DISASTER

MENTAL HEALTH SERVICES

A GUIDEBOOK FOR

ADMINISTRATORS AND CLINICIANS

Every day disasters occur and each year, millions of people are affected. Whether natural or human-made, the extreme and overwhelming forces of disaster can have far-reaching effects on individual, local community, and national stability. Though the actual event itself may last from seconds to a few days days, effects on communities and individuals can continue from months to years during the extended process of recovery and restoration. The long-term recovery of communities vary significantly due to the complex interaction of psychological, social, cultural, political, and economic factors.

Risk for post-traumatic stress disorder (PTSD) following

community-wide disasters ranges from 25% to 33%.

Casualty estimates for major earthquakes range from tens to hundreds of thousands, depending on population density, quality of building construction, and the location, time, magnitude and duration of the earthquake. High magnitude disasters can threaten to overwhelm state medical systems, pose public health threats related to food, water, wastewater, solid waste, and mental health effects, and require time-critical assistance from the Federal government.

Following a community-wide disaster, medical/health care facilities may be severely structurally damaged or destroyed. Facilities with little or no structural damage may be rendered unusable or only partially usable because of a lack of utilities, staff unable to report for duty due personal injuries, and/or damage and disruption of communication and transportation systems. Facilities remaining in operation are at risk for being overwhelmed by the number injured victims needing care. In the face of massive increases in demand and the damage sustained, medical and equipment

are in short supply. Disruptions in local communications and transportation systems could prevent timely resupply. Nevertheless, a timely and effective medical and mental health care response is critical to the community’s safety and recovery.

Although other disasters such as hurricanes, floods, etc., may not generate the casualty volume of a major earthquake, there will be a noticeable emphasis on relocation, shelters, and returning water, wastewater, and solid waste facilities to operation. In sum, major disasters require that resources from outside of the affected area be provided in as organized and as efficient as possible.

The primary objective of disaster relief efforts is to restore community equilibrium. Disaster mental health services, in particular, work toward restoring psychological and social functioning of individuals and the community, and limiting negative mental health outcomes often associated with disasters (e.g., PTSD, anxiety, depression, substance abuse).

Figure 1. Conceptual illustration

Following a community-wide disaster, community mental health administrators are faced with the challenge of having to quickly become familiar with disaster protocols (grant applications) resources (mutual and other aid) while continuing to coordinate ongoing regular services and rapidly emerging and changing disaster-precipitated needs. Public community mental health agencies, the primary sponsors of disaster crisis counseling programs, almost exclusively serve individuals with severe and chronic mental illness as part of their everyday mission. The regular mission of these agencies is very different from the mission of disaster mental health programs. Disaster mental health services are directed toward "normal" people responding normally to an abnormal situation, and to identifying persons at risk for severe psychological disorders.

Systematic, coordinated, and effective disaster mental health response is continually being re-shaped by real-world contingencies. All disasters become political events. Previously established networks, relationships, as well as political pressures, are powerful forces shaping the disaster response. There is rarely consensus about matching resources with survivors. Mental health administrators and clinicians need political savy to be able to get the right services to the right people in the wake of disaster.

The post-impact environment is constantly in flux as information and resources change rapidly. Hourly updates on community needs, political pressures, and the convergence of resources result in frequent reappraisal of how best to respond to the diverse groups of people affected. Immediately following a disaster, administrators will be beset by offers of help, media inquiries, and community assessment needs requiring unfamiliar procedures. Selecting the best team, with representation from key local and national mental health agencies is critical to the effectiveness of the mental health response within the first 24-72 hours of disaster onset.

Administrators are next faced with the the challenge of shifting disaster mental health services from crisis intervention to ongoing aid and assistance. Approximately a month after the disaster, a critical point in disaster service continuity, federal grants are reviewed, funded, and operationalized for ongoing disaster mental health services.0.

Community mental health clinicians and private practitioners also face unique challenges. In their ordinary practices, patients generally arrive at a scheduled time having made (at least implicitly), the agreement to accept the clinician in his or her role as a mental health expert. Clinics typically have private offices where clinicians and the patients meet for a set time period. After a session of therapy, clinicians make progress notes, clients may do homework and return the following weeks for follow-up and additional work. After a few sessions, clinicians generally have an understanding of the client’s presenting problem, coping style, and interpersonal dynamics.

Immediately following a disaster, emergency mental health workers will be providing services to people who, under the circumstances, most likely not given any thought to seeking mental health services. Having to proceed without an explicit or implicit therapeutic contract, mental health interventions often take place in settings that are chaotic, and lack privacy, quiet, or comfort. The disaster mental health worker may be working a waiting line or sitting on a curb or a shelter cot next to a survivor. He or she will most likely have 10-30 minutes at most with any one individual and will probably never see a survivor more than once. The disaster mental health worker will have to establish instant rapport and make rapid assessments of large numbers of individuals who may be experiencing extreme, but normal stress reactions, including inordinate fatigue, irritability, and intense ambivalence about receiving help. In addition, disaster mental health workers will not be doing "therapy," but rather addressing pragmatic concerns while using psychoeducational techniques to teach survivors about stress reactions and stress management methods. The administrative strategy for helping victims may change several times in the course of a day, requiring clinicians to frequently change their routines, locales, and the type of victims they serve.

This guidebook is intended as introduction for administrators and clinicians to the field of disaster mental health. It is our hope that the guidebook illustrates the value of ...

* Establishing a disaster mental health service

* Providing a disaster team with operational protocols for timely and effective response

* Establishing a training program to prepare clinicians and administrators for the challenges of disaster mental health service delivery

* Developing a plan to integrate services with other emergency responders before disaster strikes

SECTION I

DEFINING DISASTER

defining disaster

A major disaster is defined as any natural catastrophe, or regardless of cause, any fire, flood, or explosion that causes damage of sufficient severity and magnitude to warrant assistance supplementing State, local, and disaster relief organization efforts to alleviate damage, loss, hardship, or suffering (FEMA Pub229(4) November 1995 p. 1).

In the event of disaster in the United States, a Governor may request a Presidential declaration. This request must satisfy the provisions of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (PL93-288, as amended by PL-100-707). "The Stafford Act provides the authority for the Federal Government to respond to disasters and emergencies in order to provide assistance to save lives and protect public health, safety, and property" (Federal Response Plan, April, 1992, p1.). The presidential declaration process is described on p. .

TYPOLOGY OF DISASTER

The type of disaster has direct bearing on the psychological and social impact on survivors. Disasters are typically classified as either natural or human-made.

Earthquakes Earthquakes are classified as small, moderate, major, or great based on the Richter scale. The scale has a logarithmic base, with each increment a factor of 10, e.g., a quake with a magnitude of 8.2 is not twice the size of a quake of 4.1, but rather releases 10,000 times more destructive energy.

Earthquake classifications

Hurricanes Hurricanes produce winds of 75 miles per hour or more and are accompanied by torrential rains and storm surges along coastal regions. Hurricanes and coastal storms cause billions of dollars of damage in the United States each year.

Hurricane classifications

Tornadoes Tornadoes may range from a width of several hundred yards to more than a mile across. Texas, Oklahoma, Kansas, Missouri, Nebraska, Mississippi, Alabama, Georgia, and Florida are at highest risk for tornadoes. Tornadoes are classified using the Fujita Wind Damage Scale.

Tornado classifications

Other natural disasters Floods, wildfires, volcanoes, tsunamis, typhoons, cyclones, landslides, blizzards, heat waves, and drought are other forms of disaster capable of causing loss of life and considerable damage to the environment.

Human-made disasters Acts of terrorism, mass-transit accidents, chemical explosions, toxic spills, civil riots are forms of disaster also capable of causing loss of human life, damage to the environment, and overwhelming psychological distress.

Buffalo Creek Disaster Lifetime PTSD 59%

(Green et al., 1992) PTSD at 14 yr follow-up 25%

PTSD in Children 37%

Mt. St. Helens Volcanic Eruption PTSD in exposed sample 3.6%

(Shore et al., 1989) PTSD among nonexposed 2.6%

Tornado PTSD 59%

(Madakasira and O'Brien, 1987)

Tornado and Flood PTSD at 4 mths 15%

(Steinglass and Gerrity, 1990) PTSD at 16 mths 21%

Natural Disasters PTSD 2-5%

(North et al., 1989; Smith et al., 1986)

Australia: Bushfires PTSD 16%

(McFarlane, 1988) PTSD at 42 mths ??%

Columbia: Armero Eruption PTSD 32-42%

(Lima, Pai, Caris, et al., 1981;

Lima, Pai, Santacruz, & Lozano, 1991)

Mexico: Earthquake PTSD 32%

(Conyer et al., 1987)

Puerto Rico: Flood PTSD in exposed sample 04%

PTSD among nonexposed 0.7%

Technological Disasters

PTSD 5-80%

(Green et al., 1992; Palinkas et al., 1993;

Realmuto et al., 1992; Silverman et al., 1985; Smith et al., 1986; Weisaeth, 1989)

Types and Numbers of Disasters, Number of People Killed, and Number of People Affected, 1967-1991

__________________________________________________________

Number Number of Number of

Type of Disaster People Killed** People Affected

_____________________________________________________________________

Accidents 1284 71,745 418,557

Avalanche 29 1,237 500,000

Chemical accident 271 15,787 1,202,536

Civil Strife 207 3,007,154 135,653,524

Cold Wave 92 4,926 71,000

Cyclone 394 846,240 80,485,116

Displaced persons 97 68,741 25,611,475

Drought 430 1,333,728 1,426,239,250

Epidemic 291 124,338 5,791,234

Earthquake 758 646,307 42,943,009

Famine 15 605,832 12,950,000

Fire 729 81,970 814,341

Flood 135 304,870 1,057,193,110

Food shortage 22 252 28,320,267

Hurricane 120 15,139 6,028,833

Insect infestation 66 __ 446,000

Landslide 236 41,992 3,603,580

Power Shortage 5 __ 1,825,000

Storm 819 54,500 68,122,580

Tsunami 20 6,390 918

Typhoon 380 34,684 63,321,930

Volcano eruption 102 27,642 1,938,270

_______________________________________________________________

Note. Data taken form IFRC (1993) World Disaster Report 1993.

*Percentage of total number of disasters.

**Dashes indicate missing data.

Disasters also have been conceptualized from a spatial/temporal perspective, that is, sites of impact and phases of time.

The spatial perspective includes the point of impact and surrounding areas which are affected by the disaster (Figure 1).

PASTE IN FIGURE 1 HERE

The temporal perspective begins at impact and is roughly divided by phases from early post-impact through a long-term restoration phase (see Figure 2).

Redo figure with terms consistent to description

SECTION II

HOW DISASTER MENTAL HEALTH SERVICES ARE MOBILIZED

Whether you are an administrator or a clinician, it is necessary to have a rudimentary understanding of who is doing what, how services become operationalized, and where service-sites are likely to be established. The complexity of government in the United States compounds the difficulty of describing "who does what" in disaster. More than 82,000 separate governments operate throughout the country in the absence of nationally integrated standard operating procedures for disaster planning and response. Numerous federal and state agencies are charged with the authority and responsibility to provide disaster services. In addition, many numerous non-governmental agencies, including the American Red Cross and others that coordinate volunteers, provide disaster mental health services.

During the immediate aftermath of a disaster, it is often difficult to determine the parameters of the agencies responsible for providing services. The architecture for a systematic, coordinated, and effective response is continually re-shaped by real-world contingencies. Furthermore, each disaster becomes a political event and the political issues related to "who is in charge" and appropriate sources of funding are factors with implications for survivors, planners, and responders. Previously established networks, relationships, as well as political pressures are powerful forces shaping the disaster response and there is rarely consensus about matching resources with survivors. In effort to familiarize administrators and clinicians with the disaster mental health "environment," this section provides an introduction to to the disaster declaration process, an overview of the Federal Response Plan, and who the primary and secondary agencies are, and the Federal Crisis Counseling Program.

Not every disaster requires federal assistance. Typically before FEMA and other federal agencies provide assistance to state and local governments, the state’s governor must request assistance and the President must then make a declaration of major disaster or emergency. Figure 1 illustrates the steps in a disaster declaration:

1. Contact is made between the affected state and the FEMA regional office. This contact may take place prior or immediately following the disaster.

2. If it appears the situation is beyond state and local capacity, the state requests FEMA to conduct a joint Preliminary Damage Assessment (PDA). Participants in the PDA will include FEMA, state and local government representatives and other federal agencies.

3. Based on the PDA findings, the governor submits a request to the President through the FEMA Regional ,Director for either a major disaster or an emergency declaration.

4. The FEMA Regional Office submits a summary of the event and a recommendation based on the results of the PDA to FEMA headquarters, along with the Governor's request.

5. Upon receipt of these documents, Headquarters senior staff convene to discuss the request and determine the recommendation to be made to the President.

6. FEMA's recommendation is forwarded to the White House for review.

7. The President declares a major disaster or an emergency.

Figure 3. Disaster declaration process

The Federal Response Plan (FRP) describes the planning assumptions, policies, concept of operations, and organizational structures by which twenty-seven federal departments and agencies mobilize resources and conduct activities to augment State and local response efforts following a domestic disaster. The FRP uses a functional approach to group the types of federal assistance under twelve Emergency Support Functions (ESFs):

ESF #1 - Transportation

ESF #2 - Communications

ESF #3 - Public Works and Engineering

ESF #4 - Firefighting

ESF #5 Information and Planning

ESF #6 - Mass Care

ESF #7 - Resource Support

ESF #8 - Health and Medical Services

ESF #9 - Urban Search and Rescue,

ESF #10 - Hazardous Materials

ESF#11 - Food

ESF #12 - Energy

Each ESF is headed by a primary agency, which has been selected based on its authorities, resources and capabilities in the particular functional area.

Mental health services falls under ESF#8, the Health and Medical Services Annex. Federal assistance provided under ESF #8 is directed by the Department of Human Health and Human Services (DHHS) through its Executive Agent, the Assistant Secretary for Health, who heads the U.S. Public Health Service.

All federal assistance is provided to the affected State under the overall coordination of the Federal Coordinating Officer appointed by the Director of the Federal Emergency Management Agency (FEMA) on behalf of the President. A more detailed account of the FRP is presented in the section describing FEMA’s operations (pp. ).

A. General

1. During the period immediately following a major disaster or emergency requiring Federal Response, primary agencies, when directed by FEMA, will take actions to identify requirements, and mobilize and deploy resources to the affected area to assist the State in lifesaving and life-protecting response efforts.

2. Agencies have been grouped together under the functional Emergency Support Functions (ESFs) to facilitate the provision of response assistance to the State. These functions are transportation, communications, public works and engineering, firefighting, information and planning, mass care, resource support, health and medical services, urban search and rescue, hazardous materials, food and energy. If Federal response assistance is required under the Plan, it will be provided using some or all of the ESFs, as necessary.

3. Each ESF has been assigned a number of missions to provide response assistance to the State, the designated primary agency, acting as the Federal Executive Agent, and with the assistance of one or more support agencies, is responsible for managing the activities of the ESF and ensuring that the missions are accomplished. ESFs have the authority to execute response operations to directly support state needs.

4. Specific ESF functional missions, organizational structures, response actions and primary and support agency responsibilities are described in the Functional Annexes to the Plan.

5. ESFs will coordinate directly with their functional counterpart State agencies to provide the assistance required by the State. Requests for assistance will be channeled from local jurisdictions through the designated State agencies for action. Based on State-identified response requirements, appropriate Federal response assistance will be provided by an ESF to the State, or at the State's request, directly to an affected local jurisdiction.

6. A Federal Coordinating Officer (FCO) will be appointed by the President to coordinate the Federal activities in each declared State. The FCO will work with the State Coordinating Officer (SCO) to identify overall requirements, including unmet needs and evolving support requirements, and coordinate these requirements with the ESFs. The FCO will also coordinate public information, Congressional liaison, community liaison, outreach and donations activities, and will facilitate the provision of information and reports to appropriate users.

7. The FCO will head a regional interagency Emergency Response Team (ERT), composed of ESF representatives and other support staff. The ERT provides initial response coordination with the affected State at the State Emergency Operations Center (EOC) or other designated State facility and supports the FCO and ESF operations in the field. The FCO will coordinate response activities with the ESF representatives on the ERT to ensure that Federal resources are made available to meet the requirements identified by the State.

8. A national interagency EST, composed of ESF representative and other support staff, will operate at FEMA headquarters to provide support for the FCO and the ERT.

9. The Catastrophic Disaster Resource Group (CDRG), composed of representatives from all departments and agencies under the Plan, will operate at the national level to provide guidance and policy direction on response coordination and operational issues arising from FCO and ESF response activities. The CDRG is also supported by the EST and will operate from FEMA headquarters.

10. Activities under the Plan will be organized at various levels to provide partial response and recovery (utilizing selected ESFs) or to provide full response and recovery (utilizing all ESFs).

B. Organization

The organization to implement the procedures under the Plan is composed of standard elements at the national and regional levels. The response structure shows the compositions of the elements providing response coordination and response operations activities at the headquarters and regional levels, but does not necessarily represent lines of authority or reporting relationships. In general, national-level elements provide support to the regional-level elements which implement the on-scene response operations in the field.

1.1. National-level Response Structure

The national-level response structure is composed of national interagency coordination and operations support elements from the participating departments and agencies. Overall interagency coordination activities are supported by the CDRG and EST at FEMA Headquarters. These elements will be augmented by department and agency operations support elements at other locations. The national-level response structure is composed of the following specific elements:

a. Catastrophic Disaster Response Group

(1) The CDRG is the headquarters-level coordinating group which addresses policy issues and support requirements from the FCO and ESF response elements in the field. It is chaired by the FEMA Associate Director, SLPS, and includes representatives from the Federal departments and agencies which have responsibilities under the Plan. The CDRG addresses response issues and problems which require national-level decisions of policy direction.

(2) The CDRG will meet on an as-needed basis at the request of the CDRG Chairperson. Meetings, unless otherwise indicated, will be held at the Emergency Information and Coordination Center (EICC), located in FEMA Headquarters, Washington, DC.

b. Emergency Support Team

The EST is an interagency group comprised of representatives from each of the primary agencies, select support agencies and FEMA Headquarters staff. It operates from the FEMA EICC. Detailed procedures regarding the EST organization and operations are found in the "EST Organization and Operational Procedures" document published by FEMA.

(1) The EST:

(a) Supports the CDRG and assists in assuring interagency headquarters information and coordination support for response activities;

(b) Serves as the central source of information at the national regarding the status of Federal response activities and helps disseminate information (through a JIC) to the media, Congress and the general public; and

(c) Provides interagency resource coordination support to the FCO and regional response operations. In this capacity, the EST provides coordination support for FCO, ERT and ESF activities, as necessary. ESF representatives from the primary agencies provide liaison between field operations, their respective emergency operations centers (if applicable) and headquarters activities. The EST also coordinates offers of donations, including unsolicited resources offered by various individuals and groups, with field elements for use in response operations.

(2) To accomplish the resources coordination function, the EST:

(a) Coordinates the acquisition of additional resources, which an ESF is unable to obtain under its own authorities, to support operations;

(b) Advises the CDRG regarding the need to resolve a resource conflict between two or more ESFs which cannot be resolved in the affected region(s); and

(c) Supports coordination of resources for multi-State and multi-regional disaster response and recovery activities.

2.2. Regional-level Response Structure

The regional-level response structure is composed of interagency elements operating from various locations. Initially, representatives from the ESFs and FEMA will assemble at the ROC located at the FEMA Regional Office (or Federal Regional Center). As needed, an Advance Element of the Emergency Response Office ( or Federal Regional Center). As needed, an Advance Element of the Emergency Response Team (ERT-A) will deploy to the field to assess or begin response operational as required. When fully operational, the regional-level response structure will include the FCO and ERT in a DFO, with regional ESFs conducting response operations to provide assistance to each affected State.

a. Regional Operations Center

The ROC is activated by the Regional Director at a FEMA Regional Office. It is staffed by FEMA and representatives from the primary agencies and other agencies, as needed, to initiate and support Federal response activity. The ROC:

(1) Gathers damage information regarding the affected area;

(2) Serves as a point-of-contact for the affected State(s), national EST and Federal agencies;

(3) Establishes communications links with the affected State(s), national EST and Federal agencies;

(4) Supports deployment of the ERT(s) to field locations;

(5) Implements information and planning activities (under ESF #5);

(6) Serves as a initial coordination office Federal activity until the ERT is established in the DFO in the field;

(7) Supports coordination of resources for multi-State and multi-regional disaster response and recovery activities, as needed.

b. Emergency Response Team

The ERT is the interagency group that provides administrative, logistical, and operational support to the regional response activities in the field. The ERT includes staff from FEMA and other agencies who support the FCO in carrying out interagency activities. The ERT also provides support for the dissemination of information to the media, Congress and the general public. Each FEMA Regional Office is responsible for rostering an ERT and developing appropriate procedures for its notification and deployment.

(1) Advance Element of the Emergency Response Team

The ERT-A is the initial group to respond in the field to an incident. It is the nucleus of the full which operates from the DFO. The Advance Element is headed by a team leader from FEMA and is composed of FEMA program and support staff and representatives from selected ESF primary agencies. It is organized with Administration and Logistics, Information and Planning, and Operations groups and includes staff for public information, congressional liaison, and community liaison activities, as required.

(a) A part of the ERT-A will deploy to the State EOC or the other locations to work directly with the State to obtain information on the impact of the event and to begin identifying specific State requirements for Federal response assistance.

(b) Other members of the Advance Element, including leasing, communications and procurement representatives, and logistical and other support staff from FEMA, the General Services Administration (GSA), the Federal Emergency Communications Coordinator (FECC) or a representative, and the Forest Service, as required, will deploy directly to the disaster site to identify or verify the location for a DFO; establish communications; and set up operations, including the establishment of one or more Mobilization Centers, as required.

(2) Structure of the ERT

The ERT is composed of the following elements:

(a) Federal Coordinating Officer

The FCO is appointed on behalf of the President by the Director, FEMA. The FCO heads the ERT and is supported in the field by staff carrying out public information, congressional liaison, community relations, outreach ( to disaster victims) and donations coordination activities. The FCO:

(1) Coordinates overall response and recovery activities with the State;

(2) Works with the SCO to determine State support requirements and to coordinate these requirements with the ESFs;

(3) Tasks ESFs or any Federal agency to perform missions in the Plan and to perform additional missions not specifically addressed in the Plan; and

(4) Coordinates response issues and problems with the which require national-level decisions or policy direction.

