Chapter 17
Defining Principles of a Crisis
Intervention Ecosystem
Coming to grips with complex ecosystem service delivery issues is daunting, to say the least. However, Conyne and Cook (2003) and Norris and her associates (2006) have generated the following principles for doing so.
1. Systems must be interdisciplinary. No single discipline or “ology” has a corner on this market. Emergency management agencies and crisis intervention systems must rely on a broad spectrum of people, ranging from sanitation workers and electrical linemen to civil and logistical engineers to medical emergency staff and communication workers to law enforcement and fire and rescue personnel to sociologists and psychologists to bankers and economists to ministers and social workers. Further, all of the people in these skills, crafts, trades, and professions must work in an integrated manner. The competent crisis worker integrates seamlessly into this smorgasbord of “ologies”; the pretentiousness sometimes associated with a college degree and the egotism of a particular profession have no place in an ecosystemic crisis. Ecosystemic crisis intervention is the most egalitarian of all mental health endeavors, and lay-person volunteers may be just as effective as psychiatrists. Anyone with an inflated ego will soon be humbled in a large crisis.
2. The system must be multi-theoretical. If we look at only the psychological component of wide-scale crises, no single psychological theory is presently adequate to deal with the complex swirl of human dynamics that comes out of a crisis. It should be stated absolutely and unequivocally that nobody has a theoretical corner on this market. That includes proselytizers for any of the “alphabet” techniques such as CISD, EMDR, TFT, or, alternatively, those who would rail against them. It especially includes the authors of this book! When dealing with large-scale crises or megacrises, psychological theory must at the very least harmonize with logistics, medical, communications, economic, and political theory. To further complicate matters, it is not just which psychological theories and techniques are used, but also when and how those services are delivered.
3. Individuals are part of the ecosystem. Like it or not, unless we can somehow find a place in the desert or mountains to become hermits, we are part of the total ecosystem of the world. Our biological makeup, interpersonal relationships, physical environment, and sociological context are all becoming more tightly interwoven into the total ecosystem of the world.
4. Multiple contexts must be considered. Micro–, meso–, exo-, and macrosystems are all components of the total ecological system that impact the individual when a megacrisis occurs. To deny that these systems are vectors and forces that impinge on the individual is to have a very parochial view of what this business is about and is to be doomed to fail
.
5. Time is of the essence. If we believe any of the PTSD research about the deleterious effects the passage of time has on the individual if nothing is done to alleviate the possible effects of the trauma, we need to understand that what occurs in the chronosystem is critical. The availability of adequate physical and psychological resources to deal with a crisis in a timely manner is paramount.
6. Meaning is important. What sense we make of the crisis from a broad systemic view is as important as what sense we make of it individually and has much to do with how quickly and effectively it is resolved for both individuals and society.
7. Parsimonious interventions are needed. Concordance and coordination within various systems are needed if large amounts of precious time and energy are not to be wasted. At the federal level, sufficient funding and information resources must be generated and disseminated. At the state level, preparedness plans should address multiple levels of the response across relevant jurisdictions, which includes clear plans on how the state agencies will communicate with the public and providers. Optimal utilization of resources is critical, and collaborative relationships and understanding between agencies need to be formed in advance. Intervention in large-scale crises is extremely expensive in terms of personal power and material resources. One of the major balancing acts of local EMAs is to have just enough resources available to bring maximum effort to bear at just the right time to experience maximum effect.
8. The process is cooperative, collaborative, and consultative. Just as no single discipline holds sway in a large-scale crisis or mega-crisis, cooperation, collaboration, and consultation within, among, and between systems and individuals are paramount. The provision of mental health services is important, but so are getting communication and power systems back on and determining where there is available shelter and whether buildings are safe.
9. There is a full range of targeted interventions aimed at individuals, institutions, communities, on up to the national level, depending on how widespread the crisis is, and they are ongoing in response to longer-term needs. Each involved system component, from the individual to the nation, needs to be triaged. Based on that assessment, target-specific interventions need to be made. How things will wind up after a disaster is not just determined in the days after it, but in the months after it. The infrastructure, and community as the client is as important to long-range as individuals.
