Disaster Mental Health Services

A Primer for Practitioners

Diane Myers, David Wee

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135454456
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

Disaster mental health is a growing field of practice designed to help victims and relief workers learn to effectively cope with the extreme stresses they will face in the aftermath of a disaster. The goal of disaster mental health is to prevent the development of long-term, negative psychological consequences, such as PTSD. This book assists clinicians and traumatologists in "making the bridge" between their clinical knowledge and skills and the unique, complex, chaotic, and highly political field of disaster. It combines information from a vast reservoir of prior research and literature with the authors' practical and pragmatic experience in providing disaster mental health services in a wide variety of disasters.

II
SERVICES, PROGRAMS, AND WORKERS

3
CODE-C: A MODEL FOR DISASTER MENTAL HEALTH SERVICE DELIVERY

INTRODUCTION

CODE-C DISASTER MENTAL HEALTH SERVICE MODEL (CODE-C DMHSM) is a comprehensive, integrated, multiservice model that can be used effectively to address the wide range of mental health needs in communities following disasters. CODE-C is an acronym that can be used as a tool by mental health practitioners. CODE-C DMHSM facilitates communication between disaster mental health practitioners, emergency managers, and persons who will receive services by using a standard nomenclature. The CODE-C DMHSM also defines service components and communicates the differences between disaster mental health services and other more traditional approaches to mental health service delivery.

The CODE-C DMHSM has been used extensively by the authors since the model’s development in November 1992. The CODE-C model has been used to plan, organize, and provide disaster mental health services, as well as in the training of disaster workers. CODE-C was first developed and used after Hurricane Andrew to plan and implement a comprehensive stress management program for state and federal workers at the Disaster Field Office in Miami, Florida (Myers, 1992). It was used as a model for disaster worker stress management programs for the Federal Emergency Management Agency (FEMA) after the 1993 Florida winter storms (Myers & Zunin, 1993a), the 1993 great Midwest flood (Myers & Zunin, 1993b), and the 1994 Northridge earthquake (Myers & Zunin, 1994a). The model was the basis of the FEMA Disaster Worker Stress Management Program implemented in 1994 to support federal and state disaster workers in the line of duty (Myers, 1993; Myers & Zunin, 1994b; Federal Emergency Management Agency [FEMA], 1998).

The CODE-C model is included as a component in the City of Berkeley Disaster Mental Health Plan and the City of Berkeley Response Plan for Weapons of Mass Destruction. The model was used during consultations by the authors with the city of Seattle following the 2001 Nisqually earthquake, the 1995 California winter storms, the Sutter and Yuba City evacuation and floods of 1997, and, most recently, the Southern California fires of 2003.

The CODE-C model has been used in training disaster mental health workers following numerous natural disasters in California, and is also taught to citizens in community crisis response training in California. It is currently included in course materials in the following courses at the California Governor’s Office of Emergency Services California Specialized Training Institute: Earthquake Recovery, Managing Sustained Operations, Terrorism, and Disaster Medical Operations (Myers, 2002a, 2002b, 2002c). It is taught in the course Disaster Mental Health: Response and Interventions at the University of California, Berkeley Extension, and in lectures at the School of Social Welfare, University of California, Berkeley. It has been used to teach American Red Cross disaster workers psychological response to terrorist events both before and after the terrorist attacks of September 11, 2001 (Myers, 2001a; Myers, 2001b). The model has been presented by the authors during over 200 presentations on disaster mental health, mental health issues in terrorism, bioterrorism, and in presentations to emergency management professionals.

The fundamental differences between disaster mental health and traditional mental health services are incorporated into the CODE-C DMHSM described in this chapter. Key differences in the model include goals and objectives, guiding concepts of disaster mental health programs, range of services provided, duration of services provided, and linkages with other providers. Disaster mental health programs must have core components including needs assessment, consultation, outreach, debriefing, education, and crisis counseling.

Consultation includes advice, education, training, and assessment services to decision makers, managers, supervisors, and line workers. Consultation is directed at solving problems involving policy, organization functioning, and service provision. Outreach is important in reaching as many people possible. Outreach is provided to victims, survivors, disaster workers, and members of the community in their natural environments. Debriefings and defusings are group crisis intervention tools for disaster mental health workers in serving survivors and disaster workers following community disasters and violence. Debriefings and defusings are psychoeducational groups that address stress reactions by providing participants with opportunities to receive information on normal reactions by normal people to abnormal events and obtain information on coping strategies and recovery resources (see chapter 5 for a full discussion of CISM services). Education services provide information and training on topics specific to disaster psychology and mental health. These services may include workshops, presentations, conferences, written materials, and intensive use of the media. Education services support individual, family, and community recovery. Crisis counseling consists of brief interventions with people impacted by disasters. The objective of crisis counseling is to identify disaster-related distress and problems in living and to provide support. Interventions include crisis intervention, problem solving, and development of individual, family, and community support systems.