(b) Administration and Logistics

This element includes activities which provide facilities and services in support of response operations, as well as for recovery activities. Includes the DFO support functions of administrative services, fiscal services, computer support and a message center.

(c) Information and Planning

This element includes information and planning activities to support operations. It includes functions to collect and process information; develop information into briefings, reports, and other materials; display pertinent information on maps , charts and status boards; consolidate information for action planning; and provide technical services in the form of advice on specialized areas in support of operations.

(d) Response Operations

This element includes the ESFs which are activated to provide direct response assistance in support of State requirements. The functions include:

ESF #1 - Transportation

ESF #2 - Communications

ESF #3 - Public Works and Engineering

ESF #4 - Firefighting

ESF #5 Information and Planning

ESF #6 - Mass Care

ESF #7 - Resource Support

ESF #8 - Health and Medical Services

ESF #9 - Urban Search and Rescue,

ESF #10 - Hazardous Materials

ESF#11 - Food

ESF #12 - Energy

Each ESF is responsible for assessing State-identified Federal assistance requirements and resource requests and to organize and direct appropriate ESF response operations. The ESF primary agency will identify the functional support requirements to be provided by itself, support agencies and other ESFs.

(e) Recovery Operations

This Element includes the program activities of FEMA and other Federal agencies (OFAs) which Assistance (including temporary housing, grants and loans to individuals, families and businesses); Public Assistance (including debris clearance, the repair or replacement of roads, streets and bridges and the repair or replacement of water control facilities, public buildings and related equipment, public utilities and the repair o r restoration of recreational facilities and parks); and Hazard Mitigation Assistance (including measures to lessen or avert the threat of future disasters).

C. Notification

1. FEMA may receive initial notification or warning of a disaster from multiple sources, including the National Earthquake Information Service (NEIS) of the United States Geological Survey (USGS); the National Weather Service (NWS) (including the National Hurricane Center, the Severe Storms Forecast Center and the River Forecast Center); the Office of Territorial Affairs of the Department of the Interior; The Nuclear Regulatory Commission Operations Center; the FEMA National Warning Center; a FEMA Regional Office; a State Emergency Operations Center; or the news media.

2. Upon the determination of the occurrence of a disaster or emergency, the FEMA National Emergency Coordination Center (NECC) will notify key FEMA headquarters and regional officials. If there is a need for activation of response structures of the Plan, the NECC will notify CDRG and EST members at the national level, as required. The NECC will also notify the National Response Center, as appropriate. At the regional level, the appropriate Regional Director will notify members of the regional ERT.

3. Upon notification by FEMA, each agency is responsible for conducting its own internal national and regional notifications.

4. CDRG members may be called to assemble at the FEMA EICC for an initial meeting. CDRG members or alternates must be available at the call of the CDRG Chairperson to meet at any time during the initial response period, as necessary.

5. Detailed Federal headquarters and regional response notification action as are described in regional and headquarters procedures.

D. Activation

1. The Plan will be utilized to address particular requirements of a given disaster or emergency situation. ESFs will be activated based on the nature and scope of the event and the level of Federal resources required to support State and local response efforts.

2. Once a response requirement is identified, some or all of the structures of the Plan will be activated. This includes the establishment of the EST at headquarters level, the activation some or all of the ESFs and the deployment of an ERT from the regional office.

3. At the national level, the FEMA Associate Director, SLPS, in consultation with the FEMA Director, has the authority to activate part or all of the response structures at the headquarters level to address the specific situation.

4. At the regional level, a FEMA Regional Director, in consultation with the Associate Director, SLPS and the FEMA Director, also may activate part or all of the response structures of the Plan within the Region for the purpose of providing response support to an affected State.

5. Based on requirements of the situation, FEMA headquarters and offices will notify Federal departments and agencies regarding activation of some or all of the ESFs and other Structures of the Plan. Priority for notification by FEMA will be given to contacting primary agencies.

E. Deployment

When activated, ESFs and other operational elements will take actions to identify, mobilize and deploy personnel and resources to support regional and national response operations, including the ROC and ERT activities in the regions and CDRG and EST activities in FEMA headquarters.

PHS is the lead agency for ESF #8, directing the provision of the federal government health and mental health resources to fulfill the requirements identified by the affected State/local authorities having jurisdiction. Included in ESF #8 is overall public health response, and the triage, treatment and transportation of victims of the disaster, and the evacuation of patients out of the disaster area, as needed, into a network of Military Services.

DMATs are operationalized by PHS to assist in providing care for ill or injured victims at the site of a disaster or emergency. DMATs can provide triage, medical or surgical stabilization, and continued monitoring and care of patients until they can be evacuated to locations where they will receive definitive medical care. Specialty DMATs can also be deployed to address mass burn injuries, pediatric trauma, chemical injury or contamination, etc. In addition to DMATs, active duty, reserve, and National Guard medical units for casualty clearing/staging and other missions will be deployed as needed. Individual clinical health and medical care specialists may be provided to assist State and local personnel.

Develop narrative and gather info

SAMSHA (formerly the National Institute of Mental Health) is the lead mental health agency of the Public Health Service and incorporates what Alcohol, Drug Abuse, and Mental Health Administration: Assist in assessing mental health needs; provide mental health training materials for disaster workers; assist in arranging training for mental health outreach workers; assess adequacy of applications for Federal crisis counseling grant funds; address worker stress issues and needs through a variety of mechanisms.

Gather info

Administrates crisis counseling program through the provision of the Stafford Act, Section 416. The program is implemented using the Interagency Agreement with CMHS within SAMHSA. The crisis counseling grants are awarded through state mental health authorities. Staff of the CMHS Emergency Services and Disaster Relief Branch travel to the site of major disasters and assist in needs assessment, training, and program design. Throughout the period of funding, CMHS staff provide program consultation and monitoring. For description of grants available, see page #, .

(Request statement from CO )

Emergency Management Preparedness Office (EMPO)

Request statement

National Center for PTSD (NC-PTSD)

Develop statement

Readjustment Counseling Service (RCS) Request statement

The governor appoints a state coordinating officer (SCO) to coordinate the state and local efforts with those of the federal government. To date, the 50 states do not have a universal disaster mental health organization chart. Generally, local county mental health administrators are in charge of coordinating the local response. A few states have a designated state disaster coordinator within their respective departments of mental health who work with local mental health officials.

State mental health departments have the responsibility to apply for crisis counseling assistance and training funding (Immediate Service Grant, Regular Service Grant, see pp. ). The Immediate Service Grant provides funding to pay for non-federal mutual aid assistance received by the state and the Regular Service Grant state-run special mental health programs to communities affected by disaster. Assistance under this program is limited to Presidential-declared major disasters.

County Mental Health Services

Public mental health agencies, the primary sponsors of disaster crisis counseling programs, almost exclusively serve individuals with severe and chronic mental illness as part of their everyday mission. Following a disaster these agencies must shift their services to assist "normal" people responding normally to an abnormal situation. They must also maintain the care of their regular clientele, who often experience an exacerbation of symptoms during the aftermath of a disaster. Consequently, community mental health staff generally require special training to be able to respond rapidly and efficiently using a disaster mental health organizational orientation. Additional staff is often needed to manage regular on-going services, immediate disaster response activities, and the crisis-counseling program.

Mutual aid (additional staffing) may come from both the non-profit and private sector. Most states have a mutual aid system designed to supplement individual county resources when a county’s own resources are insufficient (e.g., fire, rescue, law enforcement, medical services, coroners, public works, engineering). However, mental health services may not be part of the mutual aid system. If not, it is strongly recommended that action be taken to include mental health services to ensure organized rapid deployment of trained disaster mental health personnel when needed.

Non-profit agencies (e.g, Catholic Social Services, Jewish Family Services) may provide needed resources and volunteers are generally, but not always, licensed private practitioners wanting to donate their time.

The Immediate Service Grant serves as the primary resource of funding for reimbursement of public mutual aid. The Regular Service Grant is the funding mechanism for on-going crisis counseling programs and training.

Under a 1905 Congressional charter, the American Red Cross is mandated to meet human needs created by disaster by providing emergency congregate and individual care in coordination with local government and private agencies.

The first priority of ARC Disaster Mental Health Services is to promote effective disaster recovery efforts by helping ARC workers manage stress related to their disaster work. The provision of mental services to disaster vicitms and the community mental health providers are the second and third priorities.

In 1990, American Red Cross National Disaster Services convened

a multi-disciplinary task force comprised of a psychologist, two

psychiatrists, a social worker, and four nurses. Their purpose was

to determine if there was a need for an internal disaster mental

health program, and if the findings warranted, develop the program.

Disaster workers and victims were surveyed and, based on the survey

results, the task force recommended the development of an internal

disaster mental health program. Over the next few months, the

American Red Cross Disaster Mental Health Services (DMHS)

was created. Representatives from the National Institute of Mental

Health, the American Psychological Association, the National

Association of Social Workers, and the American Counseling

Association provided suggestions and reviewed materials as

they were developed.

In an effort to help our workers with stress management and good

health practices, the care of Red Cross disaster workers has been set

as the first priority of DMHS. The provision of mental health

services to disaster victims and the community mental health

providers are the second and third priorities. It was determined

that the assistance provided by Red Cross DMHS would be restricted

to crisis intervention with referrals to local providers for more

intensive needs. Only licensed or certified mental health professionals

would be utilized in the national program. Volunteers must be

currently employed in a mental health field and be license eligible

in states requiring licensure.

Disaster Mental Health Services I (2) is a two day course intended

to help mental health professionals adapt their existing skills to

the needs of disaster workers and victims. The course is not crisis

intervention training. This two day course plus a four hour orientation

to the overall disaster services program and a first aid certificate are

the sole requirements for becoming a DMHS volunteer.

The disaster mental health program is being developed at both

the national and local levels. Extensive networking is being

conducted with professional associations to inform their membership

of the Red Cross DMHS program and their opportunity to become

involved. National statements of understanding have been signed

with the American Psychological Association and the National

Association of Social Workers, the Association of Marriage

and Family Therapists. These understandings will facilitate

interagency cooperation and increase the number of available

mental health professionals for local and national assignments.

Utilizing Disaster Services Regulations and Procedures: Disaster

Mental Health Services, local Red Cross chapters are developing

and incorporating disaster mental health response plans in

their overall chapter disaster plan. Chapters are encouraged to

network with community agencies and individual providers

to coordinate services and obtain agreements that provide pro bono services to disaster victims and workers. These services would be

then utilized in the chapter's response to local disasters.

When disasters occur that are beyond the response capabilities

of a local chapter, the national organization provides assistance

with personnel, materials, and financial resources. The

Disaster Services Human Resources System (DSHR) is the national

personnel inventory that tracks individual disaster workers. From

this system, volunteers are recruited to respond to these large

disasters. To become a DSHR member, licensed mental health

professionals must meet the training requirements listed above

and be available for a minimum of a 12 day operational assignment.

Additional experience and training provides further opportunities

for volunteer career advancement. Any mental health professional

interested in becoming a volunteer should contact their local chapter

of the American Red Cross.

AADPA             Assistant Associate Director for Public and Intergovernmental Affairs

AE                Aeromedical Evacuation

AEC               Agency Emergency Coordinators

AECC              Aeromedical Evacuation Control Center

AECE              Aeromedical Evacuation Control Element

AECM              Aeromedical Evacuation Crew Members

AELT              Aeromedical Evacuation Liaison Team

AES               Aeromedical Evacuation System

AMC               Air Mobility Command, U S  Air Force

ALCC              Airlift Control Center

AMS               Aerial Measuring System

AOC              Army Operations Center, Pentagon

AP                Assembly Point

ARC              American Red Cross

ARES              Amateur Radio Emergency Services

ARRL              American Radio Relay League

ASH               Assistant Secretary for Health, Department of Health and Human Services

ASMRO             Armed Services Medical Regulating Office, Department of Defense

AUTODIN     Automatic Digital Network

AUTOVO Automatic Voice Network

BIA              Bureau of Indian Affairs

BIFC            Boise Interagency Fire Center

BLM              Bureau of Land Management

BOR             Bureau of Reclamation

BPA              Blanket Purchasing Agreements

C               Base Camp

CAR             Congressional Affairs Representative

CAT            Crisis Action Team

CCC            Commodity Credit Corporation

CCP            Casualty Collection Point

CDC             Centers for Disease Control, U S  Public Health Service

CDRG           Catastrophic Disaster Response Group

CEPPO           Chemical Emergency Preparedness and Prevention Office

CERCLA          Comprehensive Environmental Response, Compensation, and Liability Act

CFR             Code of Federal Regulations

CINC           Commander-In-Chief

CLO             Congressional Liaison Officer

CMT            Crisis Management Team

CONUS           Continental United States

CONUSA         Continental United States Army

CR             Congressional Relations

CRC             Crisis Response Cell

CRM             Crisis Resource Manager

CRO             Congressional Relations Officer

CWA             Clean Water Act

DAE             Disaster Assistance Employee

DASH            Deputy Assistant Secretary for Health, Department of Health and Human Services

DCLO           Deputy Congressional Liaison Officer

DCO             Defense Coordinating Officer

DFO             Disaster Field Office

DFSG            Disaster Financial Services Group

DLA            Defense Logistics Agency

DMAT            Disaster Medical Assistance Team

DMORT          Disaster Mortuary Team, National Disaster Medical System

DOC             Department of Commerce

DOD            Department of Defense

DOE             Department of Energy

DOEd            Department of Education

DOI             Department of the Interior

DOJ             Department of Justice

DOL             Department of Labor

DOMS            Directorate of Military Support, Department of Defense

DOS             Department of State

DOT             Department of Transportation

DPAO            Deputy Public Affairs Officer

DWI             Disaster Welfare Inquiry

EC             Emergency Coordinator

ECS             Emergency Communications Staff

EEI             Essential Elements of Information

EICC            Emergency Information and Coordination Center

EMS             Emergency Medical Services

EO              Executive Order

EOC             Emergency Operations Center

EPA             Environmental Protection Agency

ERB             Economic Resources Board

ERC             Emergency Response Coordinator

ERCG            Emergency Response Coordination Group, Public Health Ser-vice/Centers for Disease Control and Agency for Toxic Substances and Disease Registry

ERT             Emergency Response Team

ERT-A           Advance Element of the Emergency Response Team

ESF             Emergency Support Function

EST             Emergency Support Team

FAA             Federal Aviation Administration

FAX             Facsimile

FBI             Federal Bureau of Investigation

FCC             Federal Communications Commission

FCO             Federal Coordinating Officer

FECC            Federal Emergency Communications Coordinator

FEMA            Federal Emergency Management Agency

FERC            FEMA Emergency Response Capability

FESC            Federal Emergency Support Coordinator

FHWA            Federal Highway Administration

FNS             Food and Nutrition Services

FORSCOM         Forces Command, Department of Defense

FRCM            FEMA Regional Communications Manager

FRERP           Federal Radiological Emergency Response Plan

FSS             Federal Supply Service

FTS             Federal Telecommunications Systems

GSA            General Services Administration

GSACR           GSA Communications Representative

HET-ESF         Headquarters EmergencyTransportation - Emergency Support Function

HF              High Frequency

HHS             Department of Health and Human Services

HQDA           Headquarters, Department of the Army

HQUSACE Headquarters, United States Army Corps of Engineers

HUD             Department of Housing and Urban Development

HWC             Health and Welfare Canada

IAEA            International Atomic Energy Agency

ICC             Interstate Commerce Commission

ICPAE           Interagency Committee on Public Affairs in Emergencies

ICS             Incident Command System

IEA             International Energy Agency

IRMS           Information Resources Management Service

J-4/JCS        Office of the Joint Chiefs of Staff

JIC             Joint Information Center

JIS             Joint Information System

JTF            Joint Task Force

JMMO            Joint Medical Mobilization Office

JTRB            Joint Telecommunications Resources Board

KCCO            Kansas City Commodity Office

LOC-TFCS   Letter-of-Credit - Treasury Financial Communications System

M              Marshalling Area

MARS            U S  Army Military Affiliate Radio System

MASF            Mobile Aeromedical Staging Facility

MC              Mobilization Center

MCR             Military Communications Representative

MOA             Memorandum of Agreement

MOU             Memorandum of Understanding

MRE             Meals Ready to Eat

NASA            National Aeronautics and Space Administration

NCC             National Coordinating Center

NCP             National Oil and Hazardous Substances Pollution Contingency Plan

NC-PTSD National Center for Post-Traumatic Stress Disorder

NCS             National Communications System

NCS/DCA-OC   National Communications System/Defense Communications Agency-Operations Center

NCSP            National Communications Support Plan

NCSRM           National Communications System Regional Manager

NDMOC           National Disaster Medical Operations Center

NDMS            National Disaster Medical System

NDMSOSC         National Disaster Medical System Operations Support Center

NECC            National Emergency Coordination Center (FEMA)

NEIS            National Earthquake Information Service

NFDA            National Funeral Directors Association

NGB             National Guard Bureau

NICC            National Interagency Coordination Center

NIFCC           National Interagency Fire Coordination Center, U S  Forest Service

NIMH            National Institutes of Mental Health

NOAA           National Oceanic and Atmospheric Administration

NP              National Preparedness

NRC             Nuclear Regulatory Commission

NRT             National Response Team

NSEP            National Security Emergency Preparedness National Strike Force

NTIA            National Telecommunications and Information Administration

NTSP            National Telecommunications Support Plan

NVOAD           National Voluntary Organizations Active in Disaster

NWS             National Weather Service

OASH            Office of the Assistant Secretary for Health, Department of Health and Human Services

OCHAMPUS      Office of Civilian Health and Medical Program of the Uniformed Services, Department of Defense

OEP            Office of Emergency Preparedness, U S  Public Health Service

OET             Office of Emergency Transportation

OFA            Other Federal Agency

OFDA            Office of U S  Foreign Disaster Assistance

OJCS            Office of the Joint Chiefs of Staff, Department of Defense

OMB            Office of Management and Budget

OPA            Oil Pollution Act

OPM             Office of Personnel Management

OSC             On-Scene Coordinator

OSHA            Occupational Safety and Health Administration

OSTP            Office of Science Technology Policy

PA              Public Affairs

PAO             Public Affairs Officer

PBS             Public Building Service (GSA)

PHS             U S  Public Health Service, Department of Health and Human Services

PIO             Public Information Officer

P L             Public Law

POA             Point of Arrival

POD             Point of Departure

PRA             Patient Reporting Activity

PSR             Personal Service Radio

RACES           Radio Amateur Civil Emergency Services

RCP             Regional Oil and Hazardous Substances Pollution Contingency Plan

RD             Regional Director

REA             Rural Electrification Administration

REACT           Radio Emergency Associated Communication Team

REC             Regional Emergency Coordinator

RECC            Regional Emergency Communications Coordinator

RECP            Regional Emergency Communications Plan

REP             Regional Evacuation Point

ACRONYMS

RET             Regional Emergency Transportation

RETCO           Regional Emergency Transportation Coordinator

RHA             Regional Health Administrator (HHS)

RMNCS           Regional Manager National Communications System

ROC             Regional Operations Center

ROST            Regional Operations Support Team

RRT             Regional Response Team

S               Staging Area

SAR            Search and Rescue

SARA           Superfund Amendments and Reauthorization Act

SCO             State Coordinating Officer

SCS             Soil Conservation Service

SF              Standard Form

SITREP          Situation Report

SLPS            State and Local Programs and Support Directorate (FEMA)

SOP             Standard Operating Procedure

TAES            Tactical Aeromedical Evacuation System

TCP             Telecommunications Priorities

TOA             Transportation Operating Agencies

TREAS           Department of the Treasury

TSP             Telecommunications Service Priority

TVA             Tennessee Valley Authority

U S             United States

USACE           United States Army Corps of Engineers

USAF            United States Air Force

USCG            United States Coast Guard

USDA            United States Department of Agriculture

USGS            United States Geological Survey

USLANTCOM   United States Atlantic Command

USN             United States Navy

USPACOM         United States Pacific Command

USPHS           United States Public Health Service

USPS            United States Postal Service

USTRANSCOMUnited States Transportation Command, Department of Defense

US&R            Urban Search and Rescue

VA              Department of Veterans Affairs

VHA             Veterans Health Administration, Department of Veterans Affairs

ZECP            Zone Emergency Communications Planner

To meet the mental health needs of survivors following a Presidential-declared disaster, FEMA provides funding for crisis counseling programs through provisions of the Stafford Act (see p. ). Funds for the crisis counseling, training, public information and education services are available only when States can document that needs exist which cannot be met with State and local resources. The needs assessment under the crisis counseling program must demonstrate that disaster-precipitated mental health needs are significant enough that a special mental health program is warranted and it cannot be provided without federal assistance

A grant application is required for all States applying for funds for post-disaster crisis intervention programs under the "immediate services" and the "regular program" types of grants. Staff of the Emergency Services Branch of the Center for Mental Health Services are available to assist in the preparation of the grant applications.

The grant application requires the submission of Form 424 (Part I of Public Health Service grant application form 5161-1 -- the other parts of Form 5161-1 are not required for the crisis counseling program). The workbook, referred to in the footnote, is a necessary guide to completing the form because there are specific formulas for calculating need.

Two methods of assessment are recommended by the workbook: use of indicator data and the use of key informants.

* estimation of average number of persons per household in each service provider area of state

* estimation of the number of directly impacted households in service provider area (e.g., number of dead, hospitalized, non-hospitalized injured, homes destroyed, homes with major damage, homes with minor damage, disaster unemployed)

* estimation of the total number of individuals in need of services (prevalence rates for different types of loss have been developed to represent the percent of person expected to be in need of mental health services)

* estimation of outreach, consultation, and education needs

* description of population demographics (high risk groups: children, frail elderly, the disadvantaged, ethnic groups)

As defined by the workbook, "the key informant approach to needs assessment is based on the assumption that certain persons in the community know the community well enough to be able to estimate both mental health needs attributable to the disaster and needed resources." Key informants can be surveyed to estimate a) specific groups impacted by the disaster; b) gaps and problems in existing services; and c) resources required to meet the needs resulting from the disaster.