10. The service characteristics of credibility, acceptability, accessibility, proactivity, continuance, and confidentiality should be adopted as “cast in stone” goals for service delivery in disaster-stricken areas. Norris and her associates (2006) found adherence to these characteristics to be one of the most impressive of her findings of the 9/11 response in New York City. Meeting this gold standard of service delivery most likely means that the whole disaster mesosystem is integrated with host systems and running well. To do that effectively requires a variety of organizations and individuals who operate with a high level of cooperation to make that system work.
Overarching all of the foregoing points are planning, more planning, practicing, critiquing, evaluating, and yet more planning. The necessity for vertical and horizontal links in the ecosystem of disaster planning cannot be overemphasized. The result of not having such links became clearly evident after Hurricane Katrina. One of the critical components to planning is making sure that disaster mental health planning and activities do not take a backseat to security and safety concerns; people who can make clear decisions must be in place and have the authority to make those decisions (Flynn, 2003). That issue became abundantly clear in the aftermath of Katrina, with local and state leaders bickering about plans that should have been carved in stone long before the hurricane made land- fall (Flynn, 2003; Gheytanchi et al., 2007).
National Crisis Response Teams
Perhaps the most important outreach approach has been taken by national agencies in the on-site delivery of mental health services during major disasters and the coordination of these services with other relief efforts. Because of past criticism of how both charitable and federal agencies have handled major disasters, those agencies have done a great deal of work to better coordinate their efforts in providing comprehensive disaster relief that cuts across the survivors’ total environment (Bass & Yep, 2002; Pyszczynski, Solomon, & Greenberg, 2002; Smith, 2002). Mental health support does little good when people don’t have a roof over their heads because it has been blown away in a hurricane. However, it also does little good for survivors to obtain housing but be so traumatized and depressed from the disaster that they cannot begin to regain control over their lives. From plane crashes to university campus shootings, to floods, to post office shootings, to forest fires, to train wrecks, to building bombings, to earthquakes, to school shootings, and to 9/11, some of the most potent and appropriate examples of the ecological nature of crisis intervention have occurred in the United States in the last 10 years, as has a large mobilization, training, and response effort to provide emergency mental health services to victims and survivors of any type of imaginable disaster.
An enormous number of mental health workers from throughout the country, working under the auspices of the American Red Cross, NOVA, FEMA, and state and local EMAs, and supported by the major professional mental health organizations in the United States, have contributed monumental services to the thousands of clients affected by those disasters (Bass & Yep, 2002; Gladding, 2002; Hayes, 2002; Juhnke, 2002; McCarthy, 2002; Modrak, 1992; Morrissey, 1995; Pyszczynski, Solomon, & Greenberg, 2002; Riethmayer, 2002a, 2002b; Smith, 2002; Sullivan, 2002; Underwood & Clark, 2002). Among the comments of hundreds, perhaps thousands, of mental health work- ers over dozens of major crises, the following is perhaps both descriptive and representative:
In that capacity, I was an escort who walked with families from the front of the building to the back and talked with them about what they were feeling, what they had felt, or what they anticipated doing in regard to the emotions that would be coming. I also accompanied families to Ground Zero so they could see for themselves the horror and finality of the event. The view from the site helped many individuals begin the process of grieving in-depth, as they realized in a stark and striking way that those they had loved and cherished in so many ways were indeed dead and would not be coming back to be with them. (Gladding, 2002, p. 7)
Development of Crisis Response Teams (CRTs). The Oklahoma City federal building bombing, the shootings at Columbine High School and Sandy Hook Elementary School, and the 9/11 attacks struck a nerve in the United States. The massive amounts of media coverage of those traumatic experiences and the disaster relief that followed in their wake brought graphic attention to how disasters are handled, including the work of immediate follow-up rapid response teams. These teams did not just spring up full grown at the time of those disasters. Rather, throughout the late 1980s and 1990s, rapid response teams were developed to handle numerous tragedies and disasters, including hurricanes (Shelby & Tredinnick, 1995), serial murders (Wakelee-Lynch, 1990), plane crashes (Modrak, 1992; Shafer, 1989a), bank robberies and hijackings (Brom & Kleber, 1989), campus shootings (Guerra, 1999; Guerra & Schmitt, 1999; Sleek, 1998), and train explosions and post office shootings (National Organization for Victim Assistance, n.d.).