Disaster mental health services and programs comprehensively target populations at various levels: the community, organizations, groups, and individuals. In the United States, disaster mental health services are provided by a variety of organizations: private and public mental health programs, mental health professional organizations, disaster relief organizations, employee assistance programs, corporations, and local, state, and federal agencies. Federal government programs include those sponsored by FEMA (FEMA Crisis Counseling Program for disaster survivors and workers), the U.S. Public Health Service National Disaster Medical System (NDMS), the military (e.g., U.S. Navy Special Psychiatric Rapid Intervention Team [SPRINT]), and the Department of Veteran Affairs. Other groups that provide special training and volunteers in disaster mental health include the American Psychological Association, American Psychiatric Association, National Association of Social Workers, California Association of Marriage and Family Therapists, American Red Cross, International Critical Incident Stress Foundation, International Association of Trauma Counseling, International Society for Traumatic Stress Studies, and Green Cross. Numerous universities and graduate programs now offer programs in traumatology and disaster mental health.

DISASTER MENTAL HEALTH SERVICES

Disaster mental health services differ from traditional mental health services in their goals, objectives, methods, and settings. These differences are based on how people perceive their disaster-related problems and the resources they are willing to use to cope with these problems. Table 3.1 shows the differences between disaster mental health services and traditional mental health services in relation to goals, objectives, methods, and the settings in which the services are provided.

TABLE 3.I: COMPARISON OF DISASTER MENTAL HEALTH SERVICES AND TRADITIONAL MENTAL HEALTH SERVICES

COMPARISON OF DISASTER MENTAL HEALTH AND TRADITIONAL MENTAL HEALTH SERVICES

The goal of disaster mental health services is to mitigate disaster-related stress reactions and to assist persons and communities impacted by disaster to return as soon as possible to their predisaster level of functioning. In contrast, the goal of traditional mental health services is to provide treatment to mentally ill individuals, with the goal of change in the individual and management or cure of the individual’s mental disorder. The target population of disaster mental health services is those in the community affected by the disaster. Persons living in the community are considered normal and are not generally considered mentally ill or suffering from mental disorders that are clinically significant. Traditional mental health services provide intensive assessment, diagnosis, treatment planning, and treatments including individual, group, and psychiatric services. These mental health services are provided to persons who are self-identified or referred by the family or community as mentally ill and needing mental health treatment. The objectives of disaster mental health programs include providing crisis counseling, education, support, and development of community resources. Traditional mental health objectives include the identification of the mental illness and definition of appropriate treatment leading to symptom reduction or cure. The methods used in disaster mental health include needs assessment, consultation, outreach, debriefing, education, and crisis intervention and brief crisis counseling (CODE-C). The methods used in traditional mental health services include individual and group psychotherapy, psychiatric and medication services, milieu therapy, and case management. The settings where disaster mental health services are provided might, at times, include an office setting, but most frequently are community-based and are in locations where people affected by the disaster are located. Persons impacted by disaster seldom seek out mental health services following the disaster. Traditional mental health services are typically office, clinic, or hospital based.

COMPARISON OF CRISIS COUNSELING AND PSYCHOTHERAPY

Another way to address the differences between disaster mental health services and traditional mental health services is to compare the differences in core activities found in crisis counseling programs and psychotherapy. Crisis counseling is proactive. Crisis counselors seek out and actively interact with persons impacted by disasters, inquiring about the person’s disaster experiences, disaster-related stress, family functioning, coping strategies, and resources that might be needed. Although it is impossible to generalize across the wide variety of modalities of psychotherapy, many approaches to psychotherapy are more passive, allowing the individual the opportunity to self-disclose events, memories, and meanings that are important to the client. Crisis counseling seeks to restore the individual’s ability to cope with the additional stress brought on by disaster. Enhancement of coping might include education, problem solving, specific suggestions on coping based on the experiences of other disaster survivors, teaching of coping skills, use of community resources, and referral for more in-depth assessment or psychotherapy. Traditional psychotherapy emphasizes exploration of the client’s feelings and experiences, with the client providing the solutions to the problems he or she faces. Crisis counselors gather history strategically with the priority on current problems and challenges faced by the disasterimpacted persons. The strategic history is largely current and disasterspecific, although a history of previous trauma and loss should be included. Traditional psychotherapy, in contrast, usually includes an in-depth historical approach. The traditional psychotherapist will want information on the client’s early childhood experiences, development, schooling, social history, medical history, and psychiatric history. Traditional psychotherapy may be insight-oriented, with the clients (with the guidance of the psychotherapist) learning about their inner lives and about how this discovered truth can help them find true meaning and purpose in life. Psychotherapy may also take a biopsychological approach, utilizing such techniques as biofeedback or psychopharmacology to treat specific conditions and to help clients manage their symptoms. Crisis counselors assist clients with the problems of daily living, such as the stress of relocation due to damage or destruction of their homes. Crisis counseling is oriented toward prevention of mental problems through education and intervention before a disaster-impacted person’s disaster problems result in the person’s needing intensive treatment. Traditional psychotherapy, on the other hand, involves treatment to alleviate suffering and work toward management or cure of the mental disorder.