* Gatekeepers: Professionals such as public health nurses ,school nurses, social workers, clinicians, teachers, clergy, ad disaster workers

* Administrators and directors of service organizations

* Influential leaders: County commissioners, mayors, judges, school board leaders

The program plan section of the grant application should describe the proposed service delivery mechanisms to meet the mental health needs of the impacted population as estimated by the assessment procedures. Crisis counseling programs services generally include outreach, consultation, diagnostic, individual crisis counseling, referral, advocacy, and education services.

In addition to the description of proposed services, the plan should include a description of organizational structure, staffing and training requirements, job descriptions, facility and equipment requirements, and the process of recordkeeping and program evaluation.

There is no required form for presenting a budget, however, many applicants choose to use Part III of Form 5161-1. The budget must be tied to program elements and present sufficient detail about the fiscal resources necessary to administer the program.

SECTION III

DISASTER MENTAL HEALTH SERVICES TEAM AND PROGRAM DEVELOPMENT

TEAM FORMATION

STAFF TRAINING

DEVELOPMENT OF STANDARD OPERATING PROCEDURES

EARLY POST-IMPACT PHASE CRITICAL DISASTER MENTAL HEALTH ADMINISTRATIVE TASKS: LOCAL LEVEL

RESTORATION PHASE CRITICAL DISASTER MENTAL HEALTH ADMINISTRATIVE TASKS: LOCAL LEVEL

RESTORATION PHASE DISASTER MENTAL HEALTH SERVICES

* Disaster Coordinator -- responsible for administrative management of operating procedures including fiscal mechanisms, mobilization procedures, inter/intra agency relations, and staff development/training (see p. administrative tasks)

* Direct service providers -- multidisciplinary team

1. Field coordinator(s)

2. First responders, back-up teams

* Ad hoc secretarial support

* Program analyst/researcher

Candidates seeking to become a member of the disaster mental health team should have the following qualifications.

* Possess mental health clinical license

* Be available for service on "hours-2 days" notice for 10-14 day assignment

* Have letters of reference that indicate the candidate has:

1) A high tolerance for difficult working conditions which may include:

- long hours

- substandard lodging

- unstructured or ambiguous situations

- intense political competition

- rapid change

2) Ability to establish rapport with people of various ages, ethnicities, and social, economic, and educational backgrounds

3) Ability to give educational group presentations to survivors, helpers, community groups

All members of a disaster mental health team require specialized training because many of the intervention skills needed differ from those used in traditional outpatient or inpatient clinical work.

Although training cannot fully prepare disaster workers for the impact of disaster stressors (Hodgkinson & Shepherd, 1994; Paton, 1994), training and experience do predict optimal versus maladaptive (e.g., freezing, flight) response in disaster emergencies (Weisaeth, 1989). Content of training should include the following:

* Dimensions of disaster: Temporal/spatial implications for interventions

* Key characteristics and behaviors of effective disaster mental health workers

* Biopsychosocial stressors associated with disasters

* Biospsychosocial stress reactions associated with disasters

* Key principles of helping survivors, disaster workers, and organizations including assessment, treatment, and consultation strategies appropriate to the phases of disaster

* Orientation to primary disaster agencies

* Self-care management strategies

It is also important to develop a library of educational materials which can be made available to team members.

Each disaster mental health team will need to develop standard operating procedures to address fiscal, skills development and maintenance, mobilization, field, return to home site, and evaluation practices. Each of these mechanisms are to a degree contingent upon size and scope of the parent organization, the dimensions of any given disaster, and whether the team is responding to an in-house incident, a community-wide local disaster, or a disaster in another community. These considerations aside, standard operating procedures should address:

Fiscal

* Fiscal responsibility mechanisms

* Budget for equipment (cell phones, laptops, miscellaneous stationery supplies, flashlights, identification badges, etc.)

* Budget for logistical support (transportation to and from site, on-site vehicles)

* Budget for lodging and per diem expenses

* Budget for miscellaneous expenses (postage, phone bills, etc.)

Mobilization

* Equipment procurement procedures

* Staff notification procedures

* Staff check-in procedures

* Logistical support (providing staff transportation, lodging, and per diem)

Field Procedures

* Conduct of needs assessment

* Coordination of staff assignments, frequency of status reports, scheduling

* Liaison with other agencies

* Mitigation and monitoring of stress level of staff

* Post-operation debriefing

* Demobilization procedures

* Reintegration back into regular assignment

* After action report formats

Miscellaneous

* Intra/inter-agency relationships

* Development & distribution of educational materials

* Development of program evaluation mechanisms

* Continuing education of team

Trainings

Mock exercises

* Clarification of liability for services rendered

At the local community mental health level, the disaster coordinator or adhoc designate coordinates the immediate mental health response. The following tables delineate key administrative tasks during the early post impact and restoration phases.

EMERGENCY RESPONSE PHASE: ON SITE EMERGENCY DISASTER MENTAL HEALTH SERVICES

EMERGENCY RESPONSE PHASE: OFF SITE DISASTER MENTAL HEALTH SERVICES

EARLY POST-IMPACT DISASTER MENTAL HEALTH SERVICES

RESTORATION PHASE DISASTER MENTAL HEALTH SERVICES

SECTION IV

STRESS REACTIONS OF SURVIVORS

Post-traumatic stress reactions can result from very different life threatening events including natural disaster, sexual abuse/assault, war zone duty, or the witnessing of terrible things happening to other people. Accidental disasters (i.e. car, train, boat, airplane, fires, explosions); natural disasters (i.e. floods, tornadoes, hurricanes, earthquakes), or deliberately caused disasters (i.e. bombings, shootings, torture, rape, assault and battery) are all capable of producing stress. Although there are many types of traumatic events, survivors experience a common stress response which may include feelings of terror, vulnerability, helplessness, fear of bodily injury, or overwhelming loss and guilt over actions taken or avoided. The typical pattern of response to a traumatic event is recognized as a post-traumatic stress reaction or syndrome.

In addition to the stress of trauma exposure and the initial losses incurred (e.g., loss of loved ones, friends, and/or property), the stress response of a survivor may be influenced by resulting problems with unemployment, financial resources, substance abuse, marital and family discord, or medical or mental health problems, as well as disaster-related organizational politics involving safety, rebuilding, and relocating.

It is important to help survivors recognize the normality of stress reactions to disaster. Mild to moderate stress reactions in the emergency and acute phases of disaster are highly prevalent. Although reactions are often unpleasant, they often do not become chronic problems. Most people recover fully from moderate stress reactions within 6 to 16 months.

[Baum & Fleming (1993); Bravo et al. (1990); Dohrenwend et al. (1981);

Green et al. (1994); La Greca et al. (in press); Steinglass & Gerrity (1990);

Vernberg et al. (in press)]

Emotions Cognitive Effects

shock impaired concentration

anger confusion

despair disbelief

terror distortion

guilt decreased self-esteem

grief or sadness decreased self-efficacy

irritability self-blame

helplessness intrusive thoughts and memories anhedonia worry emotional numbing dissociation (e.g., "dreamlike," tunnelvision," "spacey," automatic pilot")

Physical Impact/Hyperarousal Interpersonal Effects

fatigue alienation

insomnia social withdrawal

nightmares increased conflict within relationships

hyperarousal vocational impairment

somatic complaints

startle response

Extreme "peritraumatic" stress symptoms (i.e., those symptoms which occur during or immediately after the disaster experience) include any of the following reactions IF they are of sufficient intensity to cause significant impairment in reality orientation, communication, relationships, recreation and self-care, or work and education:

* Dissociation (depersonalization, derealization, fugue states, amnesia)

* Intrusive re-experiencing (flashbacks, terrifying screen memories or nightmares repetitive automatic re-enactment)

* Avoidance (agoraphobic-like social withdrawal, alexithymia, catatonia)

* Hyperarousal (panic episodes, startle reactions, fighting or temper problems),

* Anxiety (debilitating worry, nervousness, vulnerability or powerlessness)

* Depression (anhedonia, worthlessness, loss of interest in most activities, awakening early. persistent fatigue and lack of motivation)

* Problematic substance use (abuse or dependency, self-medication)

* Psychotic symptoms (delusions, hallucinations, bizarre thoughts or images)

[Cardena & Spiegel (1993); Joseph et al. (1994); Koopman et al. (1994, 1995); La Greca et al.

(in press); Lonigan et al. (1994); Schwarz & Kowalski (1991); Shalev et al. (1993)]

People at highest risk for extreme peritraumatic stress include those who experience:

* Life-threatening danger, extreme violence, or sudden death of others

* Extreme loss or destruction of their homes, normal lives, and community

* Intense emotional demands from distraught survivors (e.g., rescue workers, counselors, caregivers)

* Prior psychiatric or marital/family problems.

Children: [Green et al. (1994); Hardin et al. (1994) La Greca et al. (in press) Lonigan et al. (1994); Pynoos et al. (1993) Rubonis & Bickman (1991) Vernberg et al. (in press)]

Adults: [Baum & Fleming (1993); Dohrenwend et al. (1981); Goenjian et al. ( 1994);

Green et al. (1990b); Hanson et al. (1995) ;Palinkas et al. (1992); Rubonis & Bickman (1991); Solomon et al. (1987); Turner et al. (1995); Webster et al. (1995)]

Elders: [Goenjian et al. (1994); Livingston et al. (1994); Phifer & Norris (1989)]

People who experience extreme peritraumatic stress reactions are at greatest risk for delayed or chronic post-traumatic psychosocial impairments (e.g., PTSD, anxiety disorders, major depression, addictive disorders).

[Cardena & Spiegel (1993); Joseph et al. (1994); Koopman et al. (1994, 1995); La Greca et al. (in press) ; Lonigan et al. (1994); Marmar et al. (1996) ;Schwarz & Kowalski (1991);

Shalev et al. (1996)]

Disasters affect everyone involved. People directly exposed to danger and life threat are at risk for the greatest impact. The literature examining the role of traumatic exposure is definitive...that is, regardless of the traumatic stressor, be it war-zone related, or that stemming from physical or sexual assault, or a natural disaster, it has been shown conclusively that the dose-response is the strongest predictor of who will likely be most affected. The greater the perceived life threat, and the greater the sensory exposure, that is, the more one sees distressing sights, smells distressing odors, hears distressing sounds, or is physically injured, the more likely the post-traumatic stress will manifest. Victims are not the only ones at risk. Helpers, including medical and security personnel, rescue workers, fire and safety workers, may also experience either direct or primary traumatization or indirect secondary traumatization or what is being referred to as compassion fatigue. Family members of victims too, are at risk for what has been referred to as vicarious traumatization -- relationships with traumatized individuals can in much distress for others.

Several studies of various types of traumatic exposure have reported that degree of exposure is a reliable predictor of post-traumatic stress. Knowing the spatial relationship of survivors to traumatic stimuli is a useful guide to initially directing resources where they will be most likely needed. The spatial relationship of survivors to the impact may be conceptualized as follows:

Primary exposure (ground zero survivors)

Secondary exposure (witnesses and helpers present during immediate aftermath)

Tertiary exposure (close ties with primary victims)

Quaternary exposure (concerned others in community)

Although the experience of the passage of time is subjective and may become distorted for survivors, generally, the longer a survivor is exposed to the disaster's sensory stimuli, the more at-risk he or she will be for severe stress reactions.

* Personal injury * Previous traumatization

* Injury or fatality of loved ones, friends, associates * Self-expectations

* Property loss/relocation * Prior disaster experience

* Pre-existing stress * Perception/interpretation of causal factors

* Level of personal and professional preparedness * Level of social support

* Stress reactions of significant others

One of the roles of the disaster mental health worker during the early-post impact phase is to identify individuals at risk for longer term problems. Therefore, it is helpful to be informed about the various factors associated with such risk. Of course, it is important to remain aware that many individuals who may be considered "at risk" on the basis of the signs listed in this guide will not develop problems, and that the primary reasons to note risk are to direct attention to certain survivors and to prompt and help guide selection of individuals who may later benefit from systematic efforts at follow-up contact.

[Baum & Fleming (1993) Dohrenwend et al. (1981) Hodgkinson (1989) Lopez-Ibor (1987)]

Survivors/witnesses of mass destruction or death (e.g., body handling; ethnic cleansing; torture) are at high risk for intrusion, demoralization, and PTPI.

[Goenjian et al. (1994) Ramsay et al. (1994) Ursano et al. (1995)]

Unresolved bereavement places survivors at high-risk for chronic PTPI.

[Livingston et al. (1994) Green et al. (1983) Joseph et al. (1994) Shore et al. (1986)]

Loss of home or community and associated emotional support places survivors at high risk for chronic bereavement and PTPI.

[Bland et al. (1996) Erikson (1976) Freedy et al. (1992) Keane et al. (1994) Lima et al. (1993) Lonigan et al. (1994) Palinkas et al. (1992) Phifer & Norris (1989) Quarantelli et al. (1986) [Solomon et al., 1993]) Shore et al. (1986) Vernberg et al. (in press)]

Note: property damage per se may not be traumatic [Norris & Uhl, 1993]

Survivors of other trauma as well as disaster are at high risk for PTPI.

[Bland et al. (1996) Goenjian et al. (1994) Hodgkinson & Shepherd (1994)]

Survivors who experience major life stressors (e.g., divorce, job loss, financial losses) after experiencing a disaster are at high risk for PTPI.

[Bland et al. (1996) Garrison et al. (1995) Hardin et al. (1994) Joseph et al. (1994) Koopman et al. (1994) La Greca et al. (in press)]

The research literature also suggests that survivors with certain personal or social background characteristics are at high-risk for delayed or chronic post-trauma psychological impairments.

Chronic psychophysiologic stress/anxiety or unexplained somatic problems.

[Baum, Cohen & Hall (1993) Davidson & Baum (1986) Escobar et al. (1992) Norris & Uhl (1993) Solomon et al. (1987) Turner & Lloyd (1995)]

[Escobar et al. (1992) Lima et al. (1989)]

[Green et al. (1991) J. Harvey et al. (1995) McFarlane (1987, 1988b)]

[Bartone et al. (1989) Duggan & Gunn (1995) Lopez-Ibor (1987) McFarlane (1988b) Nolen- Hoeksema & Morrow (1991) [Depression, Rumination] North et al. (1994) [Depression NOT PTSD] Resnick et al. (1992) [Depression] Rubonis & Bickman (1991) Smith et al. (1990)

Turner et al. (1995)]

Prior socioeconomic problems (e.g., unemployment, homelessness)

[Bartone et al. (1989) Lopez-Ibor (1987)]

Females (although see La Greca et al. [in press] for contrary finding)

[Garrison et al. (1995) Green et al. (1991, 1994) Hardin et al. (1994) Lonigan et al. (1994)

Lopez-Ibor (1987) North et al. (1994) [Only With Prior Psychopathology] Palinkas et al. (1993)

Pynoos et al. (1993) Solomon et al. (1987) [Somatization, not GAD/MDD/PTSD]

Steinglass & Gerrity (1990) Vernberg et al. (in press) Webster et al. (1995)]

Men (for alcohol abuse and depression)

[Solomon et al. (1987)]

[Garrison et al. (1995) La Greca et al. (in press) Lopez-Ibor (1987) Palinkas et al. (1992, 1993)

Webster et al. (1995)] Note: White adolescents were found to be at highest risk after Hurricane

Hugo (Hardin et al. 1994)

Finally, the literature suggests that risk for delayed or chronic problems following disaster is associated with survivor social support, coping style, and occupation:

[La Greca et al. (in press) Vernberg et al. (in press) -- Children] [Solomon et al. (1987, 1993) -- Caregivers or Single Parents]

[Hodgkinson & Shepherd (1994) Nolen-Hoeksema & Morrow (1991) La Greca et al. (in press)

Norvell et al. (1993) Titchener et al. (1986) Vernberg et al. (in press) Webster et al. (1995)]

Note: coping may be the result rather than cause of PTPI [Vernberg et al. (in press)

[Joseph et al. (1993)]

Disaster rescue workers (e.g., police, fire, EMT, healthcare professionals)

[Bartone et al. (1989) Hodgkinson & Shepherd (1994) Holen (1993) Lundin & Godegard (1993) Marmar et al. (1996) McFarlane (1988a)]

SECTION V

HELPING SURVIVORS

HELPING SURVIVORS: CENTRAL PRINCIPLES

KEY HELPING BEHAVIORS OF DISASTER MENTAL HEALTH WORKERS

EMERGENCY PHASE

ON-SITE INTERVENTIONS

OFF-SITE INTERVENTIONS

GENERAL INTERVENTIONS

DEATH NOTIFICATION PROCEDURE

defusing

INITIAL DEBRIEFING PROTOCOL

"DEBRIEFING" PROTOCOL FOR LARGE GROUPS

SUBSTANCE ABUSE PREVENTION

TEACHING RELAXATION TECHNIQUES

HELPING ESTABLISH SELF-HELP GROUPS

Pharmacotherapy Following Disaster

RESTORATION PHASE

CENTRAL PRINCIPLES

SCREENING INSTRUMENTS

Disaster Trauma Exposure MEASURES

EFFECTIVE TREATMENTS

EXposure Treatment for PTSD

COMMUNITIY ACTIVITIES - VIGILS & COMMEMORATIONS

SPECIAL POPULATIONS

CHILDREN

OLDER ADULTS

Helping survivors is best understood in the context of when, where, and with whom interventions take place. For example, on-site interventions with ambulatory survivors will have as their primary objective the providing of a safe and secure base from which survivors can regain (within reason) a degree of equilibrium; three weeks following a disaster, interventions are apt to be educational and exploratory with the objective of increasing survivor awareness of the biopsychosocial impact of the event and ways to maximize coping. This section provides guidelines for various types of interventions from a temporal/spatial perspective including:

Emergency on-site interventions Emergency off-site interventions

Early post-impact interventions Restoration phase interventions

* Support survivors’ indigenous helpers through consultation and training

Disaster mental health work with survivors requires key helping behaviors. The behaviors outlined below transcend theoretical orientation and are applicable across various settings. They help establish a positive relationship between helper and survivor which may often be more important in disaster than more "technical" therapeutic intervention approaches. Moreover, they help provide the kind of communication which can help debriefing methods have their intended effects, and they help create conditions under which helpers can increase survivors’ positive self-images, perceptions of control, and knowledge of skills to manage stress, anger and conflict.

To show Empathy To show Genuineness

Express desire to comprehend survivor Make your action congruent with your intent to help

Discuss what is important to survivor Be spontaneous rather than rigid or overly formal

Refer to survivor's feelings Be friendly and open

Correctly interpret survivor's implicit feelings

Be on time for appointments and meetings Ask clarifying questions

Make statements that express respect for the survivor Paraphrase survivor statements accurately

Express non-verbal attentiveness and concern Verbally reflect survivors' feelings accurately

(e.g., appropriate eye contact, tone of voice) Help clarify survivors’ mixed (incongruent) messages

Recognize overt and covert problems with stress

Recognize antecedent conditions that trigger stress responses

Understand how survivor's response to stress influences post-disaster behavior

Educate survivor about stress response syndromes & stress management strategies

Provide possible explanations for associated behaviors

Provide information that encourages alternative views and new behaviors

Assist, when appropriate, with pragmatic problems

Maintain the role of helper, rather than friend or help-receiver

At disaster sites immediately following the impact, initial mental health interventions are primarily pragmatic:

PROTECT Find ways to protect survivors from further harm and from further exposure to traumatic stimuli. If possible,

Create a "shelter" or safe haven for them, even if it is symbolic. The less traumatic stimuli people see, hear, smell, taste, feel, the better off they will be.

Protect survivors from onlookers and the media.

DIRECT Kind, but firm direction is needed and appreciated in mass disasters. Survivors may be stunned, in shock, or experiencing some degree of dissociation. When possible, direct ambulatory survivors...

Away from the site of destruction

Away from severely injured survivors

Away from continuing danger

CONNECT The survivors that you encounter at the scene have just lost connection to the world that was familiar to them. A supportive, compassionate, and nonjudgmental verbal or non-verbal exchange between you and survivors may help to give the experience of connection to the shared societal values of altruism and goodness. However brief the exchange, or however temporary its effects, in sum such "relationships" are important elements of the recovery or adjustment process. Help survivors connect:

To loved ones

To accurate information and appropriate resources

To where they will be able to receive additional support

TRIAGE The majority of survivors experience normal stress reactions. However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, erratic behavior. Signs of intense grief may be loud wailing, rage, or catatonia. In such cases, attempt to quickly establish therapeutic rapport, ensure the survivor's safety, acknowledge and validate the survivor's experience, and offer empathy. Medication may be appropriate and necessary, if available (see, pharmacology).

There will be many places where survivors are congregated away from ground, that should be considered when assigning staff. Such "off-site" settings include:

SHELTERS AND MEAL SITES DISASTER APPLICATIONS CENTERS (DAC)

RED CROSS SERVICE CENTERS HOSPITALS AND FIRST AID STATIONS

CORONER’S OFFICE EMERGENCY OPERATIONS CENTER (EOC)

SCHOOLS AND NEIGHBORHOODS COMMUNITY CENTERS & CHURCHES

FIRE AND POLICE DEPARTMENTS ...WHERE EVER SURVIVORS ARE

PROTECT As with on-site help, it is important to protect survivors from further harm and, as much as possible, from further exposure to traumatic stimuli. At this phase, the less traumatic stimuli people see, hear, smell, taste, feel, the better. Protect survivors from onlookers and the media.

DIRECT Again, kind but firm direction is needed and appreciated in disasters. When possible, keep ambulatory survivors away from severely injured survivors and those experiencing extreme emotional distress, to minimize fear and emotional contagion. When possible, help prevent survivors from visiting or returning to the site of destruction.

CONNECT Your support and compassion, whether expressed in words or in non-verbal ways, helps to reduce fear and re-connect the survivor to the shared society. Survivors will be greatly afraid for their loved ones, so it is vital to help locate them. Try to present accurate information at regular intervals, and connect survivors to available appropriate resources. When possible, refer survivors to additional sources of support.