National Organization for Victim Assistance (NOVA) CRTs. The rapid crisis response team movement re- received impetus and support on a national level with the establishment of the National Crisis Response Project by the National Organization for Victim Assistance (NOVA) in the late 1980s (Young, 1991). Originally established to help victims of crime, NOVA, a private, not-for-profit organization, has branched out to offer help to victims of all kinds of disasters through the National Crisis Response Project. It has state and local affiliates throughout the United States. The project set up national crisis response teams (NCRTs) to assist communities following community-wide crises or disasters. One of the first major organized national responses of an NCRT for the specific purpose of providing mental health assistance was on August 20, 1986, when an Edmond, Oklahoma, postal worker shot and killed 14 coworkers and himself.
The main objective of an NCRT in dealing with a local community disaster is to form local crisis response teams that are in a position to deal with the community’s grief reactions, stress effects, and posttraumatic stress disorder resulting from the disaster. According to Young (1991), the “project is based on the premise that disasters can cause individual and community-wide crisis reactions and that immediate intervention can provide communities with tools that are useful in mitigating long-term distress” (pp. 83–84).
NCRTs are dispatched at the request of leaders in the affected community. “When a disaster occurs, NOVA is placed in contact with the community in one of two ways: either the community calls NOVA, or NOVA, on hearing of the tragedy, calls the community and offers assistance” (Young, 1991, p. 95). Three types of disaster service are available: (1) providing written material giving details on how to deal with the aftermath of a disaster; (2) providing telephone consultation to leading caregivers in the area affected; and (3) sending in a trained team of volunteer crisis workers to assist the community.
The Red Cross. The American Red Cross, like its Red Cross and Red Crescent counterparts around the world, is tasked with dealing with all kinds of disasters. Founded by Clara Barton, the American Red Cross has been in business for about 120 years. It is a private organization that has close ties with local, state, and federal governments. It helped the federal government start the Federal Emergency Management Agency. It is a major contributor to crisis intervention in the wake of large-scale disasters and megadisasters through its training of mental health professionals as members of rapid response teams
(Red Cross, 2015). Professional organizations in counseling, psychology, and social work are closely linked with and provide candidates for its mental health training program.
Federal Emergency Management Agency (FEMA) and the National Institute of Mental Health (NIMH). FEMA was born in 1979 as the result of complaints about federal agencies’ slowness, bureaucratic red tape, inefficiency, ineptitude, and duplication of effort in responding to a disaster. Several different agencies were merged into FEMA, and it is now housed in the Department of Homeland Security. FEMA has numerous responsibilities. Among them are education about all kinds of disaster preparedness and coordination between federal, state, and local emergency management agencies in regard to preparedness, training, and disaster mitigation. It provides disaster assistance that ranges from debris removal and rescue efforts to disaster loans for rebuilding and on-site mental health crisis response teams. Its Emergency Management Institute at Emmitsburg, Maryland, is a virtual university of emergency preparedness courses. Courses range from training community emergency response teams (CERTS), made up of ordinary local citizen volunteers who provide support to first responders to aid in rescue efforts, to colloquiums with state mental health service providers on the latest techniques for providing mental health services after a large-scale disaster (Federal Emergency Management Agency, 2015).
Sometimes more than one agency of the federal government coordinates the work of crisis response teams. Several instances of events during modern times that triggered such a coordinated effort were the earthquakes in both the Los Angeles and San Francisco areas; hurricanes Hugo, Andrew, Floyd, and Katrina that brought devastation and flooding to large parts of the southeastern United States; the nuclear accident at Three Mile Island; and the Love Canal contamination. The response teams were sent in by the National Institute of Mental Health (NIMH) and sponsored and funded by FEMA. In all such natural disasters, FEMA and NIMH provide the widely affected areas with instruction, consultation, and expertise in developing local and regional support systems to cope with the enormous aftermath of these disasters (Shafer, 1989b).
