisis service in some states. Massachusetts supports a peer-run respite program, and Wisconsin has 11 peer-run warm lines across the state.


Some form of a crisis hot line or warm line is provided by all states interviewed. Their 24-hour crisis hotlines are provided via a central statewide line or contractually required for local entities. Warm lines staffed by trained peers are available in Maine, Massachusetts, Missouri, Texas, and Wisconsin.
Many states have a variety of programs that include work with law enforcement as an adjunct to the crisis services continuum. The Massachusetts state mental health agency is partnering with police for jail diversion programs. Some partnerships with police follow the model of including a mental health worker who rides along with the police to respond to crisis 911 calls. Other states including Maine, Missouri, and Tennessee partner with law enforcement through Crisis Intervention Teams (CIT), which are teams of police officers who have received specialized training in mental illness and crisis intervention techniques.


Crisis Services Infrastructure and Collaboration


Provision of crisis services occurs in a variety of manners. States with Medicaid managed care—such as Massachusetts, Tennessee, and Michigan—provide crisis services to individuals who are eligible for Medicaid through contracts with managed care organizations. Services for individuals who are not Medicaid eligible are covered under contracts or agreements between state mental health agencies and managed care organizations.


In Massachusetts, The Massachusetts Department of Mental Health (DMH) and MassHealth (the state Medicaid agency) are key partners in the provision of crisis services. Through an Interagency Service Agreement between DMH and MassHealth, most emergency services are provided through MassHealth’s mental health and substance abuse vendor, Massachusetts Behavioral Health Partnership. Community-based services are provided by DMH directly or through contracted vendors.


Tennessee provides all publically-funded mental health and substance abuse crisis services through a managed care system. The state has reported that, because of the flexibility of their TennCare Medicaid waiver and use of state funds, they have a mental health crisis system that works well. The overarching goal of crisis services is to serve people in the least restrictive setting. The Tennessee system serves all who present for services, regardless of their insurance status.


The Michigan Department of Community Health (the state mental health agency) contracts with the Prepaid Inpatient Health Plans (PIHPS) to provide Medicaid managed behavioral health services and with Community Mental Health Service Providers (CMHSPs) to provide crisis services to individuals who are not eligible for Medicaid using allocated state general funds. CMHSPS and PIHPs are funded at a capitated rate, and performance and service standards are delineated in the contracts. Medicaid health plans are responsible for individuals with mild to moderate symptoms; however, if these individuals are in crisis, responsibility for treatment transfers to the behavioral health carve-out plan.


States that do not have Medicaid managed behavioral health care use a variety of mechanisms to provide crisis services. In Maine, crisis services are purchased from private behavioral health 24
organizations through a request for proposal (RFP) process. Services are managed via performance contracts and a formal review of crisis services is conducted every two years.


Illinois contracts with a limited number of hospitals for short-term acute treatment, and funds community support, and Mobile Crisis Teams. Crisis residential services are funded by the state but operated by community mental health agencies. In Wisconsin, counties are responsible for the development and delivery of crisis services. The state provides supervision, regulations, and funding along with optional county support. Counties can also collaborate with one another where the economies of scale call for more shared services across less densely populated areas. Medicaid pays for most of the services, and there are Medicaid-certified, level-two crisis programs in 56 of the 72 counties. The remaining level-one counties provide limited walk-in, hotline, and crisis triage services.


Many states are developing collaborative relationships in order to improve the delivery of crisis services. Missouri reports that the state is spearheading efforts to improve linkages between regional community mental health centers, the crisis system, and Missouri’s hospital association. In Massachusetts, the state has developed ED alternatives for individuals with behavioral health crises, and has also assembled best practice committees, which include representatives from the Department of Mental Health, The Department of Public Health, ED staff, and consumers. The Department of Mental Health has also convened workgroups to address ED wait times and access to acute care services. They also seek to improve the service referral process, including a new, statewide referral process for inpatient specialty units. Finally, they promote community-based medical screening. In Massachusetts, there are also routine regional meetings among community-based providers, inpatient facilities, and EDs.


Maine reports that both the size of the state and the remote nature of some of the state’s population pose challenges to geographic accessibility for individuals in crisis. Thus, individuals often use hospital EDs to receive services because they are closer than the crisis stabilization units. To address this, Maine provides web-based training for emergency staff. The state also has ED visit reduction projects that target individuals with multiple chronic conditions.


Funding Crisis Services


The states are using a wide variety of funding sources to provide a core continuum of crisis services. All states participating in this project reported using state general funds, state Medicaid match, and Medicaid, including Medicaid Rehabilitation Option and 1115, 1915(b), and 1915(c) waiver funds. Some states reported using other funding sources to various degrees, including federal grants (e.g., SAMHSA’s mental health and substance abuse block grants, Projects for Assistance in Transition from Homelessness [PATH] grants, and Cross Area Service Program [CASP] grants), local government, first-party payments (self-pay), and third-party payments (private insurance). A summary of crisis services and funding sources by states is provided in Table 4.


As reported by the states, each funding source presents opportunities and challenges in providing crisis services. These issues are summarized by funding source below.


State Funding. State funding, along with Medicaid, represents the largest proportion of crisis services funding for states. States reported using state funding for many purposes and to fill in gaps from other funding sources. State funding is used to finance services for which there are no other billable insurance sources. Examples include the operation of crisis hotlines and warm lines; mobile crisis programs in states that do not bill Medicaid for these services; and services for individuals with Medicare, the 25
uninsured, or those seeking services outside of their catchment area. State funds are also used for infrastructure for crisis services to fund facilities or pay staff salaries. For example, four of the 21 ESPs in the state of Massachusetts are operated by state personnel and are therefore primarily SMHA funded, although Medicaid-eligible services provided by the programs are billed to Medicaid.
Some states earmark state funds for specific crisis services. For example, many individuals in Massachusetts with behavioral health crises experience lengthy ED wait times because they lack health insurance. To ameliorate this, the state spends approximately $10 to $12 million to support the uninsured and Medicare-only populations. The state also gives $18 million to the state’s Medicaid agency (MassHealth), which uses some of this funding to provide services to individuals with Medicare. For those without insurance, SMHA funding is issued to fund crisis services for the uninsured through an inter-agency transfer of funds to the Medicaid PIHP. There are plans in the future for funding to serve the uninsured to run through all of the six Massachusetts managed care programs.


Medicaid. Medicaid covers a significant amount of crisis care for interviewed states. States with Medicaid managed care tend to combine state and Medicaid funds to operate their crisis services programs. For example, Massachusetts uses two main funding streams for its emergency crisis services program: state general funds and Medicaid funds. Medicaid funds include 1115 Waiver funds and funds available under the Medicaid state plan. The two streams of funds are combined to operate one program. In Tennessee, state funding and Medicaid are woven together to create a crisis services system that is mandated to serve all who present for services, regardless of their insurance status. Crisis residential and emergency crisis services are provided through the state’s 1115 Medicaid waiver. The crisis stabilization units receive a base amount of funding. The mobile crisis teams are funded at a flat, per capita rate through Medicaid waiver funds and with state general funds. The crisis stabilization units are funded through state general funds, although they can also use Medicaid waiver funds.


Some states are working to ensure appropriate use of Medicaid funds for crisis services. For example, Michigan has established an electronic system allowing the center to immediately determine if the individual is covered by Medicaid. Maine reports that the Maine State Mental Health Agency is working with the State Medicaid Agency for increased Medicaid coverage for crisis services.
Some states publish their Medicaid crisis services rates. Table 4 provides information on the available Medicaid crisis services rates for the states interviewed.


Table 4. Medicaid Crisis Residential and Crisis Intervention Rates State

Medicaid Crisis Residential Rates

Medicaid Crisis Intervention Rates

Maine

Billed a per diem basis (rates not currently available)

Billed in 15-minute increments (rates not currently available)

Massachusetts

Not available

Medicaid is billed a single rate per episode—currently $500 per episode

Michigan

Billed at $288 per day

Billed at $53 per 15 minutes

Providing Crisis Services


Tennessee provides all publically funded crisis mental health and substance abuse services through a managed care system. The state has reported that, because of the flexibility of their TennCare Medicaid waiver and use of state funds, they have a mental health crisis system that works well. The overarching goal of crisis services is to serve people in the least restrictive setting. The system serves all who present for services, regardless of their insurance status.


The state has reached out to several stakeholders to improve services for those in behavioral health crisis. They have partnered with the state’s largest employer of emergency department staff to provide updates on available crisis and noncrisis services and have partnered with the Tennessee Hospital Association in crisis workgroups. The state also collaborates with law enforcement through crisis intervention teams—a program that originally began in Memphis—and with schools through school-based mental health liaisons.
Tennessee has noted barriers in providing timely crisis services to rural areas compared to suburban and urban areas. To address this, in situations where a mobile crisis team is too far away from the individual in crisis to provide timely services, the individual can go to a regional mental health center for telemedicine or other treatment services. The state notes that telemedicine can only be billed if the consumer is physically located in a mental health center, and the state would like to be able to bill for telemedicine to directly contact a consumer in his or her home or place of crisis.


Funding Crisis Services


Crisis services are funded via the state general funds, SAMHSA’s mental health block grant, local government, first-party payments (self-pay) and third-party payments (private insurance). Crisis residential and emergency or crisis services are provided through the state’s 1115 Medicaid waiver. The crisis stabilization units receive a base amount of funding. The mobile crisis teams are funded at a flat, per capita rate through Medicaid waiver funds and with state general funds. The crisis stabilization units are funded through state general funds, although they can also use Medicaid waiver funds. Approximately 70 percent of the individuals served are uninsured. In Tennessee, Medicare typically does not cover crisis services, so those covered by Medicare only and uninsured consumers are covered through general funds. Private insurance pays for about two percent of those receiving services. Warm lines are funded through state general funds and Medicaid managed care funds. The crisis intervention teams are funded through local grants.


Texas
Types of Crisis Services Provided
The Department of State Health Services (DSHS) funds 14 facility-based emergency service centers with a budget of $30 million. These centers provide extended observation and jail diversion services, and they are developing community alternatives to state-funded psychiatric hospitalization. These psychiatric emergency centers also assist individuals in psychiatric crisis in general hospital waiting rooms. The state hospitals also have an “over capacity” plan that diverts individuals to other state psychiatric hospitals when that hospital is full, thus allowing for full utilization of all service system beds. 40
DSHS funds crisis hotlines, mobile crisis outreach, outpatient crisis services, residential crisis services, extended observation, crisis stabilization, and crisis respite. The state also has rapid crisis stabilization beds, in which state funds are used to pay for private hospital beds for crisis stabilization.


Providing Crisis Services
In Texas, all counties have mobile crisis teams with the larger counties hosting multiple teams. Each county also hosts a locally run hotline, which also work as warm lines. Some counties have mental health deputy programs that work with local law enforcement. As previously mentioned, there are 14 facility-based emergency service centers located across the state.


