Disaster Mental Health Interventions

Core Principles and Practices

James Halpern, Karla Vermeulen

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317227168
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Disaster Mental Health Interventions uses DSM-5 diagnostic criteria and the latest research to help build disaster mental health intervention skills that will last a lifetime. Students and emerging professionals across the fields of mental health counseling, social work, school counseling, spiritual care, and emergency management will appreciate the accessible tone, level of detail, and emphasis on practice. Case studies and anecdotes from experienced professionals add an additional level of depth and interest for readers.

Chapter 1

What Is Disaster Mental Health?

Consider the following case study and think about how it differs from your typical counseling or social work training or your current work situation.

Tropical Storm Allison dropped as much as 40 inches of rain in Southern Texas and Louisiana in spring 2001. There were 41 fatalities, most by drowning. In rural Louisiana, there was talk of copperhead snakes and alligators roaming the neighborhood as their habitats were disturbed. Fire ants too were considered a danger; as one resident said: “Don’t worry about the gators, but if you see a stick on the ground that appears to undulate—do not touch it! It’s covered with fire ants and they can cause you a world of pain.” Local residents were less afraid of wildlife and more distressed about their flooded homes. At the Family Assistance Center, clients from varied economic classes, races, religions, and ethnicities waited to meet with caseworkers, who would be able to arrange for damage assessment and provide them with immediate emergency funds for food, clothes, and lodging. The line was long, extending far outside. Some had to wait for hours in the blazing heat; some held children; some were in tears. Some were wet, and all were hot and miserable. Most mental health workers were inside the building. However, others were assigned to “work the line.” This meant letting survivors in the queue know how long we thought the wait would be, and getting them water and snacks or small toys for the children. Most of what we did involved making contact and conversations, letting them know they were not alone—that we cared about them and what they were going through. We introduced ourselves, told them where we were from, gave them a bottle of water, and asked how they were doing. We did a lot of listening. Clients told us about belongings that were lost. They struggled to do a mental inventory of what would need to be replaced—and they talked about items destroyed that were not replaceable, such as wedding albums or photos of deceased relatives. Many were thankful that they and their family members were not injured, but most were upset and frustrated with family members, nature, luck, and God. Many were upset with themselves for not having enough home insurance, or not protecting their property, or keeping valuables in the basement, or living in an area that tends to flood.

When you respond to a disaster, you leave the familiar and ordinary world and many of the props and structures of routine work and clinical practice. There’s no couch or comfortable chair for the therapist, no office and no waiting room. You enter a world where assumptions have been shaken or shattered. We live our lives thinking that the earth doesn’t shake so violently it brings down buildings, that rainstorms end without creating chaos, and that planes don’t crash. Yet when you enter the disaster scene you need to expect the unexpected. You might be doing counseling on a bench out in the cold. There are no scheduled appointments. There are no insurance forms. Counseling can last for a few minutes or a few hours. The practice of disaster mental health (DMH) is unpredictable. There can be unusual sights, sounds, and smells. You might be underwhelmed one day, overwhelmed the next. It’s not unusual for you to go to a Disaster Response Center (DRC) or Family Assistance Center (FAC) and find that there are far too many mental health workers on the scene. It’s also quite possible that, when working in a shelter or DRC that has recently been set up, you’ll need to be an expert at triage, deciding whom you should help first—an angry parent, a crying child, an upset volunteer, or an overworked kitchen staffer. The settings where you might work can be most unusual.

It should be clear from the case study that disaster mental health is quite different from traditional practice, and it requires helpers to remain flexible and open-minded. Disaster mental health is not for everyone, and even if you are right for it there may be times when you shouldn’t be doing this work. If you’re under unusual stress, are grieving yourself, or if you think you’re not quite fit for duty, it may be best to postpone working at a disaster. If there’s one thing you can count on, it’s that there will be another disaster at some point in the future. The emotional hazards of this work and the importance of self-care will be discussed in Chapter 11. Although it’s reasonable to be careful and circumspect when you’re deployed to a disaster, with training and experience you have the opportunity to be very helpful to people who are very much in need.