Professional Organizations. Professional organizations, such as the American Psychiatric Association, the American Psychological Association, the American Counseling Association, and the National Association of Social Workers, provide volunteers for the Red Cross and NOVA CRTs. These organizations also provide a variety of publications for both professionals and laypersons that can be obtained on their websites or ordered from them. Their conferences and conventions provide formats for discussion and dissemination of the theory and practice of crisis intervention.
The American School Counseling Association and the National Association of School Psychologists are involved in providing crisis intervention services to schoolchildren and adolescents in the face of a large-scale disaster. As an example, on April 19, 1995, immediately after the Oklahoma City federal building bombing, an American Counseling Association team of Oklahoma school counselors and an art teacher wrote and illustrated The Terrible, Scary Explosion. This book, modeled after one written for children after hurricane Hugo in South Carolina, was in the hands of Oklahoma City schoolchildren by April 25, with local school counselors serving as facilitators. The purpose of the book was to help children of all ages process the whole incident and provide a tool to help adults help children (Morrissey, 1995).
The National Association of School Psychologists has national emergency assistance teams (NEATs), which are tied in with NOVA. The mission of NEAT is to develop policies and procedures, disseminate in-formation, provide consultation, and facilitate the training of school-based crisis teams in response to significant emergencies affecting children and adolescents. These NEAT teams go to the scene of school disasters and provide support for local agencies. They are composed of nationally certified school psychologists who have expertise in crisis prevention, intervention, and postvention. The intention of the NEAT team is to help save lives, reduce trauma and injury, facilitate the psychological well-being of students and staff, and allow schools to return to regular activities as soon as possible (Zenere, 1998).
Constructing an Outreach Team. Depending on the nature of the crisis and the ecological setting, out- reach teams generally have a diverse occupational range: from psychiatric nurses, paramedics, emergency workers, and psychiatrists to social workers, volunteers, rehabilitation counselors, police officers, and psychologists. These outreach teams are characterized by their multidisciplinary team approach, strong social and community networks, user participation in policy and service delivery, and egalitarianism in the workplace (Gulati & Guest, 1990). Alise Bartley, a private practice licensed professional counselor, describes her experience as a volunteer worker following Hurricane Katrina. Based in Gulfport, Mississippi, she slept in a large Navy Seabee storage facility with 600 other volunteers. She slept two feet from a retired nurse on one side and a Vietnam veteran on the other, both of whom she had just met for the first time in her life (Kennedy, 2007).
Integrative-collaborative teams have a distinctive operational setup and are characteristic of many geo-graphical areas where financial and human resources are not sufficient to form freestanding, specialized crisis units. They are not an ad hoc group collected after a crisis but rather are trained prior to the crisis. Each member has different skills that, combined, allow the team to respond to a variety of crisis situations. They operate much as a volunteer fire department does. Members typically have primary jobs in other settings, but when a crisis call comes in on a hotline, they immediately leave their regular jobs, form a crisis team, and go to the crisis site. They are identifiable within the community as the crisis response team and are a cost-efficient and effective way to provide generic crisis intervention (Silver & Goldstein, 1992).
Vertically and Horizontally Integrated Local Emergency Management Systems
Overarching all local agencies involved in a crisis after a disaster are the local emergency management agencies. They are the offspring of the old Civil Defense system of the Cold War. The examples that follow refer to Florida, where each local agency is directly linked to one of seven regional areas, and Illinois, where there are eight regions linked to the state emergency management agency. In turn, the state agency is linked to FEMA (Freeman, 2003; Lane, 2003).
Role of Local EMA Directors. Jerry Lane and Nancy Freeman are two public servants whose lives have been anything but simple. They both run local emergency management agencies.
Jerry was executive director for the Dekalb County, Illinois, Community Mental Health Board and director of the Sycamore, Illinois, Emergency Management Agency. Sycamore is a small town in northern Illinois, located on rolling farmland about 60 miles west of Chicago. It is not famous or notorious for much of anything. However, it does have grain elevators and agricultural chemical warehouse fires, tornadoes, straight-line windstorms, blizzards, and flooding.
But does it really need an emergency management system and a local manager? Listen to Greg Brown, former director of EMT services in White County, Illinois, and chemical mixing and applications supervisor for Brown Feed and Chemical in Carmi, Illinois. “If you want to talk about the potential for terrorism or accidental disaster, talk about what we have in this warehouse. We easily have enough agricultural chemicals, if used with malice or handled incorrectly, to kill everybody in this town twice over and have some left to spare. You’d better have somebody around who knows what to do with them, and that would apply to about every town in the country that has an agricultural base” (G. Brown, personal communication, December 15, 2004).
For Jerry Lane, living in a small town that may need his skills is the greatest reward of the job. His agency’s problems were those of most beginning crisis agencies: inadequate funding, little respect, and a whole lot of politics. Many emergency management jobs were filled by patronage seekers, which may satisfy the needs of a political party but will probably leave a lot to be desired when the crisis starts—as evidenced at the national level with Hurricane Katrina. Listen to the comment of a county commissioner in White County, Illinois, about the volunteer EMT program that was asking for an increase in funds from the county board: “Why, they could train a monkey to do that job! Why do they need to be paid anymore?” We certainly hope that commissioner doesn’t have a heart attack “way out there on Possum Road” because we doubt whether a chimpanzee could make the drive in an ambulance and keep him alive long enough until a life flight arrived, piloted by—we would guess—a baboon.
Although you may consider the commissioner’s comment outrageous and patently stupid, this is not an atypical response to any new upstart agency that deals in crisis. Until it becomes politically necessary, little government funding is forthcoming to support crisis intervention programs. Certainly, 9/11 and Hurricane Katrina put a new perspective on the need for local emergency management agencies and competent people to run them.
Nancy Freeman is a retired deputy director of the Nassau County, Florida, Emergency Management Agency. Nassau County is next to Jacksonville, Florida. Nancy got into the emergency management business doing research analysis for hazard mitigation while she was a graduate assistant at the University of North Florida. While doing research for various coun- ties in north Florida, she learned enough about the business of emergency management that she applied for a job with one of the counties and got it! Besides being adjacent to a large urban population—with all of its potential hazards for disaster—Nassau County is situated on the shore of the Atlantic Ocean, with all of the hurricane risks attendant to that locale. To add a little more to the hazardous, potential-for-disaster mix, the county also has military facilities with nuclear capabilities. Suffice it to say that the Nassau County EMA is very, very interested in hurricanes and their potential effects under a variety of conditions.
Nancy’s world is defined by the term networking and, as is true for most emergency managers, it is a double-edged sword. On the one hand, Nancy sees networking with a variety of very committed professionals as one of the most rewarding parts of her job. On the other hand, when egos, turf guarding, and politics get involved, it can be one of her major headaches.
These managers are a new breed of technocrat that is being placed in charge of coordinating a welter of activities, agencies, and logistical problems in regard to managing every conceivable emergency you might imagine and then some. If you’d like a job like this, you had better be good with acronyms and know what they stand for. Want to be able to do a HHVA (hospital hazard vulnerability analysis) or get a RACES (radio amateur civil emergency system) up and running? Curious to know what the difference between cold, warm, and hot zones are, or whether you need a Level A protection suit when you venture into one of them? Does that sound like an interesting job? Think you’d like to do that?
Background and Training. What are the qualifications? you may ask. What university do I need to attend to major in that “stuff”? The answer to that question now is, “About any place in the world!” Specifically in regard to mental health crisis intervention, the University of South Dakota had established the first doctoral program with a specialty track in clinical/disaster psychology. Now, if you go to www .chds.us/?partners/institutions, which is the website for the Center for Homeland Defense and Security (2015), you will find 477 programs that range across associate, bachelor’