Although Texas utilizes telemedicine, very little telemedicine is applied to crisis services. Rural areas are typically served by on-call crisis clinicians who are deployed from their homes. The Texas SMHA is also responsible for substance abuse services and notes that provision of substance abuse crisis services can be more difficult than mental health crisis services. There is a dearth of funding and services for detoxification in many parts of the state.


Funding Crisis Services
In Texas, crisis services are funded in a variety of ways including state general funds, state Medicaid match, the Medicaid Rehabilitation Option, a Medicaid 1915(b) waiver, a Medicaid 1115 waiver, Federal Emergency Management Agency (FEMA) funds, and local government funding. In FY 2012, there were over $82 million in general funds for crisis services. This figure includes services for adults and youth, but excludes state and community hospital beds.


Individuals who receive services through the state’s Medicaid waiver programs are provided with crisis services through the waiver. Emergency and crisis services are provided through the state’s 1115 Medicaid waiver and the 1915(b) waiver. The 1915(b) waiver also covers crisis residential services in Texas. About 40 percent of those served by crisis services programs are covered by Medicaid, with the remaining 60 percent being uninsured and covered by state general and local funds.


In Texas, hotlines are funded through state general and local funds and warm lines are typically funded through state general funds and the mental health block grant. Medicare does not reimburse for crisis services in Texas.


Texas reports that providing crisis services to individuals with mental and substance use disorders can be complicated. Texas has limits on what substance abuse services Medicaid will cover. Providers bill Medicaid when possible; however, Medicaid cannot be billed if an individual is determined to have a substance use-related crisis. The SMHA perceives that these unreimbursed crisis services divert individuals from hospitalizations.


State officials report that facility licensure can be problematic in serving those with comorbid mental and substance use disorders who are in crisis. The state would like to have facilities that are able to address both mental health and substance abuse services—to provide detoxification and crisis residential levels of care. However, negotiating between these two types of services is difficult because of licensing and billing rules. Texas is working to develop a new licensing category that will cover both detoxification and crisis residential services.


Regulations regarding Institutes of Mental Disease (IMD) are seen as a barrier to providing crisis services in Texas. Crisis facilities are used to serve multiple populations and purposes. However, there is concern that increasing facility capacity to over 16 beds may result in these programs receiving IMD classification and becoming ineligible for Medicaid reimbursement. For example, some programs see a need to add beds for competency restoration and crisis residential services; however, this expansion could cause facilities to be reclassified as IMDs.


The Texas SMHA agency perceives that current rates for crisis services are a barrier to their successful implementation. Rates are insufficient, particularly in rural areas, to pay for the “fire-house” staffing model that is needed for most crisis services programs. The currently published maximum allowable Medicaid rate for Crisis Intervention is $31.33 per 15 minutes.


Wisconsin
Types of Crisis Services Provided
In Wisconsin’s Administrative Code for Crisis Services, there are two levels of certification. Each county is required to provide a basic level of crisis services (level one). Most counties are certified to provide more extensive services (level two), although they are not required to do so. This certification is required if a county wants to be eligible for Medicaid and other third-party reimbursement. Level two counties are required to provide walk-in services 5 days per week and telephone services 24 hours per day, 7 days per week, and 365 days per year. They must also provide mobility services 7 days per week that are not available 24 hours per day but are available at times of peak use, which is generally between 7 a.m. and 11 p.m. For level two counties, residential crisis services are optional for qualifying for Medicaid certification. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is used for alcohol and drug abuse issues. Some counties provide medically monitored, nonhospital-based, social detoxification programs with crisis stabilization.


Providing Crisis Services


Counties are responsible for the provision of most services, and Medicaid pays for most of the services. There are Medicaid-certified, level-two crisis programs in 56 of the 72 counties. Individual Peer support is often provided by the counties as part of the staffing, but it is not a requirement. In addition to individual peer support, the governor is proposing funding for three peer-run centers. Warm lines exist in just a few large urban areas of the state because of limited availability of funding. Individuals can obtain services regardless of their insurance status if there is an emergency. There is no central warm line, but there are 11 peer-run warm line programs.


Milwaukee has a Wraparound program that takes a systems-of-care approach. The Milwaukee Wraparound program grew out of a SAMHSA Systems of Care grant and is focused on children and adolescents. The base funding for the Milwaukee Wraparound is from Medicaid, with a mix of additional dollars from juvenile justice funds and child welfare. The program members have expanded their role and now work with the local school district to provide services for children in schools who are experiencing crises. Wisconsin also has CIT programs in a number of regions. Milwaukee is about to initiate CIT trained officers used as second responders which will be funded by state general funds.


Wisconsin created a new state statute in 2009 that requires law enforcement to consult with county mental health authorities—which often means the county crisis service—before emergency detentions 42
can be initiated. As a result, Wisconsin has seen a 32 percent decrease in emergency detentions, a 73 percent increase in the use of crisis services, and a decrease in state hospital admissions.


Funding Crisis Services


Crisis services are funded via the state general funds, Medicaid FFP matched by local funds under the Medicaid Rehabilitation Option, the Clinic Option, and waivers. Other funding sources include SAMHSA’s mental health block grant, local government, first-party payments (self-pay), and third-party payments (private insurance). Counties are responsible for the total cost of hospitalization for persons who are civilly committed between the ages of 22 and 64, although counties are also responsible if there is no other source of funding regardless of the individual’s age. Milwaukee’s Wraparound services are funded through a Medicaid 1915a waiver.


Wisconsin respondents noted many challenges in funding crisis services. The primary funding challenges are related to the number of uninsured individuals who use services and the difficulties experienced by the smaller, less-populated counties in funding and organizing services. An additional cited challenge was the reticence of private insurance companies to pay for crisis services. Under Wisconsin law, crisis programs are eligible for third-party reimbursement, but private insurance companies are not required to provide or reimburse these services. Some private insurance companies do have contracts with crisis programs. Additionally, insurance companies define medical necessity differently than do the county service providers. They often require that services be provided by individuals with a master’s degree or higher and decline payment for services that are not part of their list of plan providers, even if the consumer is suicidal. The state has informed insurers that they are required to pay for crisis services, but they have had limited success in getting insurers to meet these obligations.


In Wisconsin, counties bill the most appropriate funding source for the episode. In instances where there is a gap in funding for a particular service episode, counties use their own resources or general state funding. Collaborations with law enforcement have been funded by general funds, in part through hospital diversion funds that became available as a result of state psychiatric hospital closures.


In Wisconsin, the Medicaid maximum allowable contracted rate for crisis intervention ranges from $47.42 per hour for a paraprofessional, to $88.90 per hour for an individual with a bachelors or master’s degree to $148.16 per hour for a nurse practitioner or psychiatrist. The Medicaid per diem rate for crisis intervention is $139.54.


Wraparound Milwaukee: A Model of Blended Funding


We also interviewed the director of the blended funding program known as Wraparound Milwaukee and provide a description below as an example of blended funding used in support of crisis services.
The expansion of children’s mental health services has been a long-standing goal of the Wisconsin Council on Mental Health (WCMH), parents, providers, advocates, and the Department of Health Services. Through increased funding from the Mental Health Block Grant, the CST initiative began in December 2002 with collaboration between multiple systems: mental health, child welfare, substance abuse, juvenile justice, and public instruction. Initiative funding is made available through a blend of mental health block grant and substance abuse block grant funds, state general purpose revenue, and child welfare dollars. Current funding is approximately $42 million and serves over 1400 children with serious emotional disturbance annually. This funding is being used to transform service delivery to families who require substance abuse, mental health, and/or child welfare services.


Target Population


The target population for Wraparound Milwaukee is youth who have mental health needs who are identified by the child welfare or juvenile justice system as being at immediate risk of residential or correctional placement or psychiatric hospitalization (served in two or more childserving systems). However, the program is designed to provide limited services to families of any child who presents in crisis.


Service Description


The program has several core components including care coordination, the child and family team, the Mobile Urgent Treatment Team (MUTT)—a mobile crisis team that is available to meet the needs of youth and families when a care coordinator might not be available—and a provider network with more than 170 agencies that responds to the multiple needs of youth and families.


Youth can be referred to Wraparound Milwaukee from any system (e.g., mental health, child welfare, juvenile justice, and soon also the school system). Eligibility is then determined by a screening or assessment. Following eligibility determination, care coordinators are assigned to each family through one of nine agencies under contract to Wraparound Milwaukee. Care coordinators conduct an inventory, convene the child and family team, and develop the care or treatment plan. Wraparound Milwaukee contracts with nine community agencies for the approximately 72 care coordinators who facilitate the delivery of services and other supports to families. Wraparound Milwaukee has also organized an extensive provider network of 204 agency and individual providers that can offer an array of over 80 services to families.


The program covers specialized mobile crisis, mobile crisis one-on-ones, and crisis group home services. Wraparound Milwaukee also operates all mobile crisis services for Milwaukee County with specialized contracts with child welfare and the Milwaukee Public Schools System. All families that are enrolled in Wraparound Milwaukee also have access to the Wraparound Milwaukee MUTT, which also serves as a “gate keeper” on all inpatient psychiatric hospitalizations. The team includes psychologists, social workers, nurses, a case manager, and a consulting physician. These individuals provide crisis intervention services on a 24-hour basis to families enrolled in the Wraparound Milwaukee Program. In addition, the MUTT provides services to any family in Milwaukee County with a child who is having a mental health crisis when the behavior of the child threatens his or her removal from home, school, etc. The MUTT team goes to where the crisis is occurring, assesses the situation, and determines if the child's behavior or mental health condition can be met with interventions in the home, or whether temporary placement in a crisis group home or other emergency setting is required. The MUTT team also assesses whether the child's behavior constitutes a danger to that child or others requiring possible psychiatric inpatient hospitalization. In addition to crisis intervention services, the Team can provide short-term case management and can link the child and family to other community services. The MUTT team oversees the operation of an 8-bed crisis/respite group home, which can serve as an alternative to inpatient hospitalization or resource for the child to transition from the inpatient facility.


Blended Funding Approach


The Wraparound Milwaukee program is funding through multiple systems including: Medicaid, child welfare, delinquency, and court services. The use of blended funding has been particularly important to the success of the program. The project is sustained by pooled funds that come from the system partners. Blending from these multiple sources allows for a flexible and comprehensive array of services. 44
The program receives a flat monthly fee for each client and must pay for all treatment services, including incarceration and residential care. The Milwaukee County Behavioral Health Division operates Wraparound Milwaukee, pools the funding streams, and the funds are managed using managed care principles with providers. Wraparound Milwaukee manages the disbursements of funds which are “decategorized,” so that the program can use them to cover any services that families need, in a mix of formal and informal services.


Medicaid provides for the highest proportion of funds through a capitated arrangement per child per month and some feeforservice funds that are billed for crisis services. Child welfare provides case rate funding for youth who are active within the system. Delinquency and court services provide funds through fixed budget and case rate.