A Brief History

The study of disaster mental health begins with the study of trauma, which, according to Judith Herman (1992), has a history of investigation followed by denial or forgetting. Herman wrote that three times in the twentieth century a particular form of trauma surfaced into consciousness.

The first was hysteria. Sigmund Freud initially listened to patients as they told him horror stories of sexual abuse, rape, and incest and deduced that the trauma led to a double consciousness or dissociation. His colleagues despised him for insisting on the sexual nature of the cause of hysteria. Later, Freud could simply not believe that so many women had been subjected to sexual trauma. He concluded that the symptoms were not the result of an unbearable or traumatic situation but, rather, an unacceptable impulse—an inappropriate desire for sex that the ashamed patient repressed, leading to the emergence of hysterical symptoms as the urge struggled for conscious awareness. Freud’s inability to accept the reality of the commonness of trauma set the field back for decades.

The second time trauma came to the fore was through the study of the combat veterans from the First World War through the Vietnam War. Although the back wards were filled with veterans suffering from “shell shock” after the First World War, once again no one wanted to think or to know about trauma. Their psychological symptoms were blamed on physical exposure to shelling, long past the point at which evidence contradicted that explanation, or on personal weakness or cowardice. Self-advocacy and a refusal to suffer in silence by veterans of the Vietnam War inspired long-term studies of the trauma from war. In the 1970s Vietnam veterans offered comfort to each other in “rap groups.” They not only told their stories of the horror of war but also forced the American Psychiatric Association (APA) to legitimize their distress with a new diagnosis: Posttraumatic Stress Disorder (PTSD), which was first included in the third edition of the APA’s Diagnostic and Statistical Manual (DSM-3), in 1980.

The third recent trauma focus is on sexual and domestic abuse. Not until the 1970s did the women’s movement bring to awareness that the most common horror causing traumatic symptoms was not the impact of war on combatants but abuse of women in civilian life, which previously had been viewed as a private matter that wasn’t worthy of acknowledgment. This history of not recognizing trauma reminds us that there can be a powerful motive to not see the emotional pain of disaster survivors. We might have to remind officials and others that disasters cause more than physical injury and property damage, and result in emotional and psychological wounds as well.

Looking specifically at disasters, in 1883 Herbert Page was one of the first to recognize and study disaster survivors in the aftermath of railway accidents as this new technology spread after the Industrial Revolution, exposing people to dramatically higher speeds than they had ever traveled at before, and to more damaging accidents when trains crashed. The symptoms he observed and reported—emotionality, sleeplessness, heightened startle response, re-experiencing, and hypervigilance—are in fact the symptoms of PTSD. Page’s colleagues assumed there must have been damage to the brain or spine and coined a new diagnosis: “railway spine.” However, Page viewed the cause of the symptoms as a shock to the whole person rather than to any particular organ, which was groundbreaking (Brewin, 2003).

Despite some early efforts, such as Page’s work, and the crisis counseling that Erich Lindemann provided to survivors and bereaved relatives of victims of the Cocoanut Grove nightclub fire in Boston that killed 492 people and injured hundreds more in 1942, it wasn’t until the 1970s that disaster mental health came into its own, as a result of a broad network of mental health practitioners responding to disasters (Morris, 2011). Their DMH work was reported in the press, and soon counseling services were included in the Disaster Relief Act, passed in 1974. In the early 1990s the American Red Cross established disaster mental health as a function not only to help disaster survivors but to support impacted staff and volunteers.

The field then expanded quickly, in parallel with the growing need created by disasters of increasing frequency and intensity. By 1995 hundreds of counselors were deployed after the Oklahoma City bombing and thousands of DMH workers responded to the attacks on September 11, 2001. At present in what is now an established field:

•DMH is practiced by some 5,000 licensed mental health volunteers working with the American Red Cross.

•Most states and counties have disaster mental health teams.

•Professional organizations, including the National Association of Social Workers, the American Psychological Association and the American Psychiatric Association, have statements of understanding with the American Red Cross to provide DMH.

•The Disaster Distress Helpline provides mental health assistance to disaster survivors 24/7 via phone and texts.