ACUTE CARE Those survivors who require immediate crisis intervention to help manage intense feelings of panic or grief can be helped by your presence. When possible, stay with the survivor in acute distress or find someone else to remain with him/her until the feelings subside. If possible, consult a physician or nurse regarding utility of medication. Ensure the survivor's safety, acknowledge and validate the survivor's experience.

DEATH NOTIFICATION It is normal to have apprehension about notifying survivors of the death of their loved one(s), particularly if you are unprepared and/or untrained to do so.

Janice Lord, Director of Mothers Against Drunk Driving (MADD), recently developed a curriculum for professional counselors and victim advocates to teach strategies for compassionate and thorough death notification (1996). The following summary is presented with the permission of MADD as an introduction to some of the key considerations related to the procedure of death notification (pp. 44-53). The summary is not intended to be a substitute for training.

As the emergency phase of disaster moves into the early-post impact phase, the pragmatic "Protect, Direct, Connect, Triage" activities are supplemented to include general psychoeducational interventions:

* Provide user-friendly educational materials and presentations

* Provide defusings, debriefings and stress-management education

* Help survivors cope with "normal" stress reactions by providing unobtrusive practical and emotional support. Emotional support in crises reduces helplessness and enhances recovery.

[Joseph et al. (1994)]

* Identify individuals and families at-risk for longer-term psychological problems. Years after disaster, 25-33% of survivors have chronic or delayed onset PTSD/PTPI, often in the form of recurrent intrusive re-experiencing.

[Baum & Fleming (1993); Baum, Cohen & Hall (1993); Green et al. (1990a, 1992);

Joseph et al. (1995); Lima et al. (1993)]

Given these rates of chronic trauma-related impairment, disaster mental health workers must take steps to assist indigenous healthcare, social service, and advocacy personnel in ongoing identification of survivors at high-risk for sustained mental health problems.

The following pages describe several early-post impact psychoeducational interventions.

HELPING SURVIVORS: EARLY POST-IMPACT INTERVENTONS - defusing

Defusing refers to a process intended to facilitate opportunities for survivors to express their thoughts and feelings about their experience and the recovery tasks at hand without their feeling pressured to do so. The following open-ended questions may be modified to fit different defusing opportunities.

* "Where are you from?"

* "How much damage did your home suffer?"

* "Was anyone hurt?"

* "How has it been applying for disaster assistance?"

* "How are your kids doing?" "Sleeping okay?"

* "What is it about this situation that troubles you the most?"

* "How do you handle what's going on?"

* "Have you ever been through anything like this before?"

Defusing gives survivors the opportunity to better understand their own reactions and allows mental health workers to educate survivors about normal stress reactions and stress management strategies, as well as ascertain who may benefit from crisis intervention or referral. Unlike the time needed to conduct debriefings (2-4 hours), defusings can be brief (10-30 minutes), take place continuously as the mental health worker "works" a room, and be delivered one-to-one or in small groups. "Aggressive hanging out," that is, finding ways to unobtrusively be in the vicinity of survivors, is often a means to conduct informal defusings. Defusings can take place over a cup of coffee, standing next to a survivor waiting in a line, or almost anywhere survivors are to be found.

Originally developed by Jeffrey Mitchell to mitigate the stress among emergency first responders, critical incident stress debriefing (CISD) is now a widely-used protocol with survivors and providers of disaster-related help of all kinds (e.g., teachers, clergy, administrative personnel) in a wide range of settings (e.g., schools, churches, community centers).

Debriefing has become a generic term applied to a structured process that helps survivors understand and manage intense emotions, identify effective coping strategies, and receive support from peers. Two types of protocols are commonly used: an initial debriefing protocol and a follow-up debriefing protocol. The rationale for this process is that it provides several therapeutic features which may reduce stress: early intervention, opportunity for verbalization of traumatic experience and catharsis, structure, group support, and peer support.

Case reports and anecdotal evidence suggest that the process of debriefing may lead to symptom improvement; however, the technique has not seen rigorous controlled investigation to date. CISD may provide some immediate opportunities for survivors to talk with one another, but is unlikely to be effective as the sole intervention for complex, ongoing, or persistent problems that are the result of stress reactions to the operation, pre-existing stress, or various organizational stressors. The lifetime and current prevalence rates of PTSD (9%) and adult psychiatric disorder (48%) suggest that many disaster survivors need to address trauma reactivation or pre-existing mental disorders. In such cases, additional individual assessment is recommended.

HELPING SURVIVORS: EARLY POST-IMPACT INTERVENTONS - INITIAL DEBRIEFING PROTOCOL

The protocol for an initial debriefing usually consists of eight steps:

1. Preparation 5. Reaction phase

2. Introduction 6. Symptom phase

3. Fact phase 7. Teaching phase

4. Thought phase 8. Re-entry phase

* Try to limit each debriefing group to 8-10 participants. The greater the number of participants attending, the less time each will have to actively participate. Depending on the setting, there may be people who wish to attend, but are unwilling to speak. Encourage active participation, however, suggest those who are too uncomfortable to talk may benefit from hearing about others experience and from hearing information about stress reactions and stress management strategies.

* Arrange to work with a co-debriefer and discuss respective roles.

* Arrange for a private quiet room for 2 to 4 hours.

* Those in attendance should not be on call. Have educational/referral handouts ready.

* Schedule time for post debriefing discussion with co-debriefer

Depending on the number of participants and the time allotted, debriefers will necessarily have to evaluate how much time to spend on each phase and whether or not each participant will have equal time to speak.

3. Fact phase

Depending on the number of attendees, the next phase of the debriefing involves asking participants to describe from their own perspective what happened, where they were, what they did, and what they experienced with their senses (perception of sights, smells, sounds). With more than 12 people in attendance, it may be necessary to limit the number of people sharing their descriptions.

"Was there anything anyone said to you that stands out in your memory?"

4. Thought phase

In this phase, participants are asked to describe cognitive reactions or thoughts about their experience. In many instances, there are several events that have made a memorable impact. Target the most prominent thoughts or thoughts that have been ignored since the event. If there are more than 12 in attendance the debriefer may ask each participant to recall thoughts about the one event that is "the one thing you constantly think about."

During the course of descriptions, debriefers may interject to ask if other participants had similar thoughts. The intent is to normalize common cognitive reactions.

5. Reaction phase

In this phase, participants are encouraged to discuss the emotions they experienced during and after the disaster. This is the most "challenging" phase for facilitators. On one hand, the articulation of painful or frightening feelings and emotional catharsis is considered therapeutic for some survivors. On the other hand, the participant/survivors in the debriefing have not been previously assessed by the facilitators. The effect of not knowing participants’ coping strengths, psychiatric history, quality of social support, and the disadvantage of having limited time and possibly no follow-up opportunity results in having to quickly and carefully consider how much emotional exploration is appropriate during the debriefing. It is recommended to error on the side of being conservative, i.e., avoiding emotional material that generates overwhelming feelings of vulnerability, helplessness, and anxiety.

Give participants an opportunity to discuss if there have been any positive outcomes as a result of the event. Note: Unlike the preceding questions, this is not an early disaster phase inquiry. Stabilization and the regaining of a fair amount of equilibrium needs to have occurred in the survivor's life before possible positive effects can be appreciated. Depending on the severity of the trauma, and whether some degree of equilibrium has been restored, survivors often report a new appreciation for life, the disaster having provided an opportunity to re-evaluate and reset priorities.

6. Symptom (stress reaction) phase

In this phase, stress reactions are reviewed in a temporal context, i.e., what survivors experienced while the disaster was taking place, what stress reactions have lingered, and what they are experiencing in the present. Help participants recognize the various forms of stress reactions taking care to avoid using pathological terminology.

Emotional: shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase.

Cognitive: impaired concentration, confusion, distortion, self-blame, intrusive thoughts, decreased self-esteem/efficacy.

Biological: fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response.

Psychosocial: alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment.

Actually, teaching occurs throughout the process of debriefing. Debriefers must assess what participants know and don’t know and ensure that they have accurate information about stress reactions and stress management strategies. Given time constraints, not everything can be addressed and the debriefers will have to decide what information is most relevant to the participants.

"What has worked before when you have experienced tremendous stress?"

Topics addressed during this phase may include:

8. Re-entry phase

The final phase of the debriefing is allotted to a discussion of unfinished issues and reactions to the debriefing, along with a summation of the debriefing, a reminder about confidentiality, and a clarification of the referral process.

When possible, a follow-up debriefing should be scheduled to take place within two weeks. The protocol for follow-up debriefings is described on page___.

Debriefers should remain available after the debriefing to allow anyone in attendance to meet with the debriefers privately.

Occasionally, circumstances require meeting with a large (25-50) number of survivors and a modification of the process and content of the eight steps used in formal debriefings is necessary. The primary objectives of such meetings are to provide information about common reactions to traumatic stress, useful stress management strategies, signs that suggest individual help may be beneficial, and where to get additional information or help. Even though not everyone will be able to participate, encourage participation and interaction and relate the material to their experiences.

* Arrange to work with a co-debriefer and discuss respective roles.

* Arrange for a private quiet room for 2 to 4 hours.

* Those in attendance should not be on call. Have educational/referral handouts ready.

* Schedule time for post debriefing discussion with co-debriefer

Debriefers begin with self-introductions, including brief description of disaster mental health experience, the purpose of debriefing (clarifying that debriefing is not a critique of how they have responded). Explain that a debriefing with a large group is an opportunity to learn about stress reactions and stress management strategies, and an opportunity to learn from one another.

* Review confidentiality: Personal disclosures are to be held in strict confidence by the group. Educational information may be shared outside the group. Inform attendees about mental health professionals’ limits to confidentiality and the duty to report.

* Explain group rules: Inform attendees that no one is required to talk, but participation is encouraged. Agree on length of time. Inform attendees that everyone must stay until the end and that there will be no breaks. Inform that there will be handouts and notes should not be t aken. Ask if anyone cannot meet these requirements and reconcile accordingly.

* Faciliatate participant introductions: Depending upon the number of people in attendance, introductions may include name, role, hometown or vicinity, and whether or not there has been previous experience with debriefing.

Depending on the type and scope of the disaster and the make-up of the group (e.g., primary, secondary, tertiary, etc., victims), the process of the fact finding phase will vary. It will not be possible to have each participant describe his or her experience. The primary objective will be to help participants acknowledge that they have been part of an event capable of producing significant levels of stress.

4. Thought phase

Discuss how thoughts play a role in how they each initially responded and their adaptation to what has occurred. In many instances, there are several events within the entirety of a rescue operation that make a memorable impact. The debriefer may suggest that ask each participant to note their thoughts about the one event that "is the one thing you constantly think about."

Ask two or three participants to share their answers with the group. Debriefers may interject to if other workers had similar thoughts. The intent of course is to universalize and normalize common cognitive reactions.

5. Reaction phase

In this phase, the debriefer discusses common emotional reactions and asks two-three participants to share with the group the emotions they experienced since ______ happened. As with "regular" sized groups, this is the most "challenging" phase for facilitators. On one hand, the articulation of painful or frightening feelings and emotional catharsis is considered therapeutic for some survivors. On the other hand, the participant/survivors in the debriefing have not been previously assessed by the facilitators. The effect of not knowing participants’ coping strengths, psychiatric history, quality of social support, and the disadvantage of having limited time and possibly no follow-up opportunity results in having to quickly and carefully consider how much emotional exploration is appropriate during the debriefing. It is recommended to error on the side of being conservative, i.e., avoiding emotional material that generates overwhelming feelings of vulnerability, helplessness, and anxiety.

During the course of descriptions, debriefers may interject to ask if other participants had similar feelings. As in the thought phase, the intent is to universalize and normalize common reactions.

6. Symptom (stress reaction phase)

In this phase, common stress reactions are reviewed in a temporal context, i.e., what they may have experienced when the disaster struck, what stress reactions have lingered, and what they are experiencing in the present. Help participants recognized the various forms of stress reactions avoiding pathological terminology.

Common stress reactions in survivors (or relief workers)

Emotional: shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase.

Cognitive: impaired concentration, confusion, distortion, self-blame, intrusive thoughts, decreased self-esteem/efficacy.

Biological: fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response.

Psychosocial: alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment.

In reality, teaching occurs throughout the process of debriefing. Debriefers must assess what participants know and don’t know and ensure that they have accurate information about stress reactions and stress management strategies. Topics may include:

1. Quantitative and qualitative dimensions (DSM-III-R criterion A; DSM-IV issues; sensory exposure; phenomenology of loss --loved ones, property, perceived control, and meaning)

1. Emotional (shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase)

2. Cognitive (impaired concentration, confusion, distortion, self- blame, intrusive thoughts, decreased self-esteem/efficacy)

3. Biological (fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response)

4. Psychosocial (alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment)

C. Factors associated with adaptation to trauma

1. Degree of sensory exposure (severity, frequency, and duration)

2. Perceived and actual safety of family members/significant others

3. Characteristics of recovery environment (existence/access/utilization of social support)

4. Perceived level of preparedness

5. Pre-disaster level of psychosocial functioning (coping efforts)

6. Pre-disaster level of psychosocial stress (vulnerability/resilience)

7. Interrelationship among factors of personal history, developmental history, belief system, and current and past stress reactions including previous exposure to trauma (war, assault, accidents)

1. Relationship between behavior and stress (exercise, eating habits, exercise, receiving and giving social support, relaxation techniques -- excessive and deficient behaviors)

2. Self-awareness of emotional experience and selected self-disclosure

3. Stress-related disorders (PTSD; disorders which may be exacerbated by stress)

4. Parenting guidelines (how to enhance children's coping)

5. Disaster preparedness

6. Characteristics of the disaster environment (phases of disaster)

7. When and where to seek professional help

8. Re-entry phase The final phase of the debriefing is allotted to discussing unfinished issues, reactions to the debriefing, a summation of the debriefing, and the referral process. When possible, a follow-up debriefing should be schedule to take place within two weeks. The protocol for follow-up debriefings is described on page___.

Debriefers should remain available after the debriefing to allow anyone in attendance to meet with the debriefers privately.

PTSD has a strong likelihood being accompanied by one or ore other psychiatric disorders, of which substance abuse is especially common. Sparse evidence and clinical experience suggest that survivors may accelerate their alcohol, illicit drug, and medication use following disaster exposure.

Disaster mental health workers may play a potentially significant role in helping prevent development of alcohol and drug abuse by taking the following steps.

1. Ask survivors about drinking and drug use habits as part of assessment and helping activities

2. Educate survivors about the common inclination and risks of increasing substance use as a "self-medication" strategy following disaster exposure.

3. Recommend to survivors that during the months following disaster to abstain or moderate alcohol use (i.e., 1-2 drink daily maximum, no drinking on a daily basis, and frequent non-drinking periods, and to adhere to physician-determined levels of prescribed medications

HELPING SURVIVORS: EARLY POST-IMPACT INTERVENTONS - TEACHING RELAXATION TECHNIQUES

Who is willing to relax when there is a disaster to attend to? The inordinate demands upon survivors often result in resistance to any form of relaxation. Nonetheless, it is essential that survivors be reminded to take breaks from the many tasks at hand and be taught how to use brief relaxation techniques.

Teaching time itself will often be brief and, as a disaster mental health worker, you must be prepared to quickly address the rationale for relaxation, the resistance to it, and how to do it. This requires a modification of the "verbal set" typically used in a outpatient or inpatient setting.

1. Inquire about their sleeping patterns and level of fatigue.

2. Inquire about how they are taking care of themselves.

3. Inquire about pre-disaster coping styles (what did they typically do to relax?).

4. Provide rationale for relaxation, first validating fatigue and its effects.

5. Begin instruction and demonstration of techniques (e.g., muscle relaxation, conscious breathing, autogenics, visualization, etc.). Remember, the circumstances and or settings that you will be teaching in are, more often than not, far from ideal. You may have from five to fifteen minutes to demonstrate the value of relaxation. The challenge is to efficiently facilitate the experience of relaxation in the midst of chaotic a environment.

6. When possible, have handouts available that describe the techniques (give handouts after instruction).

"It's been non-stop for you since the (_____disaster) and it sounds like you're more tired than you've been in a long time. There's much you have to do to get things straightened out. Given all these demands and changes, it's vital that you find ways to get breaks from all this, even if ihey're just for 10 or 15 minutes a day. I'd like to show you some simple, quick, and proven relaxation techniques that you can use on your own."

An efficient use of disaster mental health resources is to facilitate and provide opportunities for survivors to collectively address common reactions and problems.

* Contact newly developed self-help groups and offer support services

* Provide consultation to group

* Provide specialty knowledge (e.g., stress management)

* Help with access to resources

* Help publicize group

* Help group network

* Accept referrals

* Provide emotional support, validation, and enhanced sense of community

* Facilitate information sharing

* Provide opportunities for participants to help others

* Provide enhanced sense of personal control

* Increase political power

* Respect group autonomy, avoiding taking leadership role

* Refer to group as a self-help group, or other member generated name, avoiding labeling group as " a mental health group"

There are several matters that must be addressed when considering pharmacotherapy for survivors of recent disasters who present clinically as acute psychiatric emergencies. 

Diagnostic Assessment and Management  

A natural or technological disaster may precipitate abrupt changes in mood or behavior that demand clinical attention. Mental health services following a disaster are generally directed toward "normal people, responding normally, to very abnormal situations" (Flynn, 1994). However, abnormal reactions are neither diagnostic of an underlying psychiatric disorder nor indications of the need for pharmacotherapy. Therefore, the clinician assessing such individuals should assume, until proven otherwise, that the patient does not suffer from a major psychiatric disorder and that  symptoms associated with increased psychological and physiological arousal hyperarousal will resolve without medication within a reasonable amount of time. It is recommended that survivors receive psychoeducational information about common stress reactions and stress management strategies as well as individual or group debriefing as soon as possible. This is particularly true when a] the trauma of the disaster is marked by on-going danger or intense sensory reminders (e.g., earthquake aftershocks, a series of storms, on-going inter-racial tension following race riots), b] the trauma of the disaster has been compounded by a rescue or evacuation process marked by chaos and disorganization; c] the patient has suffered a physical injury; d] the patient does not have an adequate social support network, or social support has been severely compromised by disaster fatalities and injuries, and e] when the patient appears numb and unresponsive and fails to exhibit the normal signs of distress (Mitchell, 1983).

To date, there is a lack data on the effectiveness of debriefing disaster victims. Hiley-Young & Gerrity (1994) delineate the value and limitations of debriefing in disaster response and express concern that an "unreasonable expectation of CISD usefulness may be developing among field practitioners." They also note that as many as one in four (25%) individuals exposed to disaster may have a history of untreated mental illness. Extrapolating from case reports (Everly & Mitchell, 1992), anecdotal evidence, and military psychiatric experience (Rahe, 1988; Sokel, 1989; Solomon & Benbenishty, 1989), it is generally believed that debriefing can not only relieve current stress-related symptomatology, but can forestall the later development of PTSD or other post-traumatic syndromes.

One might also consider debriefing as a diagnostic screening process, through which one can identify those individuals who will require more intensive and prolonged clinical attention. Therefore, pharmacotherapy should only be considered after there is good evidence that standard debriefing approaches are ineffective.  

At this point, diagnosis must be considered carefully. Although it is certainly possible that the patient is suffering from an acute post-traumatic stress (PTS) syndrome, other alternatives must be ruled out before reaching this conclusion. Patients in their late teens or early twenties, are at an age when people with schizophrenia, mania, depression, or panic disorder exhibit their first

clinically significant episode of illness. In that regard, clinicians must consider the possibility that the disaster has accelerated the onset of a psychiatric illness that would have declared itself sooner or later.

Organic conditions must also be considered, especially among patients who have suffered a head injury, lost consciousness, or experienced fluctuations in their mental state following the disaster. In that regard, the clinician must rule out a delirium, subdural hematoma, seizure disorder, sleep deprivation, or some other neurological problem.

Finally, one must rule out an alcohol or drug related problem such as intoxication or a withdrawal syndrome. People who use alcohol or drugs to cope with ordinary stressors are very likely to utilize them during a disaster as long as their supplies hold out. These same people are at risk to develop a clinically significant withdrawal syndrome, if the disaster has suddenly made their alcohol or drugs unavailable.

If the patient has not responded to debriefing, psychoeducational information, or stress-management strategies, and does not appear to exhibit a non-PTS psychiatric, neurological, or alcohol/drug-related psychological abnormality, it is time to consider that s/he is experiencing either acute PTS or a severe exacerbation of chronic PTSD. Even under such conditions, it is best to withhold all medications for the first 48 hours, when possible. Such a drug-free interval will provide an opportunity for the patient to respond to the structure and safety of a clinical milieu, a shelter, or some other safe environment, catch up on lost sleep if needed, and achieve psychological stability.  

There are important exceptions to this guideline. Rapid initiation of pharmacotherapy is indicated for patients who present serious management problems, who are a danger to themselves or others, and who are extremely agitated, psychotic, noncompliant, or disruptive. A short acting anti-anxiety agent such as the benzodiazepine lorazepam (Ativan) is the treatment choice under these conditions. Unlike diazepam (Valium) lorazepam can be administered intramuscularly and has a rapid onset of action. Generally, patients who fail to respond to lorazepam are psychotic rather than extremely anxious and require aggressive treatment with an antipsychotic drug such as haloperidol (Haldol) which can be administered orally, intramuscularly, or intravenously. Haloperidol is a better choice than many other antipsychotic drugs because it has few orthostatic or anticholinergic side effects.  

Treatment of Post-Traumatic Stress Syndromes  

It must be emphasized that there are no published controlled trials on pharmacotherapy for acute post-traumatic stress. In fact, there are only two clinical articles in print, both concerning pharmacotherapy for acute psychiatric emergencies among military personnel (Ritchie, 1994; Friedman, Charney, and Southwick, 1993). Major differences between military personnel in a war zone and civilians following a disaster, are that military personnel are more likely to be healthy young adults who have been prepared for traumatic situations. Military personnel are less likely to have chronic medical or psychiatric conditions and much less likely to be taking any kind of medication on a regular basis. Therefore, a civilian post-disaster population represents a much more diverse set of problems. Special issues such as pediatric, geriatric, and chronic medical concerns are beyond the scope of this chapter, but demand particular attention. The treatment guidelines for PTSD, presented below, will not address these special issues but they should be kept in mind.  In general, starting doses should be much lower and titration of dosage should be done slowly and cautiously with youngsters, oldsters, and people with chronic medical illnesses who are taking medication on a regular basis.  