Wraparound Milwaukee has proved to be a successful endeavor in that it has reduced the number of youth in high-end residential treatment centers in Milwaukee from an average of 375 youth to 80 youth annually. Additionally, the program has reduced the utilization of inpatient Medicaid psychiatric hospitalization days from over 5000 to 500 days per year, significantly reducing inpatient treatment costs. Finally, child welfare & delinquency services have not had to put additional monies into the care of youth in residential treatment since 1997 –their base level of funding has remained at the same $18.5 million, additional evidence of system savings. Wraparound Milwaukee is a nationally recognized model program that has successfully used blended funding to provide crisis services for children at risk of out of home placement.


Illinois
Types of Crisis Services Provided
The Illinois Medicaid policy defines crisis intervention services as including preliminary assessments, brief therapy, and case management/linkage services that are necessary for the resolution of the crisis. These services may be provided in an office or within the community.


In addition, Illinois provides residential care services and hotlines that are operated by community mental health centers. They have also developed specialized programs that are located in regions of the state where the state psychiatric hospitals have been closed. These programs—Emergency Disposition and Assessment (EDA) services and Acute Community Services (ACS)—provide immediate assessment, intervention, and referral to appropriate levels of care for individuals with no other funding for such care. ACS also provides aftercare in order to reduce the reoccurrence of crises.


Providing Crisis Services
Illinois contracts with a limited number of hospitals for short-term acute treatment and funds community support, and Mobile Crisis Teams. Crisis residential services are funded by the state but operated by community mental health agencies. Each crisis residential center was developed according to the community’s needs rather than using a single, predefined service model.


The Division of Mental Health and Division of Substance Abuse have created a dual-disorder crisis residential program serving two areas of the state. The Division of Mental Health is also working with a task force to develop specialized crisis intervention services, such as working with sexual assault services providers on crisis interventions. Some of these partnerships are funded through grant money from the state general funds, and some pursue federal grants.


Funding Crisis Services
In Illinois, crisis services are funded via state general funds, the state’s Medicaid match, the Medicaid Rehabilitation Option and local government funds. In State Fiscal Year 2012, Illinois expended the following on crisis services: $6.8 million in Medicaid, $5.4 million in non-Medicaid funding, $10.6 million in capacity grant funding, and $4.2 million in crisis residential grant funding. Crisis services accounted for approximately 4.4 percent of the total SMHA service expenditures. The state uses a capitated rate for its EDA and ACS services. Often, the individuals receiving crisis services are not Medicaid eligible.
Illinois noted difficulty with providing crisis services in rural areas where adequate coverage is an issue, whereas wait times are a problem in the densely populated areas. Another challenge noted is the shortage of highly skilled clinicians, particularly psychiatrists. The state is working to improve access to crisis services provided by peers. The state is also working to expand the use of telemedicine within crisis services.
Medicaid rates for crisis residential services are billable on a per diem basis; however rates are not provided. Crisis Intervention is billed to Medicaid from $29.97 to $47.77 per 15 minutes, depending upon staff credentials and place of service (i.e., mental health site, home-based or off-site).


Introduction
Following a disaster of such magnitude that the President has declared it as eligible for Federal assistance, communities are often in chaos and individual survivors are undergoing their own feelings of disbelief and shock. It is within this context communities must respond to the emotional needs of their residents: adults and children. Adults living in the impacted area must balance their roles as survivors, responders and caregivers during this time of turmoil. They are often overwhelmed with the responsibility and immediate tasks of crisis response and recovery and must take time to meet the physical and emotional needs of themselves and family members and respond to the needs of the larger community. Consequently, children may be left in the care of unfamiliar persons or provided with limited explanations of what has actually happened.


Disaster response workers, who are providing crisis counseling and emotional recovery assistance, need to be sensitive to the emotional vulnerability of children. The materials discussed herein will give crisis response workers essential infor­mation about the impact of disasters on individuals, how the trauma associated with such events impacts children, the unique world of children, and the diversity of family structures in which children reside.


A special emphasis is placed on assisting child health workers to understand children as uniquely different from adults, and childhood as distinct from adult­hood. Child health workers must engage children in the ever changing and qualitatively distinct world of emotional and cognitive stages of development in which children find themselves. The purpose of the manual is to achieve a better understanding of the world of children and the nature of disaster response.


The manual also provides information and guidance for the broader group of individuals concerned with the mental health needs of children who experience major disasters, and may include the following:

Experienced mental health professionals who specialize in working with families and their children who experience serious emotional disorders;
Experienced mental health professionals who specialize in working with families and their children who experience serious emotional disorders;
Other health professionals such as physicians, physician assistants, nurses, and rehabilitation specialists who are experienced in working with children;
Professional and paraprofessional workers who provide crisis and suicide intervention services, case managers, and other public health and social service personnel who work with children on a regular basis;x Introduction

School and licensed day care center personnel, including teachers, teach­ers’ aides, guidance counselors, school social workers and psychologists, and administrators;
Nonprofessional volunteers from the community who have little or no training, but who have had personal experience with their own and neigh­bor’s children; and,
Adults who routinely work with children either as volunteers, or as paid service providers or caregivers who have a strong commitment to helping children in times of crisis. 1 The World of Childhood and the Developing Child


CHAPTER 1
The World of Childhood and the Developing Child
Children are one of the most vulnerable groups during and following a disaster. A disaster is a strange event that is not easily understood. It is emo­tionally confusing and frightening and results in children needing significant instrumental and emotional support from adults. Children, parents, and whole families in need of assistance are found at shelters, recovery centers, and other locations. A review of some basic principles and reminders from child devel­opmental theory show how a child’s current stage of development influences their behavior and their understanding of traumatic events associated with the disaster. Below is a list of basic principles that may be helpful as we, the helpers, are rapidly trying to determine the best strategy for providing assistance to chil­dren in both the early stages of crisis response and the later stages of emotional recovery from the disaster:

Be a supportive listener.
Be sensitive to the child’s cultural, ethnic, and racial experiences.
Respond in a way that is consistent with the child’s level of development.
Be aware of the child’s emotional status. Is the child actively afraid or withdrawn?
Determine if the child is comfortable/secure about his/her current surround­ings and those of his or her parents, and other significant persons/pets,
Assist the child in normalizing his/her experiences.
Seek assistance from a child specialist or mental health professional, if necessary. Assistance is needed when the helper does not know what to do or think or if he or she is making things worse.


Theories of Child Development
An abundance of popular press is available on the subject of children. Topical areas of interest include how to raise, parent, educate, and discipline children. It is important, especially when one is in a period of stress and turmoil, to step back from the issues at hand and assess the current situation from the perspective of life during non-crisis routine times. This is especially true when engaging children.


The most important concept to remember is that children are different from adults; childhood is different from adulthood. As trained child health workers or 2 The World of Childhood and the Developing Child
disaster mental health outreach workers who encounter children as survivors of a disaster, the preceding statement seems with a moment’s reflection as obvious. In fact, the reality is so obvious that it is often overlooked.


Jean Piaget, renowned for his elegant theory of child development, formulated much of his theory from simply observing how his own children responded to their environment. Piaget, the scientist-observer, systematically confronted his children at different chronological ages with various mental challenges and recorded his observations of their responses. Classic examples from his work illustrate how children perceive the world differently at various chronological ages.


Piaget (Flavell, 1963) noted young children have difficulty observing objects from more than one perspective. For example, a seven-year-old is shown two glass containers: one is short, wide, and filled with water; the other is empty, tall, and slim in shape. The child is convinced that when the liquid from the short container is transferred to the tall one, the volume of the contents actu­ally changes as well. Similarly, when a child of ten or eleven is asked to solve a problem that requires abstract reasoning, such as a problem of logical infer­ence (i.e., a>b and b>c; therefore, a>c), the child is often baffled by the solution. However, when the same problem is presented with solid objects, it is easily solved. Because the objects are concrete and readily visible, he or she easily recognizes the relationship. An adolescent, on the other hand, can solve this problem in the “abstract” by creating mental images of a, b, and c and then solving the problem in his or her head.


Piaget was trained as a biologist and based much of his theory of development on the notion that organisms seek homeostasis or a steady state of balance or equilib­rium. With respect to humans, he postulated that as we grow we change internally and thus, our capacity to engage the environment changes as well. Throughout our development we experience states of disequilibrium and seek to return to a state of equilibrium. The mechanisms he proposed are two active processes of assimilation and accommodation. Simply put, assimilation is the process of interpreting new information within the context of our existing cognitive structure, while simultane­ously accommodating to the new information or demands of our environment. Through the tension of these two ongoing processes we develop our cognitive knowledge and capacities. Thus, we develop from an infant who responds primarily to sensations to an adult who is capable of complex abstract reasoning.


All of us can recall conversations with friends who related their frustration as parents, complaining that their children are disobedient and refuse to do their chores. Is this refusal to behave and do the chores simply because the child is 3.


disobedient? Or is it because the parent is issuing commands in a manner that requires the child to translate the “abstract” orders into concrete actions, when they have not yet developed the necessary cognitive skills? While a comprehen­sive discussion of cognitive developmental theories is beyond the scope of the subject at hand, it is important to recognize that children think and construct their responses to the world in different ways depending on their current level or stage of cognitive development.


In summary, we should be aware when we meet a child that they are operat­ing in the world with a different set of cognitive structures than adults and are interpreting information from the environment in a different fashion. In the next chapter, there are a number of illustrations of how this actually works.
Cosario (1997) recently reasserted that when trying to understand children, we must remember that childhood is not simply an apprenticeship to the “real” world of adulthood, but is the current world in which children operate. It is the environment in which cognitive, social, and emotional development occur for individual children. “Children create and participate in their own unique peer cultures by creatively taking or appropriating information from the adult world to address their own peer concerns” (p.18). Hartup (1979) suggests that children really experience two worlds: the world of adult-child interactions, such as with teachers and parents, and the world of peer interactions with children of similar age. We must be aware of the simultaneous presence of both these environments to understand and relate to children as developing individuals.


The emotional development of children parallels, complements, and interacts with their cognitive development. Kagan (1982) has shown in studies of normal infant development that when confronted with new and different information infants may smile if the information is successfully integrated, and they show fear by crying or withdrawing if they cannot make sense of the information. The study of emotional development affirms that emotions are central to survival. Through emotional expression the infant expresses distress (a soiled diaper or hunger), pleasure (being comfortable and having a full stomach), and fear of strangers. As children in middle school and high school, we learn to respect the social standard of non-aggression toward peers and acquire the skills necessary to problem solve conflicts and modulate emotional expression accordingly. By adolescence we are well skilled in expressing empathy, pride, shame, guilt, and other emotions. Thus, throughout normal development we learn more sophisticated strategies of emotional expression.