TABLE 3.2: COMPARISON OF CRISIS COUNSELING AND TRADITIONAL PSYCHOTHERAPY

DISASTER MENTAL HEALTH SERVICE GOALS AND CONCEPTS

The goals of disaster mental health services are to identify disaster-related mental health problems, to educate the community about disaster mental health reactions, and to mitigate psychological reactions to disasters. Disaster mental health services have specific concepts of service delivery that are central to their accessibility and effectiveness in the community.

The first concept is that disaster victims are, for the most part, normal people experiencing normal reactions to an abnormal event. They are usually not suffering from mental disorders. Likewise, they usually do not seek out mental health services following disasters. For many people in the community, there is still a stigma attached to the concept of mental health intervention. Following disasters, most people experience brief stress reactions or increased stress associated with disaster; they do not view themselves or their family members as having a mental illness needing assessment or psychotherapy at a mental health clinic. Although most people do not seek out mental health services, they are usually receptive to information and education about disaster stress reactions, stress management and coping techniques, and crisis counseling services. Disaster mental health services are provided to people in their natural environment, disaster-impacted neighborhoods, homes, workplaces, supermarkets, lines, neighborhoods, shelters, encampments, meal sites, on-scene at damaged or destroyed buildings, service centers, family assistance centers, respite centers, food distribution centers, schools, religious centers, community centers, emergency operations centers, emergency services facilities, emergency services staging areas, first aid sites, hospitals, emergency rooms, casualty collection points, the morgue, and, rarely, at mental health centers.

The second concept is that it is helpful for disaster mental health programs to have names and an identification that is culturally and socially acceptable to the community impacted by the disaster. Disaster mental health programs historically have avoided names with the words “mental health” in the title or name of the program. Names such as “Project COPE” (Counseling Ordinary People in Emergencies), Project Rainbow (a flood recovery mental health program), Project Heartland (the Oklahoma City Bombing Crisis Counseling Program), or Project Liberty (New York City’s Crisis Counseling Program following the September 11, 2001, terrorist attacks) are examples. The American Red Cross, on the other hand, is quite straightforward in using Disaster Mental Health (DMH) as the name of their mental health service function. Leaders in the Red Cross DMH function believe that the stigma sometimes attached to mental health services following disaster, and avoidance of these services, are diminishing, and that disaster victims are coming to accept DMH services as important disaster resources.

The third concept is that services and programs must be creative and innovative in providing services. Disaster survivors may be overwhelmed with the demands of the postdisaster environment. Traditional “talk therapy” may not be high on their list of priorities for how to use their time. Combining disaster recovery services with disaster mental health services provides the disaster survivor with information and resources critical to their recovery as well as information and educational material that can help with disaster-related psychological reactions.

The fourth concept is that a disaster mental health program must have community acceptance and support. This involves developing partnerships, collaborations, and coordination of services before, during, and after a disaster strikes. Disaster mental health programs and established community institutions can partner to provide services. This type of partnering builds upon the existing long-term relationships among the community institutions. Disaster mental health programs must also be culturally competent, providing services that are culturally relevant in the languages that are used in the community.

Confidentiality is also important in providing disaster mental health services. Confidentiality is a right that is held by the client, and it involves maintaining information concerning the client’s identity and information about the services they receive. Confidential information should not be disclosed to any third party without permission of the individual.

Disaster mental health programs following disasters focus on education, information, assistance with resources, and crisis intervention. Citizens experiencing reactions that are more intense, severe, and disabling may need referral to a higher level of care, including psychotherapy and contemporary trauma therapies. Thus, an important role of disaster mental health programs is to identify and refer those individuals who need or would benefit from psychotherapy.

The destruction that is caused directly and indirectly by disasters leads to complex human and community needs. Disaster mental health services must be based on a comprehensive, integrated multiservice model to effectively address the wide range of community needs. The CODE-C DMHSM is presented here to assist in the assessment, development, and provision of disaster mental health services.

RATIONALE FOR THE CODE-C DMHSM

The CODE-C DMHSM was developed by David Wee, Diane Myers, and Leonard Zunin in 1992 during disaster recovery activities following Hurricane Andrew. It is a tool that can be used to develop comprehensive disaster mental health programs that are specific, appropriate, and effective. The model promotes the development, identification, and standardization of core service components that are essential in disaster mental health programs and disaster worker stress management programs. The definition of a service model and designation of its name facilitates communication between emergency planners and responders by identifying and defini...