There has been remarkable progress in our understanding of the neurobiological basis of acute stress and chronic PTSD (Friedman, Charney, and Deutch, 1995). Among the neurobiological abnormalities detected thus far, the most well established involve the adrenergic nervous system, the hypothalamic-pituitary-adrenocortical (HPA) axis and probably the serotonergic and endogenous opioid systems. Given the lack of controlled trials mentioned earlier, the following recommendations are extrapolated from the latest information on pharmacotherapy for PTSD (Friedman, 1996).

Several theorists have suggested that there are two different types of acute war zone-related traumatic stress (Catherall, 1989; Keane, 1989; Rahe, 1988; Soloman, et al., 1987) and a similar nosology for traumatic reactivation stress among disaster victims (Hiley-Young, 1992). The first is a dramatic hyperarousal state marked by anxiety, agitation, irritability, panic, phobic avoidance, startle reactions, and occasionally fearfulness or event paranoid excitement. The dominant neurobiological abnormality under such conditions is dysregulation of the adrenergic nervous system. Conventional wisdom based on military psychiatric experience would suggest treatment with a benzodiazepine anxiolytic such as lorazepam (Ritchie, 1994; Stokes, 1990). Should such treatment be sustained for a period of days or weeks, clonazepam is the best benzodiazepine to use because it has a longer half-life, does not produce the rebound anxiety of shorter acting drugs, and has a much lower abuse potential than other benzodiazepines (Friedman, Charney, & Southwick, 1993).  

Rather than benzodiazepine treatment, the alpha-2 adrenergic agonist, clonidine offers a number of advantages. First of all, it will directly antagonize the PTSD hyperarousal state by reducing excessive adrenergic activity through a direct action on adrenergic neurons in the brain. In addition, clonidine acts rapidly and has no abuse potential. There are theoretical reasons to speculate that clonidine, through its direct dampening effect on the acute stress response, might reduce the subsequent risk of developing PTSD, but there is no data to support this conjecture at this time.  Clonidine should not be administered to patients with cardiovascular problems or to patients with low blood pressure due to pre-disaster illness or post-disaster injury. Another drug that might be useful to reduce the excessive adrenergic activity associated with the PTSD hyperarousal state is the beta-adrenergic antagonist, propranolol. It has the same advantages and disadvantages as clonidine but may not be as effective.  

The second type of acute post-traumatic reaction described by Catherall (1989), Keane, (1989) Rahe (1988) and Solomon, et al. (1987) is characterized by withdrawal, dysphoria, PTSD-like avoidant/numbing symptoms, impacted grief and social isolation. This type of acute reaction is thought to have a more serious prognosis than the hyperarousal state because it is more likely to progress to full-fledged PTSD. Given the prominence of avoidant/numbing symptoms in this clinical presentation, the best drug to choose is a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac) or sertraline (Zoloft). Of all drugs tested in PTSD thus far, only the SSRIs appear to have efficacy against the avoidant/numbing symptoms of PTSD. These drugs have other advantages as well since they are potent antidepressants and antipanic agents (Friedman, 1996). There is even preliminary evidence that these drugs will reduce the alcohol abuse and dependence that is often associated with PTSD (Brady, 1995). A major disadvantage of SSRIs in a post-disaster situation is that they do not act quickly and may require several weeks to exert their clinical effects.  

Lack of rapid onset of action is also a problem with other drugs that have been successful in PTSD treatment such as monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs). In general, these drugs have been shown most effective in countering reexperiencing symptoms of PTSD such as intrusive recollections, traumatic nightmares or flashbacks (Southwick et al., 1994). In addition, MAOIs are not recommended for people who cannot remain alcohol or drug free or who cannot observe MAOI dietary restrictions.  Adherence to an MAOI diet may be particularly difficult following a disaster, if food is scarce and the choice of food is limited.

Whenever possible pharmacotherapy should be delayed for at least 48 hours. During that period patients should receive individual or group debriefing as soon as possible. Individuals who do not respond to debriefing must be carefully evaluated for non-PTS psychiatric, neurological or alcohol/drug-related psychological abnormalities. If careful assessment indicates that the individual is suffering from acute PTS, one must distinguish between the acute hyperarousal reaction and the acute dysphoric/avoidant reaction. Clonidine or lorazepam are generally indicated for individuals who require pharmacotherapy to control the acute hyperarousal state. If dysphoric/numbing symptoms are prominent, it would be best to institute SSRI treatment at an early stage so that the drug's full therapeutic effect may develop as soon as possible.  

Target Symptom Medication Dosage 

Hyperarousal Clonidine 0.1-0.6mg/day  Propranolol 40-240mg/day  Clonazepam 1-6 mg/day  Lorazepam 1-8mg/day  

Agitation Lorazepam 1-8mg/day 

Haloperidol 2-20mg/day  

Dysphoria/Numbing Fluoxetine 20-80mg/day 

Sertraline 50-200mg/day  

Re-experiencing Phenelzine (MAOI) 30-60mg/day 

TCAs 50-300mg/day  

Insomnia Flurazepam 30mg/hs 

Temazepam 30mg/hs  

As communities enter the restoration phase of disaster, it is hoped that most survivors will have received basic education about resources for addressing practical and emotional needs, and about stress symptoms and coping. Also, they should have received opportunities, formal and informal to discuss their traumatic experiences and emotional reactions.

Despite disaster mental health relief efforts, evidence suggests that years after disaster 25-30% of survivors have chronic or delayed PTSD or other disaster related psychological problems, often in the form of recurrent intrusive reexperiencing and associated distress. During the restoration phase, therefore, the focus of helping efforts shifts to identification of individuals and families with continuing disaster related emotional problems and delivery of appropriate help, e.g., Regular Service Grant (RSG) Crisis Counseling Program.

A vital component of each the crisis counseling programs is ensuring that contract providers receive specialized training, many of whom have clinical skills unrelated to those needed in disaster mental health. As contract providers receive training, they in turn can assist indigenous health care, social service, and advocacy personnel in ongoing identification of survivors experiencing problems through advising on implementation of screening procedures in health services, and by training appropriate individuals and organizations in assessment of disaster-related PTSD.

Disaster recovery requires not only relief from initial symptomatic distress but moreover restoration of key individual, relational, organizational, and community-wide resources.

[Erikson (1976); Freedy et al. (1992, 1994); Hobfoll (1991); Hodgkinson (1989);

Lopez-Ibor (1987); Quarantelli (1986); Shalev et al. (1993); Wright et al. (1990)]

Social support is of greatest benefit in the recovery (middle) phase (i.e., 2-4 months post-disaster).

[Cook & Bickman (1990); Palinkas et al. (1992)]

In the months and years following the disaster experience, medical and mental health care providers in the affected communities will be working with many disaster survivors who continue to experience distressing emotional effects. With the crisis stabilized and acute danger and distress no longer the primary priority for survivors and rescue workers, a more thorough assessment of the psychological functioning and coping resources of survivors can provide important information. When ongoing emotional problems are suspected, assessment that examines the relationship between traumatic aspects of the disaster and psychological functioning can serve to guide responses to individual survivor needs, as well as treatment program design.

As supplements to clinician interview, we include two brief measures (on the next pages) which can be given to disaster survivors in community medical or mental health settings: the Personal Experiences in Disaster Survey and the PTSD Checklist (PCL; Weathers, Litz, Huska, & Keane, 1994). The Personal Experiences in Disaster Survey allows assessment of a variety of potentially traumatic features of disaster.  (Asterisked items (*) are from Green (1993, p. 138; in J. Wilson & B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes. New York:  Plenum). All others are drawn from the instruments listed below. We have adapted Frisch's (1992) anchors from the Quality of Life Interview and S.Sarason et al.'s (1978) from the Life Experiences Survey, to enable respondents to indicate the relative importance, impact, and sense of control that they attribute to each of the potential trauma features of disaster.

Name: ____________Age: ___ Gender: M F Ethnic/Racial Background: ___________

Today's Date: ____________Place Where You are Completing the Survey: _____________

Each of the following items is an experience that people may have in a crisis or disaster. Please briefly describe the crisis or disaster you have experienced:

What date did the crisis/disaster begin: _____________.

Disasters and crises don't end all at once. Some aspects of life return to normal faster than others, and each person's, family's and community's experience is unique. Right now:

What aspects of this crisis/disaster do you consider: Back to Normal Still Not Normal

• Danger of death or serious injury to you

• Danger of death/serious injury to family/friends

• Danger of the disaster starting again

• Your physical health and well-being

• Family/friends' health and well-being

• Your emotions and frame of mind

• Family/friends' emotions and frame of mind

• Your residence

• Your (your parent's) workplace and job

• Your family income and financial situation

• Your relationship with your spouse (best friend)

• Your (your parent's) workplace and job

• Your relationship with your children (parents)

• Your community

• Your spiritual life

• Your confidence in yourself and self-esteem

• Your faith and trust in other people

Every disaster or crisis is different, and each one is different for every survivor. To take stock of how this disaster affected you, please answer the following questions for each of the following experiences that can occur during and after a crisis or disaster:

(1) Did this happen to you at any time during or since this crisis or disaster? YES NO

(2) How stressful or uplifting has this been for you during or since the crisis or disaster?

-3 Extremely stressful/upsetting ...... +3 Extremely uplifting/positive

(3) How much control did you have over whether and how this experience happened and stopped?

(4) How much were you able to prepare yourself to cope with this experience?

0 Not at all 1 Some Preparation 2 Completely Prepared

(5) How satisfied are you with how you've coped with this experience?

-3 Extremely dissatisfied ...... +3 Extremely Satisfied

(6) How long did this experience continue to occur since the beginning of the crisis or disaster?

*Danger of Death or Serious Injury to yourself

(1) YES NO (2) (3) (4) (5) (6)

*Danger of Death or Serious Injury to loved ones or close friends

(1) YES NO (2) (3) (4) (5) (6)

*Actual Serious Physical Harm or Injury to yourself

(1) YES NO (2) (3) (4) (5) (6)

*Actual Serious Physical Harm or Injury to loved ones or close friends

(1) YES NO (2) (3) (4) (5) (6)

*Exposure to Death or the Dismemberment/Disfigurement of Others

(1) YES NO (2) (3) (4) (5) (6)

*Violent or unexpected loss of close friend(s) or loved one(s)

(1) YES NO (2) (3) (4) (5) (6)

*Learning that you have been or may have been exposed to toxic substances

(1) YES NO (2) (3) (4) (5) (6)

*Being separated from family or close friends

(1) YES NO (2) (3) (4) (5) (6)

*Property damage or loss to your home, possessions, or (if applicable) family business

(1) YES NO (2) (3) (4) (5) (6)

*Dislocation from your home

(1) YES NO (2) (3) (4) (5) (6)

*Financial loss (such as due to insufficient insurance or due to loss of income from work)

(1) YES NO (2) (3) (4) (5) (6)

*Inability to get food and water

(1) YES NO (2) (3) (4) (5) (6)

*Inability to be in a sheltered place

(1) YES NO (2) (3) (4) (5) (6)

*Inability to use electricity or phones

(1) YES NO (2) (3) (4) (5) (6)

*Inability to use automobile or public transportation

(1) YES NO (2) (3) (4) (5) (6)

*Inability to work in your normal job and place of work

(1) YES NO (2) (3) (4) (5) (6)

*Inability to send your children to school

(1) YES NO (2) (3) (4) (5) (6)

Thank You For Completing this Self-Assessment

The PCL is a 17-item test that asks respondents to rate, on a 5-point scale, the extent to which they have been troubled in the past month by each of the 17 DSM-IV symptoms of PTSD. The PCL has demonstrated reliability, validity, and diagnostic utility with some trauma populations (e.g. combat veterans). A cut off score of 51 or greater has been shown to identify PTSD diagnoses (using a PTSD structured interview as the criterion) with sensitivity and specificity greater than 95%.

Instructions: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

A variety of instruments have been devised to assess the nature and

extent of exposure to specific types of civilian crises and disasters. We

recommend that you select a measure that reflects the specific experiences

likely to have occurred to survivors and rescue workers, adding items from the

more comprehensive PEDS to supplement the assessment.

Adult Measures

Self-Report: Contact with Fire (Koopman et al., 1994)

Self-Report: Firefighter Inventory of Disaster (McFarlane, 1987)

Self-Report: Oil Spill Exposure Index (Palinkas et al., 1992)

Interview: Disaster Supplement (North et al., 1990; Solomon & Canino,

1990)

Interview: Air Crash Rescue Exposure Index (Bartone et al., 1989)

Interview: Disaster Stress Scales (Green et al., 1983)

Interview: Family Responsibility/Guilt Indices (Cella, Perry et al., 1988)

Examination: Burn Severity (Perry et al., 1992)

Child Measures

Self-Report: Hurricane Related Traumatic Experiences (HURTE) (Vernberg et

al., 1996)

Interview: Disaster Supplement (Earls et al., 1988)

**Measures of Acute Stress Reactions (fear, helplessness, horror,

dissociation)**

Acute stress reactions (ASR) following disaster are normative and not

pathological, but extreme types (e.g., depersonalization, derealization) or

degrees (e.g., debilitating intrusive memories or fears) of these reactions

place the individual at high risk for continuing post-traumatic impairment.

Inquiry about stress reactions can itself be disturbing. It can serve as a

reminder of trauma or of disturbing physical or emotional reactions that the

survivor or worker is consciously suppressing or automatically defending

against. It can convey the unintended impression that the survivor or worker

is emotionally disturbed or somehow not adequately coping.

We therefore recommend that clinicians utilize the following measures

with the following precautions: (1) do NOT assess ASR by questionnaire or

detailed interview if the individual is clearly acutely emotionally distressed,

disoriented, or dissociating; (2) do NOT assess ASR if the individual is still

exposed to traumatic physical or psychological threat (e.g., in a shelter

exposed to potential community violence after an earthquake or hurricane;

awaiting notification of the death of loved one(s)); (3) DO assess ASR as close

in time as possible to the disaster; (4) DO present the ASR assessment as an

opportunity for the individual to learn about her/his normal stress reactions

and to learn about resources to assist in stress management; (5) DO ensure that

each person's responses are confidential and private (e.g., in group testing

situations, ask that each person's responses be private from others, unless

s/he chooses to discuss these with selected others); (6) DO inquire separately,

if possible, about parents' ASR as well as the child's ASR, and ask both the

parent(s) and the child to report separately about the child's ASR; (7) DO get

observer ratings of ASR when this can be done unobtrusively and without

violating the privacy of the individual, especially if the individual may not

be a reliable reporter due to ongoing or transient cognitive impairment,

motivation to under- or over-report, or inability to accurately self-monitor.

Adult Measures

Self-Report: Stanford Acute Stress Reaction Questionnaire (Koopman,

Spiegel & Cardena, 1994)

Self-Report: Peritraumatic Dissociative Experiences Scale (Marmar &

Weiss, 1995)

Self-Report: PTSD Reaction Inventory (Frederick, Nader & Pynoos, 1992)

Child Measures

Parent Report: Child Stress Reactions Checklist-Revised/PR (Saxe & Ford, 1996)

Observer Rating: Child Stress Reactions Checklist for Children-BRV (Ford &

Saxe, 1996)

Self-Report: PTSD Reaction Inventory (Frederick, Nader & Pynoos, 1992)

**Measures of Transient or Enduring Post-Traumatic Psychosocial

Impairment/Functioning**

We recommend that clinicians develop a brief battery of questionnaire

and interview measures to assess the post-traumatic psychosocial impairment AND

functioning of disaster survivors and rescue workers at the following time

intervals [after assessing Psychosocial Resources and ASR within the first

month of disaster onset]: (1) 2-4 months; (2) 6-8 months; (3) one year; (4) 18

months; (5) two years; (6) biennially thereafter.

Although PTSD is an essential assessment target, PTPI may take the form

of more prominent comorbid psychiatric impairments (e.g., anxiety or affective

disorders; substance abuse), and may include associated psychosocial impairment

(e..g, marital, family, vocational dysfunction).

**Measures of PTSD**

Adult Measures (see Newman, Kaloupek & Keane, 1996 for an overview)

Structured Interview: Clinician Administred PTSD Scale

(Weathers et al., 1996)

Structured Interview: SCID-IV PTSD Module (Spitzer et al.,

1995)

Structured Interview: PTSD Structured Interview (Davidson et

al., 1991)

Self-Report: PTSD Checklist (PCL-S: Weathers et al., 1996)

Self-Report: Mississippi PTSD Scale for Civilians (King et

al., 1995)

Self-Report: Brief Mississippi PTSD Scale for Civilians

(Fontana & Rosenheck, 1994)

Self-Report: Penn PTSD Scale (Hammarberg, 1992)

Self-Report: PTSD Symptom Survey (Foa et al., 1992)

Self-Report: Impact of Events Scale-Revised (Weiss, 1995)

Self-Report: Trauma Symptom Inventory (Briere, 1995)

Child Measures (see Newman, Kaloupek & Keane, 1996 for an overview)

Structured Interview: Clinician Administered PTSD Scale-C

(Nader et al., 1996)

Structured Interview: Diagnostic Interview for

Children/Adolescents (Reich, 1995)

Self-Report: PTSD Reaction Inventory (Frederick, Nader &

Pynoos, 1992)

Self-Report: PTSD Scale (Fletecher, 1994)

Parent Rating: PTSD Checklist-PR (Ford et al., 1996)

**Measures of Comorbid Psychiatric Symptomatology**

Adult Measures

Structured Interview: SCID-IV (Spitzer et al., 1995)

Structured Interview: Anxiety Disorders Interview Schedule

Structured Interview: Schedule for Affective Disorders

Structured Interview: Diagnostic Interview Schedule (Robins,

1995)

Structured Interview: Addiction Severity Index (McClelland et

al., 1985)

Self-Report: SCL-90 (Derogatis, 1992)

Self-Report: General Health Questionnaire (GHQ) (Goldberg &

Hillier, 1979)

Self-Report: Beck Depression Inventory (Beck et al., 1992)

Self-Report: Center for Epidemiologic Studies-Depression Scale

(Radloff, 1977)

Self-Report: State-Trait Anxiety Inventory (Spielberger et

al., 1991)

Self-Report: State-Trait Anger Expression Inventory

(Spielberger et al., 1988)

Self-Report: Drug Abuse Screening Test

Child Measures

Structured Interview: Diagnostic Interview for

Children/Adolescents (Reich, 1995)

Structured Interview: Child and Adolescent Assessment

Schedule (Hodge, 1992)

Self-Report: Revised Childhood Manifest Anxiety Scale

(March, 1996)

Self-Report: Child Depression Inventory (Kovacs, 1991)

Parent/Teacher Ratings: Child Behavior Checklist

(Achenbach, 1995)

Parent/Teacher Ratings: SNAP for ADHD and ODD

**Measures of Lifetime Trauma and Recent Stressor Exposure**

Cumulative trauma exposure increases the risk of PTPI (Follette,

Polusny, Bechtle & Naugle, 1996) and extreme disorders of traumatic stress

(Ford, Fisher & Larson, 1996), as well as of further exposure to trauma

(Breslau, Davis & Andreski, 1995). Therefore, we recomend the direct

assessment of lifetime trauma exposure in comprehensive PTPI evaluation

Adult Measures

Structured Interview: Clinician Administred PTSD Scale,

Criterion A (Weathers et al., 1996)

Structured Interview: Evaluation of Lifetime Stressors (Krinsley,

1995)

Self-Report: Traumatic Stress Schedule (Norris, 1992)

Self-Report: Potential Stressor Experiences Inventory

(Falsetti et al., 1994)

Self-Report: Sexual Experiences Survey (Koss & Gidycz, 1985)

Self-Report: Assessing Environments III (Knutson, 1995)

Self-Report: Early Childhood Trauma Inventory (Blake et al.,

1993)

Self-Report: Child Abuse and Trauma Scale (Sanders &

Becker-Lausen, 1995)

Self-Report: Childhood Trauma Questionnaire Bernstein et al.,

1994)

Self-Report: Retrospective Assessment of Traumatic Experiences

(Gallagher et al., 1992)

Child Measures

Structured Interview: Traumatic Experiences Screening

Inventory (Ribbe et al., 1995)

Self-Report: Childhood Victimization Survey (Boney-McCoy &

Finkelhor, 1995)

Intervening acute or chronic life stressors may exacerbate PTPI and

increase the likelihood of recurrent exposure to trauma (Turner & Lloyd, 1995).

Therefore we recommend assessment of the occurrence and subjective impact of

major life stressors at every assessment interval.

Adult Measures

Self-Report: Life Experiences Schedule (Sarason et al., 1978)

Self-Report: Life Stressor Checklist (Wolfe & Levin, 1991)

Self-Report: Adult Stressor Assessment (Turner & Lloyd, 1995)

Self-Report: Chronic Stress Assessment (Turner & Lloyd, 1995)

Child Measures

Self-Report: Life Events Survey (Johnson, 1986; LaGreca, Vernberg et

al., in press)

Self-Report: Stress Index (Guerra et al., 1995)

Post-traumatic adaptive functioning and social adjustment is a vital

counterbalance to PTPI. Therefore we recommend that clinicians re-administer

selected measures of coping and emotion regulation, quality of life, and social

and personal resources (see **Measures of Psychosocial Resources** above) at

each longitudinal interval.

**Summary Recommendations for Clinical Assessment**

*During Disaster: Observe unobtrusively while providing client-centered

assistance

*Immediate Aftermath: Detect and educate with brief screening instruments and

observation

*Longterm Aftermath: Assess PTPI and Psychosocial Functioning and Resources

longitudinally

**Recommendations for Research and Evaluation Assessment**

Psychosocial assessment is vital to clinical research on disaster

trauma and recovery, and to the evaluation of programs designed to enhance

mental health in the wake of disaster. Research and program evaluation are

greatly enhanced by the development of assessment databases in at-risk

communities and populations BEFORE disaster strikes. We recommend that

researchers and evaluators identify communities at risk for major disaster

(e.g., in earthquake- or hurricane- or flood-prone locations) or samples of

relevant participants in accessible settings (e.g., schools, hospitals) and

develop prospective monitoring databases that involve the repeated longitudinal

assessment of psychosocial resources and functioning, trauma and stressor

exposure, and psychosocial or post- traumatic stress impairment. In addition

to providing valuable data on developmental and cohort processes in

psychosocial functioning and impairment, and ongoing program outcome

evaluations, such databases provide an estimate of the trajectory of these key

phenomena against which any discontinuity post-disaster can be compared

meaningfully.

DURING disaster (and in the immediate rescue and relief phase),

researchers and program evaluators are best advised to STAY OUT unless only

providing authorized disaster relief assistance. Research or evaluation data

collection can be particularly obtrusive and invasive in the disaster impact

and recoil period, jeopardizing not only the well-being of survivors and rescue

workers but also of the researcher's or evaluator's ability to gain the

cooperation of these individuals, key organizations, and the larger community

for subsequent study and assessment.

However, research and program evaluation data collection can

begin as soon as the disaster setting and the surrounding organizations and

community have stablized sufficiently to be able to provide for the safety and

relief of all residents with no imminent crises. In the immediate aftermath,

researchers and evaluators can work with clinicians to offer efficient and

thorough mental health screenings at Schools, Community Organizations, and

Hospitals and Clinics. These data provide a baseline against which to compare

subsequent psychosocial impairment or readjustment or to compare

post-intervention programmatic outcomes. In this early phase it is critical to

make and closely monitor provisions for ensuring that any child or adult

surveyed who experiences emotional distress during or after the data collection

receives immediate effective (but least restrictive) care. Developing a strong

working relationship with indigeneous mental health and counseling

professionals, religious advisors, and educators, administrators, and

supervisors, can increase the likelihood that such reactions will be detected

and treated with appropriate care and confidentiality.

The selection of sample and research/evaluation design takes place in

this first assessment. The ideal approach is a representative sampling of all

relevant individuals, households, organizations, or communities; convenience

samples should be selected to best aproximate such a random sample. If a

particular independent variable is of special theoretical or programmatic

importance, a case-control design should be established by assessing comparable

samples with (case) or without (control) this feature or experience (e.g.,

individuals living in a disaster-affected community versus a comparable sample

in a demographically and geographically similar community).

Longitudinal followup assessments at intervals dictated by the

research or evaluation agenda (which often parallel the temporal intervals

recommended for longitudinal clinical assessment) permit the study of the

course of post-traumatic impairment and adaptation (McFarlane, 1988).

Sophisticated data analytic procedures such as logistic regression, path

analytic, structural equation modeling, and growth curve methodologies enable

researchers and evaluators to identify and validate constructs with the best

explanatory power and their causal relationships. A multi- source multi-method

measurement approach permits development of strong predictor, process, and

criterion measures for use in subsequent clinical assessment and research or

evaluative study. Examples of critical research and evaluation questions

longitudinal analysis include:

* Evaluate course and outcome of

education/treatment

* Determine Nature/Degree of Trauma Exposure

* Determine Prevalence of Posttraumatic Sequelae

within/across post-disaster phases

* Define the Prospective Longitudinal Course of

Sequelae

* Predict Successful/Problematic Clinical and

Community Outcomes across phases

* Identify Efficient Screening Techniques to Detect

High-Risk Trauma "Casualties"

* Determine the Relative Contributions of Prior

Trauma, Prior Psychosocial Impairment,

Prior Family Impairment, Prior

Psychosocial Resiliency and Resources, Dose of Disaster

Trauma Exposure, Crisis Coping

and Resources, and Post-Trauma Stressors, Coping, and

Resources on the Etiology and

Course of PTPI

* Determine the Impact of Parental ASR and PTPI on

Child ASR and PTPI

For Disaster Mental Health Program Supervisors and Clinicians

The RECONSTRUCT Model: Establishing an Adaptive Systemic Context for

Mental Health Svcs (JF)

Conservation of Personal, Interpersonal, and

Community Needs and Resources

Counterbalancing Intrusion with Preparation

Counterbalancing Isolation with Extension

Counterbalancing Impoverishment with Enrichment

Counterbalancing Iteration with Discernment

Psychosocial Assessment: Identifying Needs, Resources, and High-Risk

Groups (JF)

Assessment of Needs and Resources: Crisis, Ongoing

Assessment of Trauma Exposure: Resource Loss,

Traumatic Shock

Assessment of Acute Stress Reactions: Transient,

High-Risk

Assessment of Near-Term Adaptation and Stress Problems

Assessment of Long-Term Adapatation and Posttraumatic Stress

Impairment

Psychosocial Intervention: Matching Care to Specific Need(s) and

Available Resources (JR)

First Provide Resources

Crisis Management (e.g., medication,

brief counseling, hospital care, death notification)

Debriefing: Value and Vicissitudes

Early Preventive Education and Focal

Treatment

Long-term Individual, Family,

Community, and Organizational Interventions

**Measures of Psychosocial Needs and Resources**

To our knowledge there are no standardized assessment instruments to identify the precieved psychosocial needs of disaster survivors or rescue workers. We recommend that, before taking any actions to further assess, educate, counsel, refer, or otherwise assist survivors and rescue workers, that the clinician first unobtrusively observe or get information from reliable collateral sources (e.g., Red Cross social service or shelter monitor staff) concerning the relevance of the following potential psychosocial needs to individual(s), family(ies), or group(s) to whom the clinician has a mandate to provide assistance. If it appears that an informal or brief formal discussion will be of help to the individual, family, or group, the clinician can make open ended inquiries directly in conversation to validate or revise the observed needs.

For the 10-20% of survivors with debilitating post-traumatic psychosocial impairment, the limited empirical literature provides evidence for the effectiveness of the following treatment approaches:

[Chambless et al. (1996) Foa et al. (1991, 1995) Otto et al. (1996) Solomon et al. (1992)]

[Brom et al. (1989) Frank (1995) Marmar et al. (1995) Weissman (1995)]

Pharmacotherapy for PTSD, depression, anxiety disorders

[Friedman (1995) Friedman & Yehuda (1995)]

Multisystemic family therapy for relational and child behavior problems

[Henggeler et al. (1995) Jacobson et al. (1993) Pinsof & Wynne (1995)]

Substance abuse education, treatment, and mutual support

[McClellan et al. (1987) Woody et al. (1991)]

Intensive case management for chronically mentally ill individuals

[Drake et al. (1996) Linehan et al. (1994)]

Education, screening, and referral by primary healthcare providers

[Fifer et al. (1994) Koss et al. (1990) Ruzek et al. (1996)]

Treatment adherence monitoring and facilitation by primary care providers

[Lin et al. (1995) Weyrauch et al. (1995)]

The hallmark of posttraumatic stress disorder (PTSD) is traumatization and persistent intrusive reexperiencing (Keane, 1993; Kilpatrick & Resnick, 1993; McFarlane & Yehuda, 1995). PTSD's other cardinal features -- hyperarousal and cognitive processing interference, behavioral and cognitive avoidance, emotional dysregulation and numbing, and interpersonal detachment and dysfunction -- parallel the symptom indicators for phobic, panic, and other anxiety, affective and dissociative disorders. What is unique to PTSD is not only its environmental etiology but also that intrusive reexperiencing of the traumatization is the apparent catalyst for these diverse biopsychosocial impairments. Therefore, the consistent core of a broad range of treatments for PTSD has been intervention to attempt to reduce the severity and/or frequency of intrusive traumatic reexperiencing. There is suggestive evidence that the treatment methods that have the best demonstrated efficacy with PTSD -- cognitive-behavioral approaches utilizing prolonged exposure -- may be intolerable (Keane, 1994; Pitman, Altman, Greenwald et al., 1991) or only marginally beneficial for many individuals with complex chronic PTSD. However, when implemented with appropriate clinical screening and administration, exposure-based treatments have proven to be at the core of every approach to treating PTSD that has scientifically-verified effectiveness.

Cognitive-behavioral therapies have been shown to reduce PTSD re-experiencing (Brom, Kleber & DeFares, 1989; Foa, Freund, Hembree et al., 1994; Foa, Olasov, Rothbaum, Riggs & Murdock, 1991; Keane, Fairbank, Caddell & Zimering, 1989; Peniston, 1986; Resick & Schicke, 1992), avoidance (Brom et al., 1989; Cooper & Clum, 1989; Foa et al., 1991, 1994; Resick & Schicke, 1992), and hyperarousal (Cooper & Clum, 1989; Foa et al., 1991, 1994; Peniston, 1986; Resick & Schicke, 1992), as well as depressive symptoms (Foa et al., 1991; Frank et al., 1988; Keane et al., 1989; Peniston & Kulkosky, 1991; Resick & Schicke, 1992) and anxiety (Brom et al., 1989; Cooper & Clum, 1989; Foa et al., 1991; Frank et al., 1988; Keane et al., 1989; Peniston & Kulkolsky, 1991). Only Resick & Schicke's (1992) cognitive processing approach has reported clinically and statistically significant improvements in intrusive, avoidance, and arousal PTSD symptoms (and in depression). Overall adjustment was improved following exposure-based cognitive-behavioral treatment in some instances (Boudewyns & Hyer, 1990; Foa et al., 1994; Peniston & Kulkolsky, 1991) but not in others (Keane et al., 1989). On balance, although with only seven studies (all with small sample sizes), exposure-based cognitive behavioral therapies have shown the greatest promise in treating PTSD. Intensive case studies of exposure-based treatment with PTSD (e.g., Fairbank & Nicholson, 1987; Hytten & Herlofesen, 1989; Lyons & Keane, 1989; Miller, 1991; Mueser, Yarnold & Foy, 1991) also report favorable, but mixed, results.

Practitioners applying exposure-based cognitive-behavioral treatment for PTSD face several difficult challenges. Of the studies evaluating therapeutic exposure ("flooding") that reported data on premature termination or treatment refusal, high rates (i.e., 25-40% of qualified participants) were documented (Boudewyns & Hyer, 1990; Cooper & Clum, 1989; Foa et al., 1991). Exposure-based therapy's efficacy depends upon induction of trauma-comparable physiological arousal and subjective fear in an imaginal reexperiencing of trauma (Foa, 1994; Marks, 1987). Clients may not be able to tolerate the requisite arousal and/or affect intensity without escaping (e.g., by treatment refusal) or avoidance (e.g., by dropping out or by dissociating). Insufficient exposure may not only elicit demoralizing treatment noncompliance, but is likely to sensitize, rather than habituate and extinguish, traumatic fear (Foa, Rothbaum & Stektee, 1989; Levis, 1989; Marks, 1987). The danger of iatrogenic demoralization and retraumatization is especially acute for clients with histories of multiple, prolonged, physically or developmentally injurious, complex, life-threatening, or horrific traumas. Extreme traumatization induces not only fear but also pathological dissociative defenses which are associated with severe problems modulating arousal, emotion and mood, passivity and impulsivity, rage and aggression, and interpersonal enmeshment and detachment (Herman & van der Kolk, 1987; Lundberg-Love, 1990; Saxe, van der Kolk, Berkowitz et al., 1993; Yates & Nasby, 1993). For example, childhood sexual abuse of girls, is associated with higher risk than adult civilian traumatization (e.g., assault, rape, disasters) for Axis I and Axis II DSM psychiatric disorders (e.g., persistent depression, suicidality, anxiety, fears, severe sexual and interpersonal problems, substance abuse, eating disorders), as well as PTSD (Briere & Runtz, 1990; Kilpatrick & Resnick, 1993; Lipovsky & Kilpatrick, 1994; Nash, Hulsey, Sexton, Harrrelson & Lambert, 1993; Rowan & Foy, 1993; Weaver & Clum, 1993). Similarly, men with warzone-related PTSD (who tend to have high rates of childhood traumatization [Bremner, Southwick, Johnson, Yehuda & Charney, 1993; Ford & Kidd, in preparation; Zaidi & Foy, 1994]), are at high risk for comorbid Axis I (Roszell, McFall & Malas, 1991; Kulka et al., 1990) and Axis II (Ford, Fisher & Larson, in preparation; Southwick, Yehuda & Giller, 1993) disorders, as well as for pathological dissociation and alexithymia (Krystal, Giller & Cicchetti, 1986; Hyer, Woods, Summers, Boudewyns & Harrison, 1990; Orsillo, Litz, Block, Weathers & Bergman, 1994), suicidality (Rosenheck & Fontana, 1995) and homelessness (Rosenheck & Fontana, 1994). Within these groups, individuals exposed to particularly violent, grotesque, or self-concept shattering traumas may be prone to especially complex and refractory sequelae (e.g., profound shame or alienation; psychotic or violent impulses; pervasive numbing).

Therefore, rather than simply following exposure protocols in a strict formulaic fashion, clinicians have experimented with individualized modifications tailored to assist clients to achieve the key goal of exposure -- reduction of subjective fear and arousal without avoidance of the traumatic memory/experience -- without intolerable distress (Keane, personal communication; Litz, Blake, Gerardi & Keane, 1990; Mueser, Yarnold & Foy, 1991; Nishith, Hearst, Mueser & Foa, 1995). Exposure-based procedures that titrate fear and arousal directly and/or teach skills for self-regulating arousal and emotion have shown promise in early trials: desensitization (Peniston, 1986), biofeedback-assisted desensitization (Peniston & Kulkolsky, 1991), cognitive reprocessing (Resick & Schicke, 1992; Schicke & Resick, 1994), and Eye Movement Desensitization Reprocessing (EMDR; Wilson, Tinker & Becker, 1994; although see Boudewyns et al., 1993 for preliminary data showning no benefit of EMDR over PE).

Interestingly, both psychodynamic (Brom et al., 1989) and interpersonal (Horowitz, Marmar, Weiss, DeWitt & Rosenbaum, 1984; Marmar, Horowitz, Weiss, Wilner & Kaltreider, 1988) therapies involve exposure to trauma memories, but not necessarily in a systematic manner designed to promote fear reduction or cognitive reprocessing. These approaches to treatment of trauma survivors aim to assist patients in altering the emotional responses and beliefs that are thought to be distorted or shattered by trauma. Thus they have proven of benefit primarily in improving avoidance/numbing symptoms, generalized psychiatric distress, and overall social adjustment, but not in resolving intrusive re-experiencing or hyperarousal.

On balance, although with very few studies (typically with small sample sizes), exposure-based cognitive behavioral therapies have shown the greatest promise in treating PTSD. Intensive case studies (e.g., Fairbank & Nicholson, 1987; Hytten & Herlofesen, 1989; Lyons & Keane, 1989; Miller, 1991; Mueser, Yarnold & Foy, 1991) report favorable but mixed results.

PTSD is hypothesized to involve a biopsychosocial fear-based "associational network" that generalizes from the stress/survival response at the time of traumatization to a global expectancy of danger and vulnerability (Chemtob et al., 1988; Foa et al., 1989; Litz & Hearst, 1994; Yates & Nasby, 1993). Psychodynamic-existential (e.g., Brende, 1983; DeFazio, 1978; Hendin, Pollinger, Haas, Singer & Ulman, 1981; Horowitz, 1986; Lifton, 1979; Shatan, 1982) and family systems (e.g., DeFazio & Pascucci, 1984; Figley, 1986; Haley, 1984; Marrs, 1986; Scaturo & Hayman, 1992; Z. Solomon et al., 1987) models are consistent with this view, although emphasizing the intrapsychic and relational manifestations of trauma-based fear, respectively. The latter models also explicate pathways by which the fear-elicited "survival mode" adopted in core trauma events can generalize not only as fear per se, but moreover as a pervasive posttraumatic "lifestyle" (Shatan, 1985) or "decline" (Titchener, 1986).

Fear-based avoidance and hypervigilance are hypothesized to perpetuate and intensify intrusive reexperiencing (Foa et al., 1989) by interfering with the habituation of fear-based arousal, preventing the learning of safety signals and non-fear-based schemas, and eliciting largely automatic and ultimately "ironic" (Wegner, 1994) cognitive processing. Trauma-related arousal, appraisals, and defensive cognitive processing are postulated to elicit a "rebound" of (Becker, Roth & Margraf, 1993; Kelly & Kahn, 1995; Salkovskis & Campbell, 1994; Trinder & Salkovskis, 1994; Wegner, 1994; Zeitlin, Netten & Hodder, 1995), or a a failure to suppress (Zeitlin, 1994), intrusive reexperiencing. Moreover, avoidance and hypervigilance "paradoxically" reinforce the apparent inescapablility and uncontrollability (Foa & Kozak, 1986; Mikulincer & Z. Solomon, 1988; Kushner, Riggs, Foa & Miller, 1993) of posttraumatic intrusive reexperiencing.

Fear-based dysregulation in self-management is associated with initially focal but increasingly diffuse psychosocial impairment. When trauma strikes, the containment and constructive utilization of the fear response's intense physiologic arousal is crucial to survival and adaptive self-regulation. Emotion awareness is not clearly beneficial at the moment of trauma, and may interfere with the implementation of an organized practical response to the traumatic stressor(s). However, it seems vital that emotion be experienced sufficiently to be encoded as a vivid central element of the trauma memory, rather than peripheralized and not encoded (Cahill, Prins, Weber & McGaugh, 1994; Koss, Trump & Tharan, 1995). PTSD risk and severity are substantially increased if, in the peritraumatic period (i.e., during and shortly after traumatization) severe dissociation occurs (cf. Cardena & Spiegel, 1993; Koopman, Classen & Spiegel, 1994; Weiss, Marmar, Metzler & Ronfeldt, 1995). Dissociation involves not only an absence of awareness of self-focused information (e.g., emotion) but an encoding of those data as totally peripheral (i.e., divorced from oneself; cf. Kihlstrom, 1994; Krystal et al., 1986).

The failure to encode emotion in trauma memories (due to its peripheralization) may be a key factor in peritraumatic dissociation's role as a risk factor for PTSD. Trauma memories encoded without emotion information may lead to posttraumatic hyperarousal, for two reasons. First, emotion is experienced when trauma memories are reexperienced, but without an affective connection to the trauma event itself the posttraumatic emotion is likely to be misattributed and inaccessible to change. Second, the triggered hyperarousal elicited by traumatic reexperiencing can only be reacted to but not modulated in the absence of emotion information. Even if full dissociation does not occur, traumatization has been observed to disrupt ordinary autobiographical memory (McNally, 1995), psychological development (Brende & McCann, 1984; Furst, 1967; van der Kolk, 1985), and the formation of a coherent sense of self (Gunderson & Sabo, 1993; Harber & Pennebaker, 1992; Laufer, 1988; Parson, 1988). The intense arousal typically elicited in persons with PTSD by trauma cues (Orr et al., 1993; Keane, 1994) is associated with a disruption of cognitive processing of nontraumatic contemporary information (Litz, Weathers, Monaco, Herman, Wolfson, Marx & Keane, 1995; McNally, 1995). Fundamental beliefs about personal safety and efficacy (Foa & Riggs, 1994; Z. Solomon, Mikulincer & Benbenishty, 1989) and trust, intimacy, and justice (Foa & Riggs, 1994; Janoff-Bulman, 1986) are shattered by trauma. Demoralization and alienation (Lifton, 1979; Jackson, 1982; Morrier, 1984; Shabad, 1993), debilitating interpersonal strife and isolation (Carroll, Rueger, Foy & Donahoe, 1985; Jordan, Marmar, Fairbank et al., 1992; Z. Solomon, 1988), and emotional numbing (Foa, Riggs & Gershuny, 1994; Litz, 1992; McFarlane, 1992), tend to follow as fear and acute stress disorders evolve into full PTSD.

Thus, although acute and chronic reactions to traumatic stressors involve both overwhelming fear and avoidance/numbing, PTSD essentially involves a breakdown in emotion modulation that occurs when these two constellations of distress operate dysynchronously. In existential or phenomenologic terms, demoralization becomes pervasive (Lifton, 1979). In social cognition terms, self-regulation has shifted from a perspective of "ideal" (e.g., hopes, aspirations) to "ought" (e.g., avoidance, self-protection) (Higgins, Raney, Crowe & Hynes, 1994). Confronted with unmodulated hyperarousal (and associated affects) and implacable intrusive memory fragments, the acute trauma survivor may attempt to cope by suppressing awareness of intrusive thoughts and emotions (Orsillo, Litz & Bergman, 1994). A "rebound effect" has been shown to ensue if suppressed thoughts are not consciously self-generated (Kelly & Kahn, 1994), such that their intensity and frequency is paradoxically increased rather than diminished. Paralleling Freud's hypothesis of the "return of the repressed" (Gedo, 1988), this rebound may account for the persistence and apparent uncontrollability of intrusive trauma memories. McNally, Kaspi, Riemann and Zeitlin (1990) have demonstrated that persons with chronic PTSD tend to dwell upon trauma-related information, as if unable to either fully process or avoid trauma memories. A mechanism for this phenomenon is suggested by Cloitre, Cancienne, Brodsky et al.'s (1994) finding that adult abuse survivors were able to intentionally forget only information that was explicitly (i.e., consciously, planfully) but not implicitly (i.e. unintentionally, automatically) memorized, and that dissociative tendencies were correlated with the ability to intentionally forget explicit memories. The attempt, whether conscious or involuntary, to "not know" a memory or an affect requires accessing and exposing oneself to the very memory or affect itself -- albeit implicitly and often out of conscious awareness. The reduction in explicit awareness of the memory and affect serves as a reinforcer of the conscious avoidance. Thus, in contrast to the motivation to reduce fear and gain mastery, an ideal paradigm is established for exacerbating not reducing fear and avoidance: repeated partial exposure terminated prior to habituation by avoidance (Foa et al., 1989; Marks, 1987). Although the "objective" evidence may overwhelmingly indicate a state of safety, the continuing inner storm of arousal, affect, and memory fragments fulfill all requirements for generating an appraisal of severe threat (Paterson & Neufeld, 1987)and perpetuating intrusive trauma re-experiencing.

Psychotherapy with PTSD, as a result, poses the formidable challenge of identifying high impact yet manageable targets for intervention in a complex multifaceted syndrome. Thus, early intervention (Foa et al., 1995) may be able to short-circuit the downward spiral of escalating avoidance and intrusive re-experiencing, by providing trauma survivors with an opportunity to "tell their story" (i.e., to restore affectively-overloaded trauma memories to ordinary narrative modes of memory) voluntarily (rather than as a passive or avoidant victim of unwanted re-experiencing) in a safe intimate setting that permits the reduction of terror, aloneness, horror, and helplessness.

When people are traumatized they are overwhelmed with their emotions - feelings of horror, terror, helplessness, grief, etc. When this happens, your mind and body act quickly to protect you - your mind focuses on the details of the event, while shutting off awareness of your feelings. Your body prepares you to protect yourself by either running or fighting (fight or flight response). Your entire mind and body memorizes the event so that it can be avoided in the future. At the same time the emotions, physical responses and visual memories are often split up and stored in memory separately so you are not overwhelmed by the event.

Later, when you are reminded of the event, the emotions, visual memories and physical responses may come flooding back. Your may feel like you are right back in the situation that caused these physical and emotional reactions in the first place. When this happens, your mind and body are trying to protect you by warning you that you may be in a similar situation to the one that traumatized you. Your body and emotions tell you to avoid the situation any way you can.

When you do avoid the situation by leaving or drinking or focusing on other things your body and mind can relax some, and that feeling of temporary and partial relaxation acts to reinforce the avoidance. However, this teaches your mind and body that the only way you can gain control in threatening situations is to avoid. Avoidance also reinforces a feeling of helplessness and hopelessness -- "Nothing I do makes things better, so the best I can do is just try to get away and shut down." This is a recipe for not taking charge of your life--for feeling self-doubt and low self-esteem, frustration and anger, and depression. When you avoid the memories of the event you never learn that the feelings and physical responses can lessen! You are reliving the memory again and again because your body and mind don't yet believe that it's really just a memory!

The solution is to focus on the memory and hold it in your mind long enough for your mind and body with learn that you are no longer IN the traumatic situation. This cannot be done all at once, because the trauma memories and feelings were learned in many repeated experiences over months and years. However, every time that you choose to focus on the memory, you are teaching your body and mind that you really are in control once again and that even the worst memory is only something that you are REMEMBERING. This is why you are learning to:

* Identify specific trauma memories that you can choose to focus on

* Write the memory down on paper to make it real AS A MEMORY

* Focus on the memory in your imagination instead of RELIVING it

* Face trauma memories with the support of other people you trust

* Take care of your needs and emotions when you face the memories

EBTPU VAM&ROC, White River Junction, Vermont

Lifetime and current prevalence rates of PTSD (9%) (Breslau, et al 1991) suggest that many disaster victims need to address traumatic reactivation, e.g., an earthquake victim who has successfully readjusted following an earlier sexual assault may begin to re-experience intrusive thoughts or nightmares about the assault. Moreover, clinicians have reported that acutely traumatized individuals with a history of previous traumatic experiences may be especially prone to experience adaptation problems (Lindemann, 1944; Solomon, et al. 1987; Solomon, et al. 1990). In these individuals, recent trauma serves to reactivate adjustment problems that are associated with the earlier trauma.

Differentiating between types of traumatic reactivations may serve as critical determinants of the type and sequence of treatment interventions. Solomon, et al. (1987) propose a reactivation model in which two categories of reactivated trauma are outlined. The first, referred to as uncomplicated reactivation, is characterized by individuals who return to their level of premorbid functioning, i.e., they become symptom-free. These individuals, however, remain particularly vulnerable to the reactivation of traumatic symptoms when exposed to stimuli that are directly reminiscent of the original trauma. In a second category called complicated reactivation, individuals develop a more generalized sensitivity and vulnerability to stressors and stimuli not directly related to the original trauma.

Parallel constructs proposed by Catherall (1989) and Keane (1989) provide valuable references for the treatment of uncomplicated and complicated trauma reactivation. In these heuristics, two central clinical issues are conceptualized: conflicts in ego integration (referred to by Catherall as primary trauma); and the loss of self-cohesion (secondary trauma). In primary trauma, "positive" symptoms related to sensory reminders, intense affective states, intrusive thoughts, and psychic numbing, are produced. The victim is intact characterologically, but cannot assimilate or tolerate the feelings associated with the trauma.

"Negative" symptoms, produced in secondary trauma, are characterized by a misalignment/dysynchrony between the victim and his or her social environment. Here, the psychological impact is more severe, and results in social withdrawal, feelings of mistrust and alienation, identity disturbance, and interpersonal difficulties that amount to a "disorder of the self."

Catherall suggested that each type of traumatization requires distinct treatment. For positive symptoms, the major therapeutic task involves facilitating the individual's (ego) capacity for conscious assimilation of trauma information that is dramatically discrepant from the individual’s beliefs, assumptions, and world view. This process involves a thorough self-examination with regard to the traumatic material and its implications. The therapeutic task in treating negative symptoms requires facilitating the individual's capacity to reconstitute a sense of self through a process of empathic engagement.

The subtypes of traumatization proposed by Catherall (1989) and Keane (1989) match the subtypes delineated by Solomon, et al. (1987). Positive symptoms are dominant in an uncomplicated reactivation, whereas, negative symptoms are dominant in a complicated reactivation. In cases of uncomplicated reactivation (that is positive symptoms), a psychoeducational approach is appropriate. The alternation of active listening and ventilation techniques with didactic information about stress response syndromes is useful to assist the survivor’s process of assimilating the trauma experience (see Table I).

Table I. Psychoeducational treatment for uncomplicated reactivation

The clinician seeks to understand the context of the reactivation in view of disaster survivor’s psychosocial history including significant life events, significant stressors prior to the recent traumatic event, coping strategies successfully employed toward adaptation to the original trauma,

circumstances of the traumatic events, the survivor’s behavioral, emotional, and cognitive response to the events, and the effect on the victim’s family, job and social relationships. Techniques are used to facilitate cognitive restructuring of the victim’s cognitive distortion, and often include the use of family counseling and efforts to mobilize the client’s support system. Exposure based treatments utilizing systematic desensitization and implosive therapy (Keane, et al, 1989; Fairbank & Keane, 1982; Keane & Kaloupeck, 1982) and psychopharmalogical treatment also work well (Friedman, 1990; Keane, et al, in press).

Disaster survivors who are assessed as having a complicated trauma reactivation, (i.e., dominant negative symptoms) are more appropriately referred to long-term psychodynamic-oriented treatment. Although the clinician must similarly seek to understand the reactivation in context of the survivor’s psychosocial history, the approach must emphasize process rather than content to facilitate the victim’s process of self reconstitution. Waldinger’s (1987) outline of treatment tenets for borderline personality disorders may be applied, since both individuals with borderline personality and this form of post-traumatic stress disorder exhibit a loss of self-cohesion. These tenets have been incorporated into the proposed psychodynamic treatment for complicated reactivation (see Table II). This approach attempts to provide a holding environment that facilitates the

___________________________________________________________

reconstitution of the self. A stable treatment framework strives to tolerate the survivor’s negative symptoms and provides empathic support. The establishment of regular appointment times, prompt beginning and ending session times, and clear payment expectations, are ancillary to the clinician representing a stable object offering consistent support and care. The clinician attempts

to facilitate the survivor’s understanding of the consequences of behavior. If and when therapeutic trust has been established, the survivor may be helped to differentiate between past threats and present stimuli. At this point, the survivor may be encouraged to find a positive meaning to his/her life events. Lastly, the clinician attempts to enhance the problem solving and stress management skills of the survivor.

HELPING SURVIVORS: CHILDREN

Like adults, children respond to trauma with symptoms of reexperiencing, emotional numbing, behavioral avoidance, and increased physiological arousal. By virtue of having less developed coping abilities, children as a whole, must be considered among high risk groups following a disaster. When traumatic death of a family member occurs are at increased risk for depression, stress reactions, and lower individuation from the family (Bradach, 1995). Helping children recover from disaster is complicated by the developmental biopsychosocial issues related to age, gender, maturity, identity, parental and sibling relationships, coping capacities, etc. Intervention strategies must take into consideration these developmental issues (see page # for summation of age-related issues and age-appropriate interventions).

Knowing a community’s resources and the types of services available to children is essential to providing aid to children survivors and their families. A number of factors (e.g., magnitude of disaster, parental and school attitudes about mental health, and resource availability) determine whether and what type of "assessment" children may receive following disaster. During the first weeks after disaster, mental health workers generally have time for only quick and informal assessments (e.g., while staffing a shelter or disaster assistance center serving hundreds). The majority of interventions to help children adjust/recover are based on the a priori assumption that support, guidance, stress management strategies, information, normalization and validation are helpful to most children exposed to traumatic events, even in the absence of individual assessment.

At disaster sites immediately following the impact, initial mental health interventions with children or similiar to those with adults, i.e., are primarily pragmatic:

PROTECT Find ways to protect children survivors from further harm and from further exposure to traumatic stimuli. If possible, create a "shelter" or safe haven for them, even if it is symbolic. The less traumatic stimuli children see, hear, smell, taste, feel, the better off they will be. Protect children from onlookers and the media.

DIRECT Children may be stunned, in shock, or experiencing some degree of dissociation. When possible, direct ambulatory children away from the site of destruction, away from severely injured survivors, and away from continuing danger. Kind, but firm direction is needed..

CONNECT The children you encounter at the scene have just lost connection to the world that was familiar to them. A supportive, compassionate, and nonjudgmental verbal or non-verbal exchange between you and a child may help them to feel safe. However brief the exchange, or however temporary, such "relationships" are important to children. Try to present accurate information at regular intervals. Connect children:

To parents, relatives

To accurate information and appropriate resources

To where they will be able to receive additional support.

TRIAGE The majority of children experience normal stress reactions. However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, becoming mute, or erratic behavior. Signs of intense grief may be loud crying, rage, or catatonia. In such cases, attempt to quickly establish therapeutic rapport, ensure the child’s safety and offer empathy. Stay with the child in acute distress or find someone to remain with him or her until initial stablization occurs.

There will be many places where children survivors are congregated away from ground zero who will be in need of psychological first aid. Such "off" sites include:

SHELTERS AND MEAL SITES DISASTER APPLICATIONS CENTERS (DAC)

RED CROSS SERVICE CENTERS HOSPITALS AND FIRST AID STATIONS

CORONER’S OFFICE EMERGENCY OPERATIONS CENTER (EOC)

SCHOOLS AND NEIGHBORHOODS COMMUNITY CENTERS AND CHURCHES FIRE AND POLICE DEPARTMENTS

PROTECT As with on-site help, it is important to protect children from further harm and, as much as possible, from further exposure to traumatic stimuli. At this phase, the less traumatic children people see, hear, smell, taste, feel, the better. Protect survivors from onlookers and the media. Advise adults that television coverage with graphic detail of death and destruction should be off-limits to children.

DIRECT Again, kind but firm direction is needed in disasters. When possible, keep children away from severely injured survivors and those experiencing extreme emotional distress, to minimize fear and emotional contagion.

CONNECT Your support and compassion, whether expressed in words or in non-verbal ways, helps to reduce fear and re-connect the child to a sense of security. Connect children to parents or relatives. Try to present accurate information at regular intervals, and connect children to available appropriate resources. When possible, refer parents to additional sources of support for children.

ACUTE CARE Those children who require immediate crisis intervention to help manage intense feelings of panic or grief can be helped by your presence. Stay with the child in acute distress or find someone else to remain with him/her until the feelings subside. Ensure the child’s safety.

OTHER ENVIRONMENTAL CONSIDERATIONS When possible, set aside a children’s area supplied with mats, toys, stuffed animals, art supplies (crayons, paints, paper, glue) and staffed by mental health professionals who specialize in working with children.

See assessment protocols (page#)

HELPING SURVIVORS: EARLY POST-IMPACT PHASE PREVENTIVE INTERVENTION Strategies with children

Preschool through Grade 2

1. Helplessness and passivity 1. Support, rest, comfort

2. Generalized fear 2. Protective shield

3. Cognitive confusion 3. Repeated clarifications

4. Difficulty identifying feelings 4. Emotional labels

5. Lack of verbalization 5. Help to verbalize

6. Reminders become magical 6. Demystification of reminders

7. Sleep disturbance 7. Telling parents/teachers

8. Anxious attachment 8. Consistent caretaking

9. Regressive symptoms 9. Time-limited regression

10. Anxieties about death 10. Explanations of death

Grades 3-5

1. Responsibility and guilt 1. Expression of imaginings

2. Reminders trigger fears 2. Identification of reminders

3. Traumatic play and retelling 3. Listening with understanding

4. Fear of feelings 4. Supported expression

5. Concentration/learning 5. Telling adults

6. Sleep disturbance 6. Help to understand

7. Safety concerns 7. Realistic information

8. Changes in behavior 8. Challenge to impulse control

9. Somatic complaints 9. Link between sensations and event

10. Monitoring parents anxieties 10. Expression of concerns

11. Concern for others 11. Constructive activities

12. Disturbed by grief responses 12. Positive memories

Adolescents (Grades 6 and up)

1. Detachment, shame, guilt 1. Discussion: Event, feelings, limitations

2. Self-consciousness 2. Adult nature of responses

3. Posttraumatic acting out 3. Link: Behavior and event

4. Life-threatening reenactment 4. Address: Impulse to recklessness

5. Abrupt shift in relationships 5. Understanding expectable strain

6. Desire for revenge 6. Address: Plans/consequences

7. Radical changes in attitude 7. Link: Changes and event

8. Premature entrance to adulthood 8. Postponing radical decisions

The classroom can play an important role in helping children recover. Mental health clinicians can work with entire classrooms at a time, individual students, parents, school officials, and teachers (Santa Cruz County Mental Health Services, Project COPE, 1990; Hiley Young, Giles, & Cohen, 1991). Teachers can also be quickly provided with brief training on how to conduct classroom exercises and how to identify children in need of professional counseling (Alameda County Mental Health Services, Cypress Corridor Nine-Month Recovery Program, 1990). Generally speaking, the setting and the time available for classroom programs and follow-up require conscientious goal-setting . Programs must include well-designed "closure" to prevent intensifying children’s fears or feelings of helplessness and vulnerability (see Pynoos & Nadir, 1993). Several types of interventions have been used in classrooms though very few have been empirically validated. La Greca et al identify the following types of interventions:

EXPOSURE TO DISCUSSION OF DISASTER-RELATED EVENTS

Various activities to promote verbal and/or non-verbal expression of the children’s experience, questions, and concerns can be used including, drawing, storytelling, puppetry, and modified debriefing protocols. See annotated bibliography at the end of this section.

Children are encouraged to develop coping and problem-solving skills and developmentally -appropriate methods for managing their anxieties.

Often, disaster disrupts familial and social support. Helping children to develop supportive relationships with teachers and classmates through the use of small group activities (e.g., letter writing other survivors, posters, commemorative rituals) can serve this purpose.

A valuable component to any intervention program offered to students is an informal drop-in meeting for parents. When possible, it should be held on the same day as the intervention. The meeting may be held when students are picked-up (thus requiring the school’s cooperation with regard to a supervised play period), or the meeting may be held at night. The purpose of offering a drop-in group for parents is fivefold:

Older adults (65 years and older) also respond to trauma with symptoms of reexperiencing, emotional numbing, behavioral avoidance, and increased physiological arousal, however, stress reactions may be less readily identified by a deterioration of functioning or a worsening of an already existent disease process. Consequently, older adults should be considered among the high-risk groups following a disaster.

The Disaster Preparedness Manual describes several factors associated with adaptation to disaster by the elderly:

Several factors common to older people may affect the stress level of an older adult.

Older person’s sense of smell, touch, vision and hearing may be less acute than that of the general population. A hearing loss may cause an older person not to hear what is said in a noisy environment or a diminished sense of smell may mean that he or she is more apt to eat spoiled food. Because the process of deterioration progresses gradually, many elderly are unaware of the degree of loss.

[Stevens & Dadrwala, 1993; Wysocki & Gilber, 1988]

Delayed response syndrome

Older adults may not react to situations as quickly as younger adults. Disaster service centers may need to kept open longer if older persons have not appeared.

[Babins, 1987; Cohen, 1987; Cunningham, 1987; Thompson, 1987; Haaland, Harrington & Gice,

Generational differences

Older adults are not a homogenous group. Religious/social/cultural pluralism in the United States as well as the wide age range of older adults affect service delivery. What might be acceptable to an 80 year old person may not acceptable to a person 65 years of age.

[Cole & McConnaha, 1986; Rosenmayr, 1985; Stahmer, 1985; Zissok, et al., 1993]

Chronic illness and medication use

Higher percentages of older persons have arthritis. This may prevent an older person from standing in line. Medications may cause confusion in an older person or greater susceptibility to problems such as dehydration. These and other similar problems may increase the difficulties in obtaining assistance.

[Kalayam et al., 1991; Oppegard , Hanson, & Morgan, 1984;

Katz et al., 1988; Rosen et al., 1993]

Literacy

Many older persons have lower educational levels than the general population. This may present difficulties in completion of applications or understanding directions.

Older persons may be limited in their command of the English language or may find their ability to understand instructions diminished by the stress situation. The resulting failure in communication could easily be further confused by the presence of authoritarian figures, such as police officers.

[Applegate et al., 1981]

Mobility impairment or limitation

Older persons may not have the ability to use automobiles or have access to private or public transportation. This may limit the opportunity to go to disaster assistance centers, obtain goods or water, or relocate when necessary. Older persons may have physical impairments which limit mobility.

Many older persons will not use services that have the connotation of being on "welfare." Older persons often have to be convinced that disaster services are available as a government service that their taxes have purchased. Older persons need to know that their receipt of assistance will not keep another , more severely affected, person from receiving help.

Mental health stigma

Many elderly have negative attitudes and lack of knowledge about mental health services. Fear of stigma often stops the elderly from seeking mental health treatment. Education is an effective way to alter the perceived stigma of seeking or receiving mental health services. Linking mental health and physical health services together may also be an effective means to reduce perceived stigmatization. Initially focusing on pragmatic needs may help build the elderly’s trust in a counseling program.

[Bumagin & Hirn, 1990; Dubin & Frank, 1992; Fink & Tasman, 1992;

Henry & McCallum, 1986; Lundervold & Young, 1992; Nelson & Brabaroi, 1985;

Peterson, Thornton, & Birren, 1986; Williams & Sturzl, 1990]

Loss of independence

Older persons may fear they will lose their independence if they ask for assistance. The fear of being placed in nursing home may be a barrier to accessing services.

Con artists target older persons, particularly after a disaster. Other targeting by criminals may also develop. These issues need to be addressed in shelters and in housing arrangements. Con artists often use home repair to victimize the elderly following a disaster. Education at disaster centers about these crimes may help prevent futher victimization.

[Stafford & Galle, 1984]

Unfamiliarity with bureaucracy

Older persons often have not had any experience working through a bureaucratic system. This is especially true for older women who had a spouse who assumed responsibility for bureacratic matters.

[Salive et al., 1994]

Sudden and unexpected relocation can result in inadequate information about individual medical needs. In addition, the psychological tasks associated with adjusting to new surroundings and routines can lead to depression, increased irritability, serious illness and even death in the frail elderly.

Memory disorders

Environmental factors or chronic diseases may affect the ability of an older person to remember information or to act appropriately. An older person may not be able to remember disaster instructions. If interviewed, the elderly may have difficulty relating details in logical order due to age-related impairment of temporal and spatial memory.

Multiple loss effect

Many older persons have lost spouse, income, home, and physical capabilities. For some persons, these losses compound each other. Disasters sometimes provide a final blow making recovery particularly difficult for older persons. This may also be reflected in an inappropriate attachment to specific items of property.

[Thompson et al., 1984; Kekich & Young, 1983; Lindgren et al., 1992; Pfeiffer, 1987]

Hyper/hypothermia vulnerability

Older person are often much more susceptible to the effects of heat or cold. This become more critical in disasters when furnaces and air conditioners may be unavailable or unserviceable.

[Collins, 1988; Thomas, 1988; Watson, 1993; Kenney & Hodgson, 1987]

SECTION VI

HELPING THE HELPERS

Stressors associated with disaster work

STRESS REACTIONS OF DISASTER WORKERS

CENTRAL PRINCIPLES

Roles of on-sITE emergency WORKERS

THE RESCUE WORK CULTURE

Guidelines to consulting command staff and rescue team managers at the scene of operations

CRISIS COUNSELING AT THE SCENE OF OPERATIONS

defusing

TEACHING RELAXATION TECHNIQUES TO DISASTER WORKERS

DEBRIEFING

INITIAL DEBRIEFING PROTOCOL

FOLLOW-UP DEBRIEFING PROTOCOL

HELPING THE HELPERS

Rescuing and aiding survivors, and the tasks of body recovery, identification, and transport are but a few of the stressors that contribute to high levels of emotional distress among disaster workers. The task of mitigating disaster worker stress is a vital component to emergency service operations and may be organized as an on-going process of prevention, early on-site intervention, and immediate follow-up. Interventions may be in the form of training, consultation, defusing, debriefing, or crisis counseling.

Disaster mental health work requires a broad clinical background and specific knowledge of stress reactions, post-traumatic stress disorder, crisis intervention, the nature and the function of emergency work, stress management, and other intervention protocols appropriate to the disaster environment (e.g., defusing, debriefing). Mitchell and Dyregrov suggest that the "wrong type of help provided by the wrong mental health professionals at the wrong time or under the wrong circumstances can be more damaging than no help at all."

Disaster mental health work involves a range of helping behaviors oriented, in general, to psychodynamic or behavioral constructs of human behavior, personality theory, learning theory, organizational theory, etc. The behaviors outlined below transcend theoretical bias and are applicable across various settings. When working with disaster workers, helpers structure interventions that increase positive self-image, perceptions of self-control, and knowledge of skills to manage stress, anger and conflict.

There are many extraordinary challenges to disaster work. Generally, disaster work is a combination of negative and positive experiences. Experiences may involve profound feelings of grief, despair, helplessness, horror and repulsion. The experience of sharing common goals and purpose, of social bonding, belonging and identity, and other experiences that foster renewed spiritual convictions or re-evaluation of life priorities also make disaster work very rewarding.

Occupational hazards of rescue work and workers' personal situation/stressors account for the majority of stress reactions.

OCCUPATIONAL HAZARDS

PERSONAL SITUATION/STRESSORS

* Personal injury * Proximity to scene of impact

* Injury or fatality of loved ones, friends, associates * Self-expectations

* Property loss * Prior disaster experience

* Pre-existing stress * Perception/interpretation of event

* Level of personal and professional preparedness * Level of social support

* Stress reactions of significant others * Previous traumatization

Stress reactions in disaster workers are normal and to be expected. Even experienced workers never fully become desensitized to the exposure of mass violent death and remain particularly vulnerable when victims include children. Stress reactions may result in short-term impairment of memory, problem-solving abilities, and communication or psychic numbing. Long-term stress reactions may include depression, chronic anxiety, symptoms resulting from vicarious traumatization (re-experiencing, psychic numbing/behaviorial avoidance, physiological arousal) and may cause or exacerbate marital, vocational, or substance problems.

Emotional Cognitive

shock impaired concentration

anger confusion

disbelief distortion

terror intrusive thoughts

guilt decreased self-esteem

grief decreased self-efficacy

irritability self-blame

helplessness

despair

anhedonia

Biological Psychosocial

fatigue alienation

insomnia social withdrawal

nightmares increased stress within

hyperarousal relationships

somatic complaints substance abuse

startle response vocational impairment

Though not always possible, mental health services are pre-arranged with its purpose and protocols understood and accepted by command staff and team managers. Generally, on-scene mental health support is delivered through consultation, defusing, debriefing, or crisis intervention services. These services may be informal or systematic and may be conducted individually or with a group in a quiet setting away from, but not too far from the disaster scene. The goals of these interventions are to:

* consult with team managers and line workers information about stress reactions and stress management strategies

* facilitate enhanced group cohesion and peer support

* provide opportunities for emotional disclosure and cognitive reframing

* mitigate long-term stress reactions (PTSD)

* improve readiness for future operations

Rescue workers may be members of highly trained teams, victims trying to help those who have been more seriously affected, or bystanders. Many types of helpers respond to emergencies.

* Search and rescue workers

* Fire and safety workers

* Transport drivers

* Medical personnel and paramedics

* Medical examiner and staff

* Police, security, and investigators

* Miscellaneous (clergy, mental health, elected officials, etc.)

Other disaster workers include volunteers who staff shelters, provide mass care, assess and repair the infra-structure.

The culture among rescue workers is one of shared values and individual differences, hence stereotyping is best avoided. For example, both common personality characteristics of disaster workers and individual coping styles of disaster workers have been noted. Understanding and respecting the rescue culture is fundamental to mitigating and monitoring worker stress levels. Without understanding the values, commitment, and performance standards disaster workers have of themselves, mental health workers are apt to be seen as outsiders and unhelpful by rescue managers and workers.

Myers identifies personality traits common to emergency service workers:

Gentleness Great strength

Trust Caution

High self-confidence High self-criticism

Dependence Independence

Toughness Sensitivity

These traits suggest that, in general, emergency workers will initially be wary of "outsiders" (mental health workers) and choose to personify their strength, independence, and toughness. If mental health workers are able to achieve the confidence of emergency workers, it is likely to increase worker comfort level for self-disclosure of vulnerability, self-criticism, and willingness to receive emotional support.

How rescue workers cope, or what they do, feel or think to tolerate or decrease the negative effects of a situation or to master a situation depends on several variables, including the contingencies of the disaster, preparedness, pre-existing team/organizational stressors, and pre-existing individual biopsycho-social stressors. A majority of disaster workers appear to favor coping responses that take problem-solving action. Some workers value and benefit from solitude while others seek the company of others. Some wish to talk with unknown professionals, others prefer to talk with a few trusted individuals.

A cornerstone of the effectiveness of mental health support at the scene of operations is the degree of rapport the mental health team is able to establish with the command staff, rescue team managers, and workers. Knowing intervention protocols is not enough to be effective. As Alexander points out, when offering help to members of well organized professional groups, the helpers themselves must be well organized and professional. Expect to encounter ambivalent feelings about your role and view this as a natural reaction by people who are in the midst of an extraordinarily challenging situation. Understanding the stressors associated with rescue work and the rescue work culture can faciliatate alliance building. An early presence can also foster becoming integral member of the response operations.

The following pragmatic suggestions for team mangers are adapted from the Community Emergency Response Team: Participant Handbook and Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Team Managers.

Crisis counseling intervention can help a worker overcome by the emotional stress associated with the operation. Crisis intervention principles (see ).

The decision whether a worker can return to the job, be transferred to less distressing tasks, or released from work must be made judiciously with sufficient information about the worker's capability to satisfactorily perform rescue duties, mental status (severity of stress reactions), and the availability of organizational and social support.

HELPING THE HELPERS: defusing interventions

Defusing refers to a process intended to facilitate opportunities for rescue workers to express their thoughts and feelings about the rescue tasks at hand without feeling pressured to do so. It is vital that mental health workers distinguish the process of facilitating voluntary emotional ventilation from a process that may be misperceived e.g., "voyeuristic" probing. Open-ended questions may be modified to fit different defusing opportunities.

* "Where are you from?"

* "What rescue tasks are you involved with?"

* "What is it about this situation that troubles you the most?"

* "How do you handle what's going on?"

* "How is this the same or different from other operations you've been involved with?"

If rapport is established, other topics related to personal and occupational stressors may be interjected.

TOPICS FOR DEFUSING WITH DISASTER WORKERS

* Personal injury * Proximity to scene of impact

* Injury or fatality of loved ones, friends, associates * Self-expectations

* Property loss * Prior disaster experience

* Pre-existing stress * Perception/interpretation of event

* Level of personal and professional preparedness * Level of social support

* Stress reactions of significant others * Previous traumatization

Defusing gives rescue workers the opportunity to better understand their own reactions and allows mental health workers to look for indications of workers who may be at risk for long-term stress reactions. Unlike the time needed to conduct debriefings (2-4 hours), defusings can be brief (10-30 minutes) and offered continuously throughout the operation. "Aggressive hanging out," that is, finding ways to be in the vicinity of workers on breaks, is often a means to conduct informal defusings.

HELPING THE HELPERS: TEACHING RELAXATION TECHNIQUES TO DISASTER WORKERS

Disasters workers have a deep commitment to working long hours without breaks and may quickly dismiss any suggestions about using any time to relax. The following "verbal set" is suggested as a means of engagement and as a potential means for workers to consider stress-management strategies.

1. Inquire about how long they have been on the job and about previous disaster experience.

2. Inquire about how coping styles (how they see their fellow workers coping, what he or she typically does to relax).

3. Inquire about unexpected stressors.

4. Inquire about sleeping patterns and level of fatigue.

5. Provide rationale for relaxation, first validating fatigue and its effects. Discuss disaster worker vulnerabilities: e.g, substance abuse, inability to stop working or thinking about the disaster.

6. Begin instruction and demonstration of techniques (e.g., muscle relaxtion, conscious breathing, autogenics, visualization, etc). Remember, the circumstances and or settings that you will be teaching in are, more often than not, far from ideal. You may have from five to fifteen minutes to demonstrate the value of relaxation. The challenge is to efficiently facilitate the experience of relaxation in the midst of chaotic environments.

7. When possible, have handouts available that describe the techniques (give handouts after instruction).

HELPING THE HELPERS: DEBRIEFING RESCUE WORKERS

Originally developed by Jeffrey Mitchell to mitigate the stress among emergency first responders, critical incident stress debriefing (CISD) is now a widely used protocol with victims and providers of all kinds (e.g., teachers, clergy, administrative personnel) in a wide range of settings (e.g., schools, churches, community centers).

Debriefing has become a generic term applied to a structured process that helps workers to understand and manage intense emotions, further understand effective coping strategies, and receive the support of peers. Two types of protocols are commonly used: initial debriefing protocol and a follow-up debriefing protocol. The rationale for this process is that providing early intervention, involving opportunities for catharsis and to verbalize trauma, structure, group support, and peer support are therapeutic factors leading to stress mitigation.

Case reports and anecdotal evidence of debriefing suggest that the process may lead to symptom mitigation, however, there has not been rigorous controlled investigation to date. CISD may provide some immediate opportunities for rescue workers to talk with one another, but is unlikely to be effective as the sole intervention for complex, on-going, or persistent problems that are the result of stress reactions to the operation, pre-existing stress, or various organizational stressors. In such cases, additional individual assessment is recommended.

The protocol for an initial debriefing usually consists of eight steps:

1. Preparation 5. Reaction phase

2. Introduction 6. Symptom phase

3. Fact phase 7. Teaching phase

4. Thought phase 8. Re-entry phase

Depending on the emergency service roles of workers, time alloted for the debriefing, and the number of workers in attendance, debriefers will necessarily have to evaluate how much time to spend on each phase and whether or not each worker will have equal time to speak.

* Arrange to work with a co-debriefer and discuss respective roles.

* Arrange for a private quiet room for 2 to 4 hours.

* Those in attendance should not be on call. Have educational/referral handouts ready.

* Schedule time for post debriefing discussion with co-debriefer.

Debriefers begin with self-introductions, including brief description of disaster mental health experience, the purpose of debriefing (clarifing that debriefing is not a critique of how they have responded, a critique of agency operations and that it is not a "fitness for duty evaluation"). Explain that debriefing is an opportunity to talk about personal impressions of the recent experience, learn about stress reactions, and stress management strategies and that it is not psychotherapy.

3. Fact phase

Depending on the number of workers in attendance, the next phase of the debriefing is asking participant/volunteers to describe from their own perspective what happened, where they were, what they did, and what they experienced sensorily (perception of sights, smells, sounds). If there more than 12 workers in attendance, it may be necessary to limit 6-10 volunteers to share their descriptions.

In this phase, workers are asked to describe their cognitive reactions or thoughts about their experience. In many instances, there are several events within the entirety of the rescue experience that make a memorable impact. Target most prominent thoughts. If there are more than 12 in attendance the debriefer may ask each worker to recall their thoughts about the one event that "is the one thing you constantly think about."

During the course of descriptions, debriefers may interject to if other workers had similar thoughts. The intent of course is to universalize and normalize common cognitive reactions.

5. Reaction phase

In this phase, workers are encouraged to discuss the emotions they experienced during the course of the operations.

During the course of descriptions, debriefers may interject to if other workers had similar feelings. As in the thought phase, the intent is to universalize and normalize common reactions.

6. Symptom (stress reaction phase)

In this phase, workers stress reactions are reviewed in the context of what they experienced at the scene, what stress reactions have lingered, and what they are experiencing in the present. Help participants recognized the various forms of stress reactions avoiding pathological terminology.

Psychosocial: alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment.

In reality, teaching occurs throughout the process of debriefing. As debriefing becomes a more common intervention, workers are increasingly understanding the effects of stress. Debriefers must assess what workers know and don’t know and ensure that they have accurate information about stress reactions and stress managment strategies. Topics may include:

8. Re-entry phase The final phase of the debriefing is allotted to discussing unfinished issues, reactions to the debriefing, a summation of the debriefing, and the referral process. When possible, a follow-up debriefing should be schedule to take place within two weeks. The protocol for follow-up debriefings is described on page___.

Debriefers should remain available after the debriefing to allow anyone in attendance to meet with the debriefers privately.

Occasionally, circumstances require that you provide a large number of workers a "debriefing" and adjustments to the formal debriefing protocol are necessary. The protocol for large group debriefing involves a modification of the process and content of the eight steps used in formal debriefings. The objective of such meeting is to provide information about common reactions disaster work, useful stress mangagement strategies, signs that suggest individual help may be beneficial, and where to get additional information or help. Even though not everyone will be able to participate, encourage participation and interaction and relate the material to their experiences.

Debriefers begin with self-introductions, including brief description of disaster mental health experience, the purpose of debriefing (clarifing that debriefing is not a critique of how they have responded, a critique of agency operations and that it is not a "fitness for duty evaluation"). Explain that a debriefing with a large group is an opportunity to learn about stress reactions and stress management strategies, and opportunity to learn from one another.

* Though generally not an issue in very large groups, it is nonetheless wise to review confidentiality. Personal disclosures are to be held in strict confidence by the group. Educational information may be shared outside the group. Inform attendees about mental health professionals’ limits to confidentiality and the duty to report.

* Inform attendees that no one is required to talk, but participation is encouraged. Agree on length of time. Inform attendees that everyone must stay until the end and that there will be no breaks. Inform that there will be handouts and notes should not be taken. Ask if anyone cannot meet these requirements and reconcile accordingly.

* Depending upon the number of workers in attendance, worker introductions may include name, role, hometown or vicinty, and whether or not there has been previous experience with debriefing.

Discuss how workers in different roles have different experiences and how degree of trauma exposure and the characteristics of the rescue/recovery environment are related to worker stress reactions.

Discuss how thoughts play a role in adaptation. In many instances, there are several events within the entirety of a rescue operation that make a memorable impact. The debriefer may suggest that ask each worker recall their thoughts about the one event that "is the one thing you constantly think about."

Ask two or three workers to share their answers with the group. Debriefers may interject to if other workers had similar thoughts. The intent of course is to universalize and normalize common cognitive reactions.

4. Reaction phase

In this phase, the debriefer discusses common emotional reactions and asks two-three workers to share with the group emotions they experienced during the course of the operations.

During the course of descriptions, debriefers may interject to ask if other workers had similar feelings. As in the thought phase, the intent is to universalize and normalize common reactions.

5. Symptom (stress reaction phase)

In this phase, workers stress reactions are reviewed in the context of what they may have experienced at the scene, what stress reactions have lingered, and what they are experiencing in the present. Help participants recognized the various forms of stress reactions avoiding pathological terminology.

Common stress reactions in disaster workers

Emotional: shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase.

Cognitive: impaired concentration, confusion, distortion, self-blame, intrusive thoughts, decreased self-esteem/efficacy.

Biological: fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response.

Psychosocial: alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment.

In reality, teaching occurs throughout the process of debriefing. As debriefing becomes a more common intervention, workers are increasingly understanding the effects of stress. Debriefers must assess what workers know and don’t know and ensure that they have accurate information about stress reactions and stress managment strategies. Topics may include:

1. Quantitative and qualitative dimensions (DSM-IV criterion A; sensory exposure; phenomenology of loss --loved ones, property, perceived control, and meaning)

1. Emotional (shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase)

2. Cognitive (impaired concentration, confusion, distortion, self- blame, intrusive thoughts, decreased self-esteem/efficacy)

3. Biological (fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response)

4. Psychosocial (alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment)

1. Degree of sensory exposure (severity, frequency, and duration)

2. Perceived and actual safety of family members/significant others

3. Characteristics of recovery environment (existence, access, and utilization of social support)

4. Perceived level of preparedness

5. Pre-disaster level of psychosocial functioning (coping efforts)

6. Pre-disaster level of psychosocial stress (vulnerability/resilience)

7. Interrelationship among factors of personal history, developmental history, belief system, and current and past stress reactions including previous exposure to trauma (war, assault, accidents)

1. Relationship between behavior and stress (exercise, eating habits, exercise, receiving and giving social support, relaxation techniques -- excessive and deficient behaviors)

2. Self-awareness of emotional experience and selected self- disclosure

3. Stress-related disorders (PTSD; disorders which may be exacerbated by stress)

4. Parenting guidelines (how to enhance children's coping)

5. Disaster preparedness

6. Characteristics of the disaster environment (phases of disaster)

7. When and where to seek professional help

7. Re-entry phase

The final phase of the debriefing is allotted to discussing unfinished issues, reactions to the debriefing, a summation of the debriefing, and the referral process. When possible, a follow-up debriefing should be schedule to take place within two weeks. The protocol for follow-up debriefings is described on page___.

Debriefers should remain available after the debriefing to allow anyone in attendance to meet with the debriefers privately.

A follow-up debriefing should be held when circumstances allow, 10-14 days after the initial debriefing. A third debriefing is recommended 3 months later. Mitchell recommends the following four questions for discussion:

* "How are things since the debriefing?"

* "Is anyone stuck on any particular part of the incident?"

* "How have things been on your own (or-off duty time)? "

* "What else do you feel you migh need to get you past this particularly bad event?"

Additional questions for discussion:

* "What, if any, changes have you noticed in your work habits since the disaster?"

* "How has the disaster affected your personal relationships?"

* "What stress management strategies have you used?"

* "Which stress management techniques work for you?"

* "Which ones don’t?"

* "Has this experience resulted in any positive changes in your professional or personal life?"

SECTION VII

HELPING ORGANIZATIONS

CENTRAL PRINCIPLES

FIVE KEY STEPS TO ORGANIZATIONAL DISASTER MENTAL HEALTH CONSULTING

ORGANIZATIONAL STRESSORS ASSOCIATED WITH DISASTER

ORGANIZATIONAL RESPONSE PLAN

PRE-DISASTER ORGANIZATION PREPAREDNESS

ESTABLISHING DISASTER MENTAL SERVICES

The post-actions of management (see p, ) can contribute significantly to mitigating work performance problems and psychological distress. Organizations Knowing disaster stress management protocols is not enough to be an effective disaster mental health consultant to organizations. As with any form of organizational change, there is apt to be ambivalence , if not resistance, to changes recommended by outside consultants. Though crisis can result in the need for change, resistance is greater when individuals who have recently experienced a loss of control are being asked to consider or make changes, as is the case following a disaster.

Providing consultation to administrators of large professional organizations requires that consultants themselves be well organized and professional. Offering a clear strategy for intervention that is amenable to modification after organizational assessment and consultation with key decision-makers can facilitate alliance building and serve to mitigate resistance. An early presence can also foster becoming integral member of the response operations.

HELPING ORGANIZATIONS: ORGANIZATIONAL STRESSORS ASSOCIATED WITH DISASTER

* Routine workload requires continued attention while role conflict and discomfort increase as a result of new and competing demands

* Personnel who are disaster victims may be experiencing mild-to- moderate-to-severe stress reactions and be unable to access usual means of support (see page # for list of variables affecting stress reactions)

* Routine management procedures are ruptured and tolerance among departments and personnel often decrease as stress, role conflict, and extreme fatigue set in

* Relationships with county, state, federal, and non-profit organizations are altered

* Limited credit may be given if emergencies are handled effectively; harsh jugdments may increase if handled poorly.

* Increased media scrutiny of procedures

* Increased scapegoating as personnel seek to relieve anxiety

* Actual or perceived decreased safety, increased management demands for flexibility, and other disaster precipitated stress result in staff having less tolerance for ambiguity and may result in their questioning their allegiance to the organization and the value of their job

* Disruption and increased stress results in intial narrowing of focus and mangers’ ability to see the "big picture" decreases

* Provide outreach to staff: personnel who are disaster victims commonly do not seek mental health assistance. Create marketing campaign" to prevent stigma of seeking assistance or participating in activities offered (e.g., "support services for normal reactions to abnormal situation").

* Offer screening for staff who are primary, secondary, or tertiary victims if they meet at least one of the following criteria:

Their work area has been relocated because of property damage

They are new hires or are new in their positions

They have pre-existing health and psychological issues

Do employees have specific safety concerns?

Are there employees related to injured victims?

Are there employees who have had to relocate residence?

Is there in increase in on-the-job accidents?

Is there greater tension among employees or departments?

How is significant is the change in work productivity?

* Recommend recognition to staff for contribution to the disaster effort, including those who stayed at behind to "mind the store"

Assist in establishing sources of information for organization: newsletters, bulletin boards, briefings by administrators, brochures about resources, etc.

Large and small group educational presentations on mental health reactions of adults and children to disaster, self-help stress management suggestions, and where to call for additional help

Distribute brochures on mental health reactions of adults and children to disaster, self-help stress management suggestions, and where to call for additional help

Debriefings for small work units

Individual assessment and referral

Brief individual counseling (1-10 sessions) and referral

Stress management programs (e.g., child care, recreation, exercise, support and drop-in debriefing groups)

HELPING ORGANIZATIONS: PRE-DISASTER ORGANIZATION PREPAREDNESS

All organizations can benefit from analyzing potential crisis

situations. Preparedness can include strategies to manage worst case scenarios including the potential effects of fatalities, employees unable to get to work, and damaged facilities. It isn’t possible to prepare for the many types of disaster, however, as Kutner suggests, many aspects of managing a crisis can be anticipated. Regardless, of the type of the disaster, management will have to deal with the media, address productivity, work with insurance companies, handle security issues, and mitigate the psychological distress of employees.

Kutner suggests that a preparedness plan include at least the following:

* Formal crisis communications procedures for addressing employees (including off-site workers), the media, community groups, and government agencies

* Security procedures to ensure safety of employees and property throughout the crisis and recovery stages

* Procedures to develop relationships with local law enforcement, fire fighting, emergency medical and related government agencies

* Procedures to address and monitor post-traumatic stress in the aftermath of the disaster

* Procedures to manage department or operations shut downs, employee job reassignments, layoffs, or leaves of absence

* Legal counsel review of communications and employee relations policies

* Establish Disaster Mental Health Preparedness committee

* Committee membership should represent administrative, environmental, allied mental health, and community relations interests

* Establish an emergency management organization chart

* Establish objectives of disaster mental health services

* Establish procedures for emergency response (See page #)

* Incorporate procedures into organization’s overall disaster plan

* Develop memorandum of understanding between your organization and other key agencies within the community (e.g., Red Cross, local mental health)

* Hire outside disaster consultant for planning and support of administration during course of disaster

* Train mental health staff in disaster mental health plan, roles, responsibilities (see Team Formation and Development section)

* Have education materials pre-assembled for distribution

* Schedule regular mock exercises with outside review

* Regular review and update of Emergency Plan should occur (including evaluation of resources and of what might hinder implementation)

HELPING YOURSELF DURING A DISASTER ASSIGNMENT (SELF-CARE)

Disaster mental health work typically involves a combination of positive and negative experiences. There are numerous occupational hazards and many disaster mental health workers may concurrently be disaster victims having to cope with the personal impact of the disaster. In addition to receiving organizational and peer support, disaster mental health workers must apply stress management methods during assignment to mitigate stress reactions.

MORE MATERIAL FORTHCOMING

Wisocki, P. A. (1988). Worry as a phenomenon relevant to the elderly.

The information on this Web site is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.

All information contained on these pages is in the public domain unless explicit notice is given to the contrary, and may be copied and distributed without restriction.

For more information call the PTSD Information Line at (802) 296-6300 or send email to ncptsd@ncptsd.va.gov. This page was last updated on Thu Jul 20 17:01:08 2006.