Closely tied to emotional development is the development of attachment. Attachment theory as originally developed by John Bowlby (1982) integrates 4 The World of Childhood and the Developing Child
psychoanalytic concepts of child development with parts of cognitive psychol­ogy, ethnology, and human information processing. He defines attachment theory as a way of conceptualizing “… the propensity of human beings to make strong affectional bonds to particular others, and of explaining the many forms of emotional distress and personality disturbance including anxiety, anger, depres­sion, and emotional detachment to which unwilling separation and loss give rise” (Bowlby, 1982, p. 39). Attachment refers to the affectional bond that forms between a nurturing figure, usually the mother, and her child in the course of time and in response to consistent care. Bowlby states that there is an innate tendency within the human baby to seek and maintain proximity to the attach­ment figure. This behavior has the function of protecting children from the risk of harm.


Mary Main (1996) recently reviewed the field of attachment research. In the years since Bowlby’s original formulation, the concept of attachment has been extended beyond infancy to account for behavior throughout the life span. Main has affirmed that the development of the attachment relationship is based on social interaction. In the overwhelming majority of instances children become securely attached to a nurturing caregiver. Children also become attached to mal­treating parents and the resulting attachment bond is expressed as an insecure attachment. The quality of the attachment bond is usually established by seven to eight months of age and is characterized as secure or insecure. Secure attach­ment is the result of an infant being able to rely on the caregiver as consistently available and nurturing. Infants who have incompetent, uncaring, or inconsistent caregivers express insecure attachment behavior. Insecure attachment behaviors related to separation and reunion with the caregiver range from ignoring the caregiver to excessive and disquieting expressions of distress.


Being securely attached to a nurturing caregiver is further expressed by using the caregiver as a “secure base” for exploring one’s immediate environment. For example, a small child playing in the park will run and play far away from his or her mother as long as he or she is in visual proximity. The child will wander farther and farther away only to spontaneously return to his or her mother and soon wander off again in spirited play. Just as the child displays organized and confident behaviors while in the comforting presence of the caregiver, he or she can also appear disorganized and highly anxious or fearful upon separation or loss of the caregiver. Brief separations from one’s parents is a common event in disasters.


Upon separation and loss of proximity to the caregiver, the child will express fear and anxiety until again secure in the knowledge of the availability of the caregiver. As discussed earlier, infants and very young children must be ablephysically to see objects to keep them psychologically available. However, with time, children can build psychological representations of objects, people, and relationships. Recent research suggests that through maintenance of mental models of caregivers, children are influenced in their formation of relationships with peers and in the development of successful interactions with friends. In a similar vein, adolescents are influenced by models of adult caregivers as they begin developing long-term relationships with significant others.


To better understand normal and abnormal child development, much research has been conducted comparing the behavior of securely attached and insecurely attached children. Carlson and Sroufe (Main, 1996) have reported “ … in peer and school settings, children who felt secure as infants with their mother exhibit greater ego resilience as well as social and exploratory competence than insecure infants … Security with fathers also contributes favorably to outcome” (p. 240).


Disasters are events postulated with separation and loss. Irrespective of the quality of the child’s attachment to the caregiver as secure or insecure, unexpected separation and disruption of one’s secure environment results in fear, anxiety, and disorganization of one’s own behavior. Children who have experienced secure attachment relationships with a nurturing caregiver are the most resilient in reconcil­ing the disruption and recovering from traumatic events. The disruption and loss experienced will most likely be more difficult to resolve for children who have experienced insecure attachment relationships.


Cassidy (1996) summarized some basic findings from the study of attachment relationships:

Linkages exist between family and peer systems.
Children’s daily experiences with parents affect their concept of self and relationships with others.
Children with more positive relationships with peers express more positive behaviors.
More positive behaviors result in being better liked by peers.
In summary, the quality of parents’ caregiving behavior initiates a process linked with the quality of peer relationships throughout childhood and early adolescence.


Erik Erickson’s theory of psychosocial development (Santrock and Yussen, 1987) offers a perspective on a child’s social development. Erickson proposed that social development is the result of the interaction between internal biological forces and external cultural pressures. As such, he proposed eight stages of development throughout the life span. The conflicts one experiences at each stage can be resolved in either a positive (adaptive) or negative (mal-adaptive) way. For Erickson, the development of a psychologically healthy adult required the successful resolution of conflict at each developmental stage. He accounted for variation of emotional expression and behavior among individuals on their reso­lution of conflict along a continuum of healthy to unhealthy outcomes. The eight stages of psychosocial development coincide loosely with eight life stages. Five of these stages occur from infancy through adolescence.


Early infancy is the stage of ‘trust versus mistrust’ in which the infant learns to view the world as a place where one can trust others to be supportive and car­ing, or a place where the infant cannot consistently rely on the support and nur­turing of others. Late infancy is the stage of ‘autonomy versus shame and doubt’. In this stage autonomy is the ability to control one’s own actions, such as success­ful toileting. An inability to learn such control may result in feelings of shame and doubt. Early childhood is the stage of ‘initiative versus guilt’. The child is confronted with the conflict of relationships with parents and unresolved feelings of love and hate. Taking the initiative and engaging in positive social activities resolves conflict; failure to do so results in unresolved guilt. Middle childhood is the stage of ‘industry versus inferiority’. During this stage, the child’s cognitive knowledge, physical abilities, and social relationships are expanded. Upon com­parison of self with others, the child ultimately measures how he or she compares to peers. If the child feels incompetent and inferior, as opposed to competent and adequate, his or her interactions with others will differ than if the child feels confident in how he or she compares with peers. During the storm and stress of adolescent years, the child is confronted with the universally known stage of Erickson’s theory ‘identity versus identity confusion’. It is during this period that the child resolves the conflict between “who I am and what I want to be” and struggles to decide the direction of his or her life. Resolution of the conflict associated with identity marks the end of childhood and the emergence of adult role-taking in society. The remaining three stages continue to deal in a similar vein with issues of role performance and development throughout adulthood.


In summary, normative development throughout childhood is generally viewed as an active and complex process. It involves the ongoing maturation of the child and how he or she engages people and events, attachment to significant adults, social relationships with peers, intellectual and emotional development, and the actual world in which he or she lives. Childhood is the culture in which individual development occurs. The quality and characteristics of their environ­ment also directly influence the healthy development of children. Is it a setting where basic needs are a struggle to meet, where danger and fear of personal safety are daily concerns? Or is it a world that is predictable in its organization and resources? Is it a nurturing place with companionship or one of disregard and isolation?


When a natural or human-caused disaster invades the world of the child, the impact disrupts the normalcy of the environment and normative function­ing. Fortunately, most children enjoy successful and normal childhoods sur­rounded by adults and peers who can help them adjust to the impact of the disaster. Traumatic events can be successfully assimilated into their worlds within the context of their own individual development. For those children who are experiencing childhood as a negative environment and are actively developing maladaptive survival strategies, recovery from traumatic events will be a complex and time-consuming process. This can result in sustained and significant altera­tions in how successfully children are functioning in their world. For example, children may experience a drop in academic performance at school and disrup­tions in their social interactions with friends, siblings, or parents. Children who are experiencing such significant disruptions in their routine social and cogni­tive functioning may be at risk for developing Post Traumatic Stress Disorder (PTSD) or another form of emotional disorder.9 Reactions of Children to Disasters


CHAPTER 2


Reactions of Children to Disasters
Normal Reactions to Disaster Induced Stress


Most parents recognize when their children’s behavior indicates emotional distress. During routine, non-crisis times parents are tuned-in to the nuances of their children’s behavior. Most mothers can tell immediately if their young son or teenage daughter had a bad day at school or a fight with their best friend. A very common sign indicating distress is the sudden appearance of a very busy child, who just suddenly decides he or she will watch TV with his or her parents, and is not even particular about what they are watching. For most parents, this is when their antennae go up and somehow they know it is time to give that extra hug and just be available. Typically, a few words eventually pass between the parent and child. The parent smiles, the child looks relieved, and as quickly as the child appeared he or she vanishes back into his or her now somewhat reorganized and normal world. Under normal circumstances in the majority of nurturing families, they play this scene over and over and without really thinking anything of it. It is just a slice of daily life.


Disasters are not normal or routine and therefore, impose a significant abnor­mality on our daily routines. Everyone is affected. Typical modes of interacting with each other are strained. All of us are trying to get a grip on things and as a result focus less on supporting each other. It is within this context that children experience the aftermath of disasters.


The American Academy of Child and Adolescent Psychiatry (AACAP, 1998) suggests that a child’s reaction to a disaster, such as a hurricane, flood, fire, or earthquake, depends upon how much destruction is experienced during or after the event. The death of family members or friends is the most traumatic, followed by loss of the family home, school, special pets, and the extent of damage to the community. The degree of impact on children is also influenced by the destruction they experience second hand through television and other sources of media reports.


Generally, most children recover from the frightening experiences associ­ated with a disaster without professional intervention. Most simply need time to experience their world as a secure place again and their parents as nurturing caregivers who are also again in charge. 10 Reactions of Children to Disasters
Studies of how children have reacted to catastrophic events are limited. However, in the available work done on this topic there emerges a consistent pattern of responses and factors that influence the difficulty children may have in returning to their pre-disaster state. Yule and Canterbury (1994) reviewed a number of studies concerning children exposed to traumatic events. The types of reactions experienced by many children reported include feeling irritable, alone, and having difficulty talking to their parents. Many experience guilt for not being injured or losing their homes. Adolescents are prone to bouts of depression and anxiety, while younger children demonstrate regressive behaviors associated with earlier developmental stages. Many children who have difficulty reconciling their feelings will engage in play involving disaster themes and repetitive drawings of disaster events. It has also been demonstrated that children as young as two or three can recall events associated with disasters. The child’s level of cognitive development will influence their interpretation of the stressful events. Some studies reviewed by Yule and Canterbury suggest that the intellectual ability of the child, their sex, age, and family factors influence their recovery. Girls experience greater stress reactions than boys, bright children recover their pre-disaster functioning in school more rapidly, and families who have difficulty sharing their feelings experience greater distress. As expected, there also appears to be a direct relationship between the degree of exposure to frightening events and the difficulty in emotional adjust­ment and returning to pre-disaster functioning.
Other researchers have attempted to explain what factors influence children’s reactions to traumatic or stressful events. In their review of the emotional effects of disaster, Lewis Aptekar and Judith Boore (1990) report that one’s belief as to who or what caused the disaster and the degree of destruction are major factors influencing children’s reactions. These authors have also identified five additional factors that influence recovery from the traumatic event:

child’s developmental level
child’s premorbid mental health
community’s ability to offer support
parents’ presence or absence during the event
significant adults’ reaction


A more recent review by Vogel and Vernberg (1993) also suggests the influ­ence of children’s developmental level on their ability to comprehend traumatic events, their coping repertoire, and their involvement with other groups of people beyond the immediate family.