•University-based programs, such as the Institute for Disaster Mental Health at SUNY New Paltz, offer both academic programs and professional trainings.

•The Council for Accreditation of Counseling and Related Educational Programs (CACREP) now requires that counselors, as part of their core curriculum, “study the effects of crisis, disasters, and trauma on diverse individuals across the lifespan” and learn the “skills of crisis intervention, trauma-informed, and community-based strategies, such as Psychological First Aid” (CACREP, 2016).

Although disaster mental health is a relatively new field, it has become an essential part of helper education as well as the post-disaster response to survivors’ needs.

The Role of the Helper

Let’s begin by noting what disaster mental health is not. DMH helpers do not provide any type of analytic therapy, prolonged exposure therapy, cognitive processing therapy, or eye movement desensitization and reprocessing therapy. No traditional therapy is appropriate because helpers don’t approach clients as patients suffering from a psychopathological disorder. Instead, helpers approach disaster survivors with the attitude that they’re under extreme but understandable stress resulting from their recent experience and are not disordered.

Counselors do use their clinical skills and assist survivors in this most difficult time because, as mental health professionals, they’re experienced at working with people who are suffering. They’re trained to be calm in the face of pain and in trying circumstances. It’s also helpful that social workers, psychologists, and counselors all receive training that each case is unique and that one size does not fit all.

Remember that, when assisting disaster survivors, flexibility is most important. In one situation and with one client the helper might need to be very active. For example, after an earthquake there could be aftershocks, but survivors will want to check their homes and remove some valuables. Helpers might need to tell them forcefully that they’re in an unsafe place and need to get to safety. Similarly, a counselor might say to an older client who is furiously shoveling mud out of his house that he needs to be more careful not to overexert himself. However, the next client, in the house next door, might not need such direct guidance, but only warmth, support, and empathy. In this home, the counselor might need to listen for a long time as survivors talk about their lost photograph albums that were stored in the basement.

In traditional counseling, most therapists work with some eclectic combination of exploration, insight, and action. In disaster work, the orientation and emphasis must be very adaptable. At one Disaster Response Center, a couple were very distraught because they weren’t sure where they and their children would sleep that night. A counselor sat sympathetically and comforted them, explaining that everything would work out and that the situation was only temporary. However, a more effective response would have included exploring possible practical solutions by checking with the clients to see if there were friends or family who might help out, or, as many agencies are at a DRC, the counselor might have identified the appropriate agency for assistance and walked with the client to the desk. At the same DRC another client was very distressed that a family member had been hospitalized. This time, effective help meant providing calm reassurance, and helping the client to obtain support from those who cared about her.

These vignettes remind us that our allegiance is to our clients, not to any particular counseling approach, and that we have to be very adaptable when doing disaster work—sometimes providing direct guidance and sometimes providing active listening. These cases also remind us that one size does not fit all. This is one reason why Critical Incident Stress Debriefing, an early approach to providing post-disaster mental health assistance that is discussed in Chapter 5, is no longer recommended for the general public. The practice of DMH requires too much flexibility to think that any one protocol or structure of clinical intervention is the best way to help all disaster survivors.

“I Don’t Need Mental Health”

In the aftermath of the most horrific events it’s possible that a DMH supervisor may experience difficulties communicating with a government official or emergency management official regarding the need for mental health services. Why? The officials might not understand or see the importance of mental health services because they’re focused on catching the bad guy who perpetrated the attack, or they’re busy thinking about how to get the roads open and the injured to hospitals. Bear in mind that government officials, first responders, and emergency managers may be traumatized themselves but are too busy to identify or acknowledge their distress. Additionally, there continues to be a stigma associated with the need for mental health services among some responders and survivors, though that’s generally improving. The responsibility of DMH leadership is to assess and provide help to the impacted community—and for DMH workers to acknowledge that we may not always be welcomed with open arms by officials or community members.

If a DMH worker is assigned to help at a shelter or DRC and sits at a desk in front of the room with a sign that says “Mental Health,” it’s unlikely that he or she will get much business. If a counselor is making home visits and asks if anyone needs “mental health,” the answer is likely to be “No.” Upset, stressed, and anxious survivors are usually no...