networks is published quarterly by the National Technical Assistance Center for State Mental Health Planning (NTAC) and is supported under a Cooperative Agreement between the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (CMHS/SAMHSA), and the National Association of State Mental Health Program Directors (NASMHPD). Cited reproductions, comments and suggestions are encouraged.

To be added to the networks mailing list, call Christine Diaz at 703-739-9333, ext. 30, or e-mail christine.diaz@nasmhpd.org. [Please include your name and return mailing address, email address and/or telephone number in the body of your message so we may respond to your inquiry].

Responding to the Mental Health Impact
of Major Disasters

Backwater blues done caused me to pack my things and go,
my house is flooded, and
I can't live there no more.
— Bessie Smith, "Backwater Blues"

In the stark, resonant "Backwater Blues," one of her most celebrated songs, legendary blues singer Bessie Smith describes the impact of a storm-produced flood that forced thousands of people from their homes in the Mississippi Delta during the 1920's. The song captures the fear and tension generated by the torrential downpour and flooding, the mixture of helplessness and hope of people stranded in their homes waiting to be rescued and finally the loss and loneliness that come with realizing that the flood had produced irrevocable and life-altering change. In her powerful yet understated way, the singer addresses not only the physical dangers and disruptions caused by the disaster but also its emotional impact on people who have lost their homes, possessions and, in some cases, family members and friends in the flood.

The Mental Health Impact of Disasters

During the past several decades, disaster relief professionals and mental health service providers have come to realize that responding to the psychological and emotional impact of disasters is an integral part of an effective disaster response strategy. There is general agreement that all people involved in a disaster are affected by it in some way, from its most immediate victims and their family members and friends to rescue workers, fire fighters, police officers and members of the larger community. Reactions range from grief, anxiety, stress and anger to post traumatic stress disorder (PTSD) and major depression. Individuals may experience psychosomatic illness or a worsening of pre-existing illness. Children, in particular, often exhibit temporary regressive behaviors, such as returning to thumb sucking or fearing to venture out of their homes.

Historically, experience with federally declared disaster relief efforts suggests that although many people may exhibit some symptoms of mental illness following a disaster, particularly PTSD, few develop diagnosable psychiatric disorders significant enough to warrant long-term treatment. However, more recent experience with "catastrophic disasters" involving large-scale loss of life, property destruction and disruption in community life reveals a pattern of more serious psychological impact that may require intensive and long-term mental health intervention.

This finding is particularly true in disasters intentionally caused by human action, such as the Oklahoma City bombing. "Problems go on longer, and we see more people who have more serious problems," notes Brian W. Flynn, Ed.D., director of the Division of Program Development, Special Populations and Projects, Center for Mental Health Services (CMHS), who participated in the Oklahoma City disaster response effort. [See Focus on the States on page 6.]

For persons with psychiatric disabilities and children with serious emotional disturbances, disasters can have a serious impact. A disaster may spark intense feelings of responsibility for the disaster itself or exacerbate an individual's already persistent distrust and fear of the world. Yet disaster response and mental health officials are quick to point out that persons with serious mental illness also experience reactions such as grief, sorrow and anxiety that could be expected of anyone in a disaster situation. These responses should not be confused with symptoms of mental illness, they note.

Federal Grants for Disaster-Related Crisis Counseling

Much of what is now known about the mental health needs of individuals and communities following either natural or man-made disasters has been learned as a result of a federal disaster relief program established in 1975. Authorized under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, the program provides federal funding, technical assistance and other assistance in the event of a presidentially declared disaster.

Of special interest to mental health professionals, the Stafford Act authorizes funding for crisis counseling, community outreach and consultation and education services through a joint effort of the Federal Emergency Management Agency (FEMA) and CMHS. FEMA provides funding, while the CMHS Emergency Services and Disaster Relief Branch is responsible for providing technical assistance, training and other support.

State mental health agencies in states covered by a presidential disaster declaration may initially apply for an immediate services grant of up to 90 days to support crisis counseling and other mental health services for persons affected by the disaster. If services are required for a longer period, states may also apply for a regular services grant, which supports up to nine additional months of services. FEMA officials estimate that about half of all crisis counseling grant applications are approved, the key factor being whether the disaster's impact goes beyond local and state mental health agencies' capacity to provide necessary services.

Understanding the Crisis Counseling Model

As a result of what has been learned in the federal disaster relief program, a model of crisis counseling has emerged that is distinct from traditional crisis intervention services provided by public mental health systems. "This crisis counseling model assists people who are experiencing emotional reactions resulting from disaster-related stress," notes Mary Elizabeth Nelson, M.S.W., chief of CMHS's Emergency Services and Disaster Relief Branch.

According to Diana Nordboe, a program specialist with FEMA's Human Services Division, one distinctive aspect of the disaster-related crisis counseling model is its strong emphasis on outreach activities. Ms. Nordboe explains that mental health outreach workers spend their time "going door-to-door in neighborhoods and visiting schools, senior and community centers, churches and synagogues" and other places where people naturally gather following a disaster. Outreach workers are usually individuals based in local communities, such as teachers, school guidance counselors, health care workers and religious leaders, who receive special training and are supervised by mental health professionals. "Active listening and public information and referral are among the primary crisis counseling techniques," Ms. Nordboe points out.

Increased Funding for Disaster-Related Services

Relatively little money was spent for crisis counseling during the first decade or so of the federal disaster relief program. In 1989, however, Hurricane Hugo devastated major sections of the southeastern United States, and the Loma Prieta earthquake shook northern California, sparking a rise in federal crisis counseling expenditures that has continued throughout much of the 1990's.

Crisis counseling is often considered a low priority — until a disaster strikes.

Peak spending for disaster-related crisis counseling to date occurred in 1994, when the federal government provided $60 million in immediate and regular services grants for crisis counseling in response to the Northridge earthquake and firestorms in California and numerous tropical storms, floods and tornadoes across the country. Expenditures leveled off at about $10 million in both 1995, the year of the Oklahoma City bombing, and 1996. As of September 1997, spending had reached about $15 million.

Disaster response officials predict that the federal crisis counseling program will continue to expand, both because of an overall rise in the number and severity of natural disasters and the potential for acts of terrorism such as the Oklahoma City and World Trade Center bombings. For example, Federal and state officials are now poised for a dramatic increase in weather-related disasters during 1998 as a result of the El Niño's warming of Pacific waters, which weather experts expect to cause severe weather disruptions around the globe. Occurring roughly every two to seven years, forecasters predict that this El Niño will be among the strongest of the century and have its greatest impact in the United States on the Pacific coast and in the Sunbelt.

Planning and Coordination: Keys to Effective Disaster Responses

State and federal mental health and disaster response officials agree that planning and coordination are key elements of an effective crisis counseling strategy. Yet they acknowledge that crisis counseling is often considered a low priority—until a disaster strikes. Michael Novinski, disaster response coordinator for the Illinois Office of Mental Health, emphasizes that state and local mental health officials need to ensure that specific plans for crisis counseling are included in a state's disaster response plan, particularly in view of the growing potential for disasters. Several states such as California and Texas, which regularly experience weather-related disasters, have full-time disaster-response coordinators in their state mental health agencies and have developed comprehensive disaster response programs. In most states, however, a member of the state mental health agency staff may work part time on disaster-related activities. Whatever the specific staffing pattern selected, experts concur that effective planning and coordination can lead to a state mounting a swift and effective response to disaster.

Disasters, whether natural or man-made, can wreak havoc on individuals and communities, leaving emotional scars long after the events themselves. Although disasters will continue to occur, we have learned from experience that certain strategies can help mitigate the emotional and physical pain they cause. However, experience has also taught us that disasters often come with little or no warning and that the best strategy is to be prepared.

Back to top

Message from NTAC's Director

The provision of mental health services following major disasters is a topic that typically does not receive much attention from mental health professionals who may be more focused on managed care, childrens health insurance, welfare reform or some other equally "hot" topic. That is, until there's a weather-related or man-made disaster. Then, the state mental health agency must move into high gear to provide crisis services following a flood, fire, hurricane, an earthquake or bombing. In that handful of states that have experience with disasters, the SMHA is poised to play a significant role in marshaling the necessary personnel and resources.

But for those states that have not had experience with disasters, preparing a mental health disaster response plan is generally not high on the list of priorities. And that's the audience whose attention we want to capture with this issue of networks. Because if disaster should unexpectedly strike, as experts are predicting with greater urgency may occur with El Nino or with terrorist attacks such as the Oklahoma City bombing, it is those states with little or no experience that will have most difficulty mounting an effective response.

The truth is, we know what mental health interventions work in disaster situations. There are effective program models that have been refined over many years by states with diverse and dramatic disaster experience. We have learned from them what works in real time, when the need for a practical, effective mental health response is most critical.

We know what training best prepares professionals, consumers and other community residents to function as disaster specialists. And we know how to access the funding available from the federal government to finance services not currently within the SMHA's capacity.

Our goal with this issue of networks is to help readers appreciate both the impact that disaster has on a population's mental health as well as the importance of planning ahead for the unforeseen disaster. We draw your attention to a need that may not seem great at the moment, not until a disaster occurs and the luxury of time to plan has all but disappeared.

We hope that this issue of networks provokes readers to consider how they can contribute to a greater level of preparedness and consequently, a more effective mental health response during such difficult times. —Bruce D. Emery, M.S.W.

Back to top

www.disaster.response

The National Technical Assistance Center for State Mental Health Planning (NTAC) maintains a comprehensive web site providing information on innovative programs and technical assistance on issues of importance to mental health planning, service delivery and evaluation. The web site contains a wealth of information, including more than 90 examples of programs and services that states and communities can use as a guide in developing similar service options. NTAC's audience includes state mental health agencies, mental health planning and advisory councils, consumers and families.