In a longitudinal study, Vernberg, LaGreca, Silverman, and Prinstein (1996) provided a thoughtful account of how elementary school children responded to the disastrous impact of Hurricane Andrew in Dade County, Florida. These researchers concluded that many symptoms experienced by these children could be understood using an integrated conceptual model first discussed by Green et al. (1991). Green et. al. investigated four factors:

exposure to traumatic events during and after the disaster
pre-existing child characteristics
post-disaster recovery environment (social support)
coping skills of the child
The model suggested by Vernberg, et al. (1996) increased the number of factors from four to five:

exposure to traumatic events during and after the disaster
pre-existing demographic characteristics
occurrence of major life stressors
availability of social support
type of coping strategies used to manage disaster-related stress


The primary focus of this study was to ascertain what factors influence the lingering symptoms and subsequent identification of children experiencing PTSD. The authors conclude that symptoms associated with PTSD could represent normal adaptive reactions and that for many children the effects of a disaster may still be observed beyond one to two years after the event. In trying to determine what made the various symptoms persist in these elementary age children, the researchers found the daily hassles of routine life in the weeks and months following the incident interacted with the severity of the trauma experi­enced making it difficult to recover. The strains of ongoing life events (e.g., loss of employment by a parent, divorce, or other stressors) also impact the availabil­ity of a supportive environment. Other factors identified by the authors were the overall loss of essential support from the community and schools given the respective impact of the disaster on these social systems.


Typical Reactions of Children
Fears and Anxieties
Fear is a normal reaction to disaster, frequently expressed through continuing anxieties about recurrence of the disaster, injury, death, separation, and loss. Because children’s fears and anxieties after a disaster often seem strange and unconnected to anything specific in their lives, the child’s relationship to the disaster may be difficult to determine. In dealing with children’s fears and anxiet­ies, accepting them as very real to the children is generally best. For example, children’s fears of returning to the room or school they were in when the disaster struck should be accepted at face value, and interventions should begin with talk­ing about those experiences and reactions.


Before the family can help, however, they must understand the children’s needs; this also requires an understanding of the needs of the family. As discussed through­out this manual, families have their own unique pre-disaster profile of beliefs, values, fears, and anxieties. Frequently, dysfunction in the family is mirrored in the child’s malfunctioning. The disaster mental health worker may need to talk with the family as a whole to better understand the role the whole family can play in responding to its own set of fears and anxieties that may exacerbate the fears expressed by the children. Sometimes, the pre-disaster level of dysfunction in the family may be so severe that referral for more formal mental health services may be necessary.


A parent’s or adult’s reaction to children makes a great difference in the children’s recovery. The intensity and duration of children’s symptoms decrease more rapidly when families can show that they understand their feelings. When children believe their parents do not understand their fears, they feel ashamed, rejected, and unloved. Tolerance of temporary regressive behavior allows children to redevelop those coping patterns that had been functioning before the disaster. Praise offered for positive behavior produces positive change. Routine rules need to be relaxed to allow time for regressive behaviors to run their course and the reintegration process to take place.


When children show excessive clinging and unwillingness to let their parents out of their sight, they are expressing their fears and anxieties of separation or loss. They have experienced the harmful effects of being separated from their parents and in their clinging are trying to prevent a possible recurrence. Generally, the children’s fears dissolve when the threat of danger has dissipated and they feel secure again under the parent’s protection.


Children are typically most fearful when they do not understand what is happening around them. Every effort should be made to keep them accurately informed, thereby alleviating their anxieties. Adults frequently fail to realize the capacity of children to absorb factual information and do not share what they know. Consequently, children receive only partial or erroneous information.


Most important to resolving disaster related fears and anxieties in children is the quality of safety and security present in the family. The family should make every effort to remain together as much as possible, for a disaster is a time when the children need their caregivers around them. In addition, the model adults present at this time can be growth enhancing. For example, when parents act with strength and calmness, while maintaining control and sharing feelings of being afraid, they serve the purpose of letting the children see that acting coura­geously even in times of stress and fear is possible.


Sleep Disturbances


Sleep disturbances are among the most common problems for children after a disaster. Behaviors associated with sleep disturbances are likely to take the form of resistance to bedtime, wakefulness, unwillingness to sleep in their own rooms or beds, and refusal to sleep by themselves. Children will also express a desire to be in a parent’s bed or to sleep with a light on, insist that the parent stay in the room until they fall asleep, or may begin to rise at excessively early hours. Such behaviors are disruptive to a child’s well-being. They also increase stress for parents, who may themselves be experiencing some adult counterpart of their child’s disturbed sleep behavior. More persistent bedtime problems such as sleep terrors, nightmares, continued wakening at night, and refusal to fall asleep may point to deep-seated fears and anxieties that may require professional intervention.


In working with families, exploring the family’s sleep arrangements may be helpful. Long-term adjustments in sleeping arrangements, such as allowing chil­dren to sleep routinely in the parent’s bed, will inhibit the child’s recovery pro­cess. However, temporary changes following a disaster may be in order. For very young children, it may be especially reassuring to have close contact with their parents during those times when disaster fears are most prominent. After a brief period of temporary changes, the parents should move toward the reinstatement of pre-disaster bedtime routines. Thus, the family may need to develop either new or familiar bedtime routines, such as reinstating a specific time for going to bed. The family may find it helpful to plan calming, pre-bedtime activities to reduce chaos in the evening. Teenagers may need special consideration for bedtime privacy. Developing a quiet recreation in which the whole family participates is also helpful.


Besides the above descriptions of fears, anxieties, and sleep disturbances, chil­dren’s reactions to a disaster can be expressed in many different forms. Below are some more common reactions. (For convenience, the reactions are presented for three age groups: preschool or early childhood, latency age, and pre-adolescence and adolescence.)


Preschool, Five Years Old and Younger


Most of the symptoms appearing in this young age group are nonverbal fears and anxieties expressed as the result of the disruption of the child’s secure world. These symptoms include:

crying in various forms, with whimpering, screaming, and explicit cries for help
becoming immobile, with trembling and frightened expressions
running either toward the adult or in aimless motion
excessive clinging
Regressive behavior, that is, behavior considered acceptable at an earlier age and that the parent had regarded as past may reappear. This includes the following:

thumb sucking
bed-wetting
loss of bowel/bladder control
fear of darkness or animals
fear of being left alone or of crowds or strangers
inability to dress or eat without assistance
Symptoms indicative of fears and anxieties include:

economic signs of intense anxiety. The child is unresponsive to the efforts of others to awaken or comfort him/her. If awakened, the child is confused and disoriented for several minutes and recounts a vague sense of terror usually without dream content.)
nightmares (i.e., frightening or anxiety producing dreams)
inability to sleep without a light on or someone else present
inability to sleep through the night15 Reactions of Children to Disasters

 

marked sensitivity to loud noises
weather fears – lightning, rain, high winds
irritability
confusion
sadness, especially over loss of persons or prized possessions
speech difficulties
eating problems
The symptoms listed above may appear immediately after the disaster or after the passage of days or weeks. Most often they are transient and soon disappear. Parents can help diminish the above symptoms in their children through under­standing the basis for the behaviors and giving extra attention and caring. If the symptoms persist for longer than a month, parents should recognize that a more serious emotional problem has developed and seek professional mental health counseling.


Latency Age, Six Years Old Through 11 Years Old


Fears and anxieties continue to predominate in the reactions of children in this age group.
However, the fears demonstrate an increasing awareness of real danger to self and to the children’s significant persons, such as family and loved ones. The reac­tions also begin to include the fear of damage to their environment. Imaginary fears that seem unrelated to the disaster also may appear.
Regressive behaviors may appear in this age group similar to those in the preschool group. Problem behaviors include the following:
Regressive behaviors may appear in this age group similar to those in the preschool group. Problem behaviors include the following:

bed-wetting
sleep terrors
nightmares
sleep problems (e.g., interrupted sleep, need for night light, or falling asleep)
weather fears
irrational fears (e.g., safety of buildings, or fear of lights in the sky) 16 Reactions of Children to Disasters
Additional behavior and emotional problems include:

irritability
disobedience
depression
excessive clinging
headaches
nausea
visual or hearing problems
The loss of prized possessions, especially pets, is very difficult for children in this age group. As noted in the previous section, the school environment and relationships with peers is central to the life of latency age children. School problems begin to appear and may take the form of:

refusal to go to school
behavior problems in school
poor school performance
fighting
withdrawal of interest
inability to concentrate
distractability
peer problems (e.g., withdrawal from play groups, friends, and previous activities or aggressive behaviors and frequent fighting with friends or siblings)


Preadolescence and Adolescence, 12 Years Old Through 17 Years Old


Adolescents have great need to appear competent to the world around them, especially to their family and friends. Individuals in this age group are struggling to achieve independence from the family and are torn between the desire for increasing responsibility and the ambivalent wish to maintain the more depen­dent role of childhood. Frequently, struggles occur with the family, because the peer group seems to have become more important than the parental world to the adolescent child. In the normal course of events, this struggle between adolescents and family plays itself out and depending on the basic relationships between the child and his or her parents, they resolve the trials and problems.17 Reactions of Children to Disasters
The effects of a major disaster on adolescents will vary depending on the extent to which it disrupts the functioning of the family and the community. The impact of the disaster may stimulate fears related to loss of family, peer relationships, school life, and even concern over the intactness of their own bodies. Adolescents struggling to achieve their own identity and independence from the family may be set back in this personal quest with reactivated fears and anxieties from earlier stages of development. The trouble signs to watch for in pre-adolescents and adolescents include:

withdrawal and isolation
physical complaints (e.g., headaches or stomach pain)
depression and sadness
antisocial behavior (e.g., stealing, aggressive behavior, or acting out)
school problems (e.g., disruptive behavior or avoidance)
decline in academic performance
sleep disturbances (e.g., withdrawal into heavy sleep, sleep terrors, or sleeplessness)
confusion
risk taking behavior
alcohol and other drug use
avoidance of developmentally appropriate separations (e.g., going to camp or college)
Most of the above behaviors are transitory and disappear within a short period. When these behaviors persist, they are readily apparent to the family and to teachers who should respond quickly. Teenagers, who appear to be withdrawn and isolate themselves from family and friends, are experiencing emotional difficulties. They may be concealing fears they are afraid to express. Just as many adults do, adoles­cents often show their emotional distress through physical complaints. 19 Helping the Child and Family


CHAPTER 3
Helping the Child and Family


This section of the manual focuses on helping children and their families deal with the emotional aftermath of a disaster. Major disaster events irrespective of their origin impact all persons who experience the event. Evidence from numer­ous disasters clearly demonstrates that persons who are impacted by the event either directly or indirectly will experience a range of feelings and emotions regarding the effect of the disaster and its consequences.


While everyone interprets life events within the context of their experiences, children interpret their personal experiences within the limited context of their current stage of psychological development. As mentioned in the previous sec­tions, the world of the child is defined by his or her stage of intellectual and emo­tional development, experiences with siblings and parents and extended family including grandparents, uncles, aunts, and cousins, the child’s history and culture, and his or her school, peers, neighborhood, and community within which he or she lives. It is within the structure of these relationships that a child must cope with the impact of the disaster event.


Understanding the definition(s) of family for a child is essential to under­standing the complexity of their emotional reaction to the disaster. Family in its most common definition is a group of persons consisting of parents and their children. However, in its broadest interpretation it can be defined as any class or group of related things. Thus given the appropriate context, a child’s family can be as broad as their neighborhood, community, or school, or as narrow as their relationship to their parents. Considering the various definitions of family when trying to assess the depth of impact of a disaster on children is important and necessary to determine appropriate crisis counseling and disaster mental health recovery strategies.


Below are examples of some potential relationships that comprise the notion of family for children:

children to natural parent, direct caregiver, or guardian
children to brothers and sisters, living in the same and other households
children to grandparents (maternal and fraternal)
children to uncle, aunts, and cousins, within and distant from the impact area20 Helping the Child and Family

 

children to significant non-related adults
children to the world of their school (teachers, staff, and students)
children to school friends and neighborhood friends — from their inner circle of very close confidants to casual acquaintances
children to community of worship (church, synagogue)
children to persons in the communities of reference, (e.g., local neighbor­hood, village, town, city, county)


General Steps in the Helping Process


A basic principle of working with children in disasters is that they are essen­tially normal children who have experienced great stress. Most of the problems that appear are likely therefore to be directly related to the disaster and transitory in nature.


The process recommended for helping children and families often starts with “crisis intervention,” which trained and supervised paraprofessionals and volun­teers can provide. The primary goal in crisis intervention is to identify, respond to, and relieve the stresses resulting from the crisis (disaster) and to reestablish normal functioning as quickly as possible. Sometimes the reaction is mild, but other times it is severe. Also, the workers must be trained to recognize when the condition is mild and can be handled by the families (with guidance), when referral to a helper, such as a school counselor is warranted, and when it is severe and requires intervention by a mental health professional.


The general steps in the helping process are:


1. Establishing rapport
Let the children know you are interested in them and want to help.
Check with the children to make sure that they understand what you are saying and that you understand them.
Display genuine respect and regard for the children and their families.
Communicate trust and promise only what you can do.
Convey acceptance of the children and their families.
Communicate to the children and their families that you are an informed authority.21 Helping the Child and Family


2. Identifying, defining, and focusing on the problem


Identify and prioritize specific problems with the children, parents, and family.
Select a specific problem, define its characteristics, and focus on solving it first.
Achieve a quick resolution to the problem so that the members of the family experience a sense of success and control.


Evaluate the seriousness of each of the identified problems and the capac­ity of the family to deal with them.

3. Understanding feelings
Demonstrate your ability to see and feel as others do.
Display patience in trying to understand children’s feelings, for children are frequently unable to express their fears.
Respond to the children’s stories frequently by commenting on the events and affirming their feelings.
Express a nurturing positive regard for the children, to convey an appre­ciation for the kind and intensity of their feelings.
4. Listening carefully
Understand the disaster concerns from the point of view of the children.
Listen to the children’s account of the disaster many times, in order to help children “work through” their feelings associated with the disaster.
Refrain from interrupting the children as they tell their stories.
Affirm children’s feelings by giving them time to express themselves.
5. Communicating clearly
Communicate in a language children understand.
Talk with children in groups or with siblings or other family members.
Seek the presence of family members to interpret code words used by the children.
Communicate with children in their dominant language.22 Helping the Child and Family


The Role of the Family


As discussed earlier, many factors can influence the child’s psychological defi­nition of family. However, for purposes of the current discussion, the child’s fam­ily is defined in terms of significant persons providing caregiving and support, who are also members of the child’s nuclear and extended family structure. Since children live in family systems, both the experience of the disaster and recovery from its aftermath are most often mutually experienced. Consequently, children will share common aspects of the disaster event experience. The retelling of these experiences between the adults and children in the family can normalize the overwhelming rush of feelings associated with the disaster. For many families, the role of the outreach worker is simply to give them permission to share their feelings with each other and to communicate that having disaster related feelings is normal and sharing these feelings with each other is appropriate and healthy.


A function of the crisis counseling program is to convey information to parents about the common reactions of families to trauma and loss following a disaster. Often parents deny the need for this type of information for themselves, but will gladly participate in programs or gatherings where this type of information is provided for helping support their children. Typically parents will recognize stress reactions and accompanying behavioral changes in their children, before they recognize them in themselves. The disaster mental health worker helps all members of the family unit by sensitizing parents to the signs of stress in their children and suggesting strategies for helping their children.


Outreach workers can remind parents of these simple facts:

Parents should acknowledge the parts of the disaster that were frightening to them and other adults.
Parents should not falsely minimize the danger as it will not end a child’s concerns.
The child’s age affects how he or she will respond to the disaster. (A six-year-old may express his or her concerns by refusing to attend school, while an adolescent may express his or her concerns by arguing more with parents.)


The way the child sees and understands his or her parent’s response is very important. Parents should admit their concerns and also stress their abilities to cope with the situation. Often the role of the family is simply to learn to work together to solve prob­lems and actively recognize the needs and feelings of both the children and the adults. The identification of concrete issues that are problematic for the family unit, as well as for individuals within the family, is often the first step in the emo­tional recovery of the family. This is followed by crafting solutions to problems, resolving problems by implementing solutions, and celebrating the successes of positively resolving problems. Through this process, family members begin to reestablish mastery over their environment and bring back into equilibrium the role of each of the family members. By routinely repeating this process through­out the various stages of recovery, the family members will become closer as a unit and individually more autonomous, thus helping all members of the family reestablish their identity and proceed with their normal developmental roles.


In working with families of diverse backgrounds, outreach workers must be sensitive to language differences and cultural needs. Children are often thrust into the role of interpreter if their parents and relatives are not fluent in English. This responsibility may require skills beyond the child’s current stage of development and be too stressful for the child. The outreach worker can relieve the child of this responsibility by seeking out adult interpreters for the family.

Common Feelings and Behaviors


Children and adults express signs and symptoms to stressful events along four dimensions: cognitive, emotional, physical, and behavioral. Common reactions expressed by children along each of these dimensions include the following:


Cognitive

trouble concentrating
preoccupation with the event
recurring dreams or nightmares
questioning spiritual beliefs
inability to process the significance of the event


Emotional

depression or sadness
irritability, anger, resentfulness
despair, hopelessness, feelings of guilt
phobias, health concerns
anxiety or fearfulness24 Helping the Child and Family


Behavioral

isolation from others
increased conflicts with family
sleep problems
avoiding reminders
crying easily
change in appetite
social withdrawal
talking repeatedly about the event
refusal to go to school
arguments with family and friends
repetitive play


Physical

exacerbation of medical problems
headaches
fatigue
physical complaints with no physical cause25 Helping the Child and Family


Case Examples


Below are examples of the situations that confront children in the aftermath of a disaster event. These examples are from ice storms in Maine, tornadoes in Texas and Arkansas, and floods in Louisiana and Texas.

 


1. SEPARATION ANXIETY
Katy, an eight-year-old girl, and her father were returning home from the video store one Saturday afternoon when a tornado struck. Katy and her father hunched down in the car, when suddenly the windows blew out and a tree fell across the hood. They crawled out of their demolished car shaken but miracu­lously unhurt. Katy’s mom and two older brothers, who were in the home when the tornado struck, survived with only bumps, bruises, and one broken arm, but their two-story home was a pile of rubble.


The next few weeks after the tornado were difficult for Katy. She did not want to go to school and had difficulty sleeping at night. She had dreams about the tornado and feared leaving her mom, dad, and brothers. The teachers at school were supportive and understanding of Katy’s needs. The first few weeks after the tornado Katy felt anxious and worried about her parents. School personnel allowed Katy to call and “check-in” with her parents at recess so she was assured that they were okay. Katy’s family also held a family meeting and discussed what they should do to be safe at home, school, or work in the event of another disaster. After a few weeks, Katy could sleep in her own room again and go to school without much anxiety.


2. ACTING OUT


Tommy, an eleven-year-old fifth grader, had been receiving mental health treatment for disruptive behavior and defiance in the classroom prior to the tornado. He was responding well to treatment and receiving positive reports from his teacher. Tommy, who had never experienced any kind of disaster, was at a friend’s house when the tornado struck and several trees came smash­ing through the windows. Tommy was not hurt physically by the tornado, but both his teachers and parents reported an increase in his disruptive and defiant behavior even though he continued in treatment. Upon review of Tommy’s situation with the school and an interview with his parents, it became clear that no one had offered Tommy any opportunity to deal with his disaster related


experience and with the subsequent stress he was trying to manage due to fears associated with the occurrence of another tornado. A series of visits by the disaster outreach workers to Tommy’s home and school helped Tommy normalize his experience and feel more open about discussing his fears. Both his parents and teacher reported a lessening of Tommy’s disruptive and defiant behavior.


3. ANXIETY


Jill, a six-year-old, was at home with her mother and father on the afternoon when the tornado struck. The family escaped with no injuries. Jill started having problems within the next few days, scared that another tornado would strike. Jill would frequently question her parents about the weather and often became tearful.


Jill’s mother called the 1-800 tornado coping line and asked for advice. The crisis counselor suggested that Jill’s parents explain tornadoes to her, discuss the warning signs for a tornado in their community, and develop and practice its own family safety plan. The crisis counselor sent the family some informational materials about tornadoes. The crisis counselor called Jill’s parents several days later to see how they were doing. Jill’s parents reported that her fears had less­ened by learning about tornadoes and knowing how to protect herself.


4. DISRUPTIVE BEHAVIOR AT SCHOOL


Following a major ice storm, Jason, age eight, was displaced from his home to a Red Cross shelter for eleven days waiting for power to be restored to his home. Greg, age eleven, was displaced from his family for thirteen days and spent this time with relatives in a very crowded house. Both children exhibited disruptive behaviors upon returning to school. Jason was constantly talking and appeared very anxious. Greg was inattentive in class and presented an angry and defiant manner. The outreach crisis counselor spoke with the teacher and offered to come to the weekly health class to talk about the ice storm and to tie the conversation with the classroom material about the five senses. The crisis worker first encouraged the children to share their personal experiences with the storm (i.e., What did you see? What did you smell? What did you hear? What did you feel?). This was a creative way of discussing the effects of the storm, providing assurance and information, and for the students to hear from
their peers that they shared many of the same feelings. Within a few days both Jason and Greg settled back into their daily routines.


5. ADOLESCENT AGGRESSION


Patrick, a sixteen-year-old, became verbally aggressive and threatened other youths after only one night in a large urban shelter following a major flood. Patrick had a history of petty crimes, homelessness, and drug use, and was well known to the local police. Given Patrick’s history and current behavior, the shelter manager and local police seriously considered removing him to a juvenile detention center. His mother met with the crisis counselor, the shelter manager, and a law enforcement official to work out an alternative plan. They asked Patrick to assist the National Guard in their duties distributing water and other food supplies. He readily agreed, helped the community, and with this more structured level of adult guidance was able to maintain good behavioral control and remain at the shelter.


6. REACTIONS THREE TO SIX MONTHS POST-DISASTER


Several months following the floods, many children remained in temporary living situations. Roger, an eight-year-old third grader, continued to struggle with school work, became increasingly withdrawn from friends, and non-respon­sive at school. As the school year was nearing the end, his teacher became concerned he would not advance to the fourth grade. Consultation with the school guidance counselor and the crisis counseling outreach workers revealed that many children displaced from the same trailer park as Roger were still feel­ing anxious and tense and doing poorly in school. In some cases, the pressures of the long disruption had affected the relationships of the parents, and separa­tions and divorces were occurring within the families of his peers.
The crisis counselors became more involved with Roger’s class, assisting with field trips and performing skits about floods and the lengthy time it takes to return families to pre-disaster status. The counselors also began encouraging the families in the trailer park to get together with their neighborhood friends over potluck suppers to talk about common issues and plans to get things “back to normal.” The school helped Roger’s parents find a retired teacher to tutor Roger with his school work, so that he would be ready to advance to the fourth grade.28 Helping the Child and Family


7. ANNIVERSARY REACTIONS OF CHILDREN AND FAMILIES


A crisis counseling team assisting the community to recover worked with schools and the local unmet needs committee to arrange a number of com­memorative events to assist survivors during the anniversary of the disastrous floods. Some families were still waiting for financial assistance, while others were rebuilding their homes. Since many families had returned to their daily routines, there was some degree of community impatience with those still struggling with the impact of the flood. During the commemorative week of the anniversary, many children expressed lingering fears and a remaining sense of loss. The anniversary events focused on individual and community healing, celebrating their survival, and the accomplishments of the last year. At several schools, outreach workers visited the younger children and distributed coloring books depicting the recovery and return to daily routines experienced by Andy and Allie, two young alligator characters who had lived through the storms. Through human interest stories revealing the ongoing needs of survivors, addi­tional resources were donated to assist in their recovery.


CHAPTER 4


Guidelines for Caregivers, Mental Health and Human Service Workers


Disaster work almost always requires training, supervision, and consultation of human service workers, many of whom have little or no training in disaster issues. This section is directed to the various roles professionals, parents and care­takers of children may be called upon to serve during and following a disaster event. Side by side, professionals and paraprofessionals alike can work together to utilize basic skills in responding to the special needs of children who have experienced a disaster.


Providing Disaster Mental Health Services


The hallmark of a disaster mental health operation is to assist persons in deal­ing with their emotional response and recovery following the trauma of a major disaster event. The intended outcome is to return persons affected by the disaster to their pre-disaster level of coping. Since most disaster survivors do not perceive themselves as ill or in need of mental health services, crisis counseling programs emphasize outreach to communities, neighborhoods, churches, schools, and existing social networks to help persons who typically would not seek assistance from mental health service agencies. Hundreds of crisis counseling programs across the nation have repeatedly demonstrated that paraprofessionals indige­nous to the affected community perform most effectively in the role of providing basic crisis counseling services. In these programs, it has been demonstrated that special services and programs for children have been developed within schools, extended school programs, communities, youth organizations, and summer recre­ational programs.


Children may have an extensive support system, but usually do not have the life experiences or coping skills that would assist them in responding to the dramatic changes in their lives caused by disaster. Knowing what kind of assistance is available in the community, through government, religious and private agencies, is critical in responding to the needs of children and families in disasters. Most services will be found in local government and private agencies. Professionals, paraprofessionals and caretakers such as teachers need to learn as much as practicable about the community resources specifically offering services to children. Examples are family services agenices, child guidance agencies, child care centers and after school programs.30 Guidelines for Caregivers, Mental Health and Human Service Workers


However, due to the unpredictable nature of outreach work and the potential for engaging persons who may significantly benefit from professionally delivered mental health services, it is crucial that outreach workers are provided with suf­ficient levels of supervision from trained mental health professionals.


Supervision of Human Service Workers


The FEMA/CMHS Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) that follows a Presidentially declared disaster employs intervention models that mobilize a broad spectrum of persons with a great diversity of experience and training. Crisis Counseling Programs emphasize outreach to communities, neighbor­hoods, schools, and other networks to help persons who typically would not seek assistance from mental health service agencies. Hundreds of Crisis Counseling Programs across the nation have repeatedly demonstrated that paraprofession­als indigenous to the affected community perform most effectively in the role of outreach workers. Outreach workers must have certain communication skills and other attributes necessary for successfully conducting their roles, which are dis­cussed in other CMHS publications. However, due to the unpredictable nature of outreach work and the potential for engaging persons who may significantly benefit from professional mental health services, it is crucial that outreach work­ers are provided with sufficient levels of supervision from trained mental health professionals. Below are examples of the broad range of supervisory roles mental health professionals provide:


Supervision Through Didactic Training — Increasing the knowledge base of workers through brief in-service sessions explaining the basics of human behavior and development, assessing survivor needs, and providing tips on engagement.
Group Supervision — Team building through weekly review of current events and activities of the outreach workers. This includes discussing recent interactions with disaster survivors, problem-solving unique situa­tions, and stimulating innovative thinking among outreach team members.
Individual Supervision — Supporting each individual team member with strategies for managing administrative workload, emotional/profes­sional commitment, personalization of outreach experiences, development of dependency relationships, and issues of transference and counter transference. 31 Guidelines for Caregivers, Mental Health and Human Service Workers


Providing Mental Health Training


Crisis Counseling Programs often engage mental health professionals to provide specific information about working with special populations. After a disaster, persons in a community who would have little reason to meet each other now find they share a bond through the common challenge of post-disaster recovery. Outreach workers, volunteers, unmet needs committee members, emergency operations personnel, clergy, housing specialists, and others may be confronted with situations and persons with special needs with whom they have little or no experience. Children with serious emotional or behavioral disorders and their families are an example of a special population that disaster recovery personnel may encounter in shelters, disaster recovery centers, and other sites. Brief training sessions for operations staff by mental health professionals can alleviate much apprehension of personnel and equip them with information and strategies that will result in successful outcomes for all involved parties. Mental health profession­als may be called upon to provide ongoing training on specific topics to crisis counseling staff. Examples include the following: specialized information topics about case finding techniques of in-home intervention, working with children with developmental disabilities, issues related to family interventions, child abuse, and recognizing maladaptive patterns of alcohol and drug use.


Systems Consultation


Mental health professionals also play a significant role as consultants to Crisis Counseling Programs. A common role of consultants is to provide orientation and ongoing project development training to the crisis counseling staff. In the context of children and their recovery, the main purpose of the consultant is to sensitize project staff to the mental health needs of children and families in their recovery from the disaster and to assist project staff to integrate their services through interagency collaboration with other child-serving agencies. Many communities throughout the country have developed Child and Adolescent Services System Programs (CASSP). These children oriented systems of care are designed for at-risk children with serious emotional disorders. In a time of a disaster, these agencies may represent significant resources to crisis counseling recovery programs. Often the child mental health professionals in a community play an important role in this network. They can provide consultation on how interagency collaboration is done in a specific community, as well as which combined community and agency resources may be available to disaster survivors. Consultants can also assist staff with issues of organizational boundaries, working with school administrators, referral criteria for various community services, and role clarification.32 Guidelines for Caregivers, Mental Health and Human Service Workers


Assisting Crisis Counseling Staff to Manage Stress


Responding to the needs of children and families who are coping with the aftermath of a major disaster is physically demanding and emotionally charged work. This is true even for the seasoned mental health professional who is accustomed to the fast paced, often chaotic environment of mental health crisis intervention work. A distinguishing characteristic of disaster mental health work is that often the worker identifies on a personal level with survivors and cannot find a quick method for establishing psychological distance with the persons seeking assistance. Additionally, the disaster mental health worker may also be a survivor of the disaster and must deal with issues concerning his or her own recovery and that of family members.


Acknowledging the high stress load of this work and implementing an array of stress reducing strategies is an important role for mental health professionals. Examples of typical stress management activities linked to Crisis Counseling Programs are: routine defusing and debriefing sessions during all phases of recov­ery operations, identifying a stress management counselor outside the project’s administrative chain of command, offering ongoing stress management training sessions, providing auto-relaxation techniques, and assisting staff to recognize the signs and symptoms of burnout in survivors and staff.


Burnout is the normal result of increased demands and overwork after a disaster and may appear as persistent physical and emotional exhaustion, unre­lieved feelings of fatigue, marked irritability, and a decrease in the individual’s desire and ability to work effectively. With respect to staff working with children and families, burnout is often the result of overwork and over commitment. Burnout among project staff may be very harmful not only to the worker, but also to the disaster survivors who are seeking assistance. Project staff may become irritable with survivors and make promises they cannot possibly keep. CMHS strongly recommends that staff responsible for implementing disaster mental health services seek consultation on the development of a comprehensive stress management program as an integral part of their disaster recovery operations.


Conclusion


Most parents are capable of assisting their children in overcoming fears and anxiety related to a disaster event. However, when the situation seems beyond their reach, assistance can easily be provided through pediatricians, family phy­sicians, or mental health and school counselors. Understanding and helpful inter­vention can reduce a child’s fears and prevent more serious problems from devel­oping. The manner in which adults, caregivers and mental health professionals 33 Guidelines for Caregivers, Mental Health and Human Service Workers


help children to resolve their emotional turmoil at uncertain times may have a lasting effect on the child. Knowing the type of assistance that is available in a community is necessary in responding to the needs of children after a disaster.


Services for Children and Families


When a disaster strikes a community, it temporarily disrupts the infrastructure of community services on which many children and families rely. It is essential for disaster mental health workers to become familiar with the remaining available post-disaster resources. Most communities have developed resource guides describing the available community services in their area. Seeking out information from community resource guides is always a good place to find what pre-disaster assis­tance was available for children and their families. Health and social services are provided through municipal, county (parish), non-profit, and private agencies in most communities. Direct services are usually not provided by the state govern­ment; however, in some areas of the country state government is directly involved in the delivery of services.


Assisting persons to cope with the aftermath of a major disaster requires access to traditional mental health services and to basic social and physical health services. The role of disaster mental health workers is to be aware of resources that can be useful to families and children as they go through the recovery process. Below is a partial listing of the types of organizations that are actively involved with chil­dren and families. These organizations are potential sources of information about existing and new resources that may be developed following a disaster:

Area church /religious organizations
Community mental health centers
Case management agencies
Child Adolescent Services System Program (CASSP) local teams
Children’s hospitals
Family service agencies
Foster care providers
Home health agencies
Local/county public health agencies
Local professional associations for mental health professionals
Local funding organizations such as the United Way and non-profit foundations40 Appendix A – Agency Assistance in Disasters

 

School counselors
Social service (welfare) and child protection agencies
Support groups for child-related disorders such as attention deficit disor­der or support groups for various learning disabilities

Providing Crisis Services


Counties are responsible for the provision of most services, and Medicaid pays for most of the services. There are Medicaid-certified, level-two crisis programs in 56 of the 72 counties. Individual Peer support is often provided by the counties as part of the staffing, but it is not a requirement. In addition to individual peer support, the governor is proposing funding for three peer-run centers. Warm lines exist in just a few large urban areas of the state because of limited availability of funding. Individuals can obtain services regardless of their insurance status if there is an emergency. There is no central warm line, but there are 11 peer-run warm line programs.


Milwaukee has a Wraparound program that takes a systems-of-care approach. The Milwaukee Wraparound program grew out of a SAMHSA Systems of Care grant and is focused on children and adolescents. The base funding for the Milwaukee Wraparound is from Medicaid, with a mix of additional dollars from juvenile justice funds and child welfare. The program members have expanded their role and now work with the local school district to provide services for children in schools who are experiencing crises. Wisconsin also has CIT programs in a number of regions. Milwaukee is about to initiate CIT trained officers used as second responders which will be funded by state general funds.


Wisconsin created a new state statute in 2009 that requires law enforcement to consult with county mental health authorities—which often means the county crisis service—before emergency detentions 42
can be initiated. As a result, Wisconsin has seen a 32 percent decrease in emergency detentions, a 73 percent increase in the use of crisis services, and a decrease in state hospital admissions.


Funding Crisis Services


Crisis services are funded via the state general funds, Medicaid FFP matched by local funds under the Medicaid Rehabilitation Option, the Clinic Option, and waivers. Other funding sources include SAMHSA’s mental health block grant, local government, first-party payments (self-pay), and third-party payments (private insurance). Counties are responsible for the total cost of hospitalization for persons who are civilly committed between the ages of 22 and 64, although counties are also responsible if there is no other source of funding regardless of the individual’s age. Milwaukee’s Wraparound services are funded through a Medicaid 1915a waiver.


Wisconsin respondents noted many challenges in funding crisis services. The primary funding challenges are related to the number of uninsured individuals who use services and the difficulties experienced by the smaller, less-populated counties in funding and organizing services. An additional cited challenge was the reticence of private insurance companies to pay for crisis services. Under Wisconsin law, crisis programs are eligible for third-party reimbursement, but private insurance companies are not required to provide or reimburse these services. Some private insurance companies do have contracts with crisis programs. Additionally, insurance companies define medical necessity differently than do the county service providers. They often require that services be provided by individuals with a master’s degree or higher and decline payment for services that are not part of their list of plan providers, even if the consumer is suicidal. The state has informed insurers that they are required to pay for crisis services, but they have had limited success in getting insurers to meet these obligations.


Human Services Programs


Below is a listing of current programs administered through the Federal Emergency Management Agency (FEMA) and other related federal agen­cies. These programs are authorized under the Robert T. Stafford Emergency Assistance and Disaster Relief Act or other federal legislation.


Cora Brown Fund


These funds are used to assist survivors of Presidentially-declared major disasters for disaster-related needs that have not or will not be met by governmental agencies or other organizations which have programs to address such needs. Disaster survivors do not apply directly for these funds. The FEMA Regional Director, with assistance from other governmental agencies and disaster volunteer agencies, identifies potential recipients. This fund may not be used in a way that is inconsistent with other Federally mandated disaster assistance programs. A verification of the facts of each case must be conducted by the FEMA Regional Director, who then prepares a memorandum of recommendation and decision to the Deputy Associate Director, Response and Recovery Directorate.


Crisis Counseling Assistance and Training Program


This program is designed to provide supplemental funding to states for short-term crisis counseling services to people affected by Presidentially-declared disasters. There are two separate portions of the Crisis Counseling Program which can be funded: immediate services for up to sixty days of assistance following the disaster declaration date and regular services for an additional nine months. The program is available to State Mental Health Authorities through the State Office of Emergency Services and is administered by FEMA with technical assistance and collaboration from the Center for Mental Health Services.


Disaster Housing Assistance Program


The Disaster Housing Assistance Program makes temporary housing and funds available to individuals whose home is uninhabitable because of a disaster. 41 Appendix A – Agency Assistance in Disasters


Disaster Legal Services


Through an agreement with the Young Lawyers Division of the American Bar Association, free legal advice is available for low-income individuals regarding cases that will not produce a fee (i.e., those cases where attorneys are paid part of the settlement which is awarded by the court). Cases that may generate a fee are turned over to the local lawyer referral service.


Disaster Unemployment Assistance (DUA)


Unemployment benefits may be available through the State unemployment office and are supported by the U.S. Department of Labor. The benefit period begins with the week (as defined by State law) following the disaster incident or date thereafter that the individual becomes unemployed and can extend for up to 26 weeks. The DUA benefit amount may not exceed the maximum weekly amount authorized under the unemployment compensation law of the State in which the disaster occurred. Individual eligibility is dependent on other available unemployment benefits to the victim/survivor. Individuals should contact a local office of the agency that administers the UI program in their State. It should be listed in the State government section of the telephone directory under such titles as Unemployment Insurance, Unemployment Compensation, Employment Security, or Employment Service.


Individual Family Grant Program (IFG)


The purpose of the IFG is to provide funds for the necessary expenses and serious needs of disaster survivors. IFG funds are for expenses that are not met through other means of federal or private assistance (e.g., Small Business Administration loan or private insurance). The maximum grant amount is adjusted annually in accordance with changes in the Consumer Price Index (CPI). IFG eligible categories include: real and personal property, medical, dental, funeral, and transportation. Ineligible costs are: improvements or additions to real or personal property, recreational property, cosmetic repair, business expenses, and debts incurred before the disaster. Home inspections are normally conducted before a check is issued. The IFG program is administered by the state.


Stress Management Program


This program is intended to ameliorate, to the extent practicable, the stresses experienced by its disaster workers as a result of the demands of working directly in a disaster operation. The Center for Mental Health Services works in collabo­ration with FEMA on the implementation of this program.42 Appendix A – Agency Assistance in Disasters


Department of Veterans Affairs (VA)


The VA provides death benefits, pensions, insurance settlements, and adjustments to home mortgages for veterans.


Internal Revenue Service (IRS)


The IRS can allow certain casualty losses to be deducted on Federal Income Tax returns for the year of the loss or through an immediate amendment to the previous year’s return.


U.S. Small Business Administration Disaster Loans (SBA)


Most, but not all, federal assistance is in the form of low interest loans to cover expenses not covered by the state or local programs, or private insurance. Loans are available to individuals, businesses, and farmers for repair, rehabilitation, or replacement of damaged and real personal property and some production losses not fully covered by insurance.


Social Security Administration (SSA)


The SSA provides no special benefits during a disaster, however SSA staff are provided to the Federal Coordinating Officer and Disaster Recovery Centers to process SSA benefit services such as: processing survivor claims, obtaining eligi­bility evidence for claims processing, resolving problems with lost or destroyed Social Security checks, and redevelopment of lost destroyed pending claims.


1 McQuistion, H.L., Finnerty, M, Hirschowitz, J, and Susser, E.S. (2003).“Challenges for Psychiatry in Serving Homelessness People with Psychiatric Disorders,” Psychiatric Services, 54, 669-676.
2 Deane, Martha, Steadman, Henry J., Borum, Randy,Veysey, Bonita, Morrisssey, Joseph P.“Emerging Partnerships Between Mental Health and Law Enforcement.” Psychiatric ServicesVol. 50, No. 1. January 1999: pp. 99-101.
3 Paula M. Ditton, Mental Health and Treatment of Inmates and Probationers, US Department of Justice, Bureau of Justice Statistics (Washington, DC: 1999), NCJ 174463.
4 James, D. & Glaze, L. Mental Health Problems of Prison and Jail Inmates (2006). Special Report, Bureau of Justice Statistics. Findings based on data from interviews with state prisoners in 2004 and local jail inmates in 2002,
5 Larkin, G.L., Claassen, C.A., Emond J.A., et al. (2005) Trends in U.S. emergency department visits for mental health conditions, 1992-2001. Psychiatric Services (56) 671-677
6 American College of Emergency Physicians (2008), Psychiatric and Substance Abuse Survey At
7 Manderscheid, Ronald and Berry, Joyce (2004). Mental Health, United States 2004.
U.S. Department of Health and Human Services, Center for Mental Health Services (2004).
Ibid.
9 Abt Associates, Inc. (1994). Conditions of confinement: Juvenile detention and corrections facilities. Office of Juvenile Justice and Delinquency Prevention:Washington, DC.
10 Nicholson, J., & Henry,A.D. (2003).Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses. Psychiatric Rehabilitation Journal, 27:122-130.
11 Parks, J., Singer P., et al (2006) Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors,Alexandria
12 Allen, M, Carpenter, D., et al (2003) What do consumers say they want and need during a psychiatric emergency? Journal of Psychiatric Practice (9) 1, pp. 39-58.
14 Stefan, S (2006) Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements, Oxford University Press
17 Practice Guidelines: Core Elements for Responding to Mental Health Crises
15 Stefan, S.,What is the current state of the law regarding the use of police force against people with psychiatric disabilities? Center for Public Representation, http://www.centerforpublicrep.org/community-integration/use-of-force-bypolice-against-people-with-psychiatric-disabilities
16 Greenfield,T.K., Stoneking, B.C. et al ((2008) A randomized trial of a mental health consumer-managed alternative to civil commitment for acute psychiatric crisis. American Journal of Community Psychology (42) 1-2, pp. 135-144.

17 Achieving the Promise:Transforming Mental Health Care in America. Final Report. (DHHS Publication No. SMA 03-3832).Washington, DC: U.S. Government Printing Office.

Johnson, R.J., Ross, M.W., Taylor, W.C., Williams, M.L., Carvajal, R.J., Peters, R.J. 2006. Prevalence of childhood sexual abuse among incarcerated males in county jail. Journal of Child Abuse and Neglect 30(1): 75–86.

Jennings, A. 2005. “The damaging consequences of violence and trauma: Facts, discussion points, and recommendations for the behavioral health system. “Alexandria, VA. National Association of State Mental Health Program Directors and the National Technical Assistance Center for State Mental Health Planning.

Fact Sheet. New York State Coalition Against Sexual Assault NYSCASA, 63 Colvin Ave., Albany, NY, 12206; 518-482-4222;

Freedman, D., 2000. Precursors of lethal violence: a death row sample. Social Science and Medicine, 50(12): 1757–1770.

Van der Kolk, B. A. 1996. “The Complexity of Adaptation to Trauma: Self-Regulation, Stimulus Discrimination, and Characterological Development.” In Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, ed.. B. A. van der Kolk, A. C. McFarlane, and L. Weisaeth. New York: Guilford Press.

Read, J. 2003. “The Contribution of Early Traumatic Events to Schizophrenia in Some Patients: A Traumagenic Neurodevelopmental Model.” Journal of Psychiatry 64 (4): 319–45.

Dvoskin, J. “Sticks and Stones:The Abuse of Psychiatric Diagnosis in Prisons” The Journal of the California Alliance for the Mentally Ill 8(1): 20–21.

Robin et al. 2005. The Cutting Edge, 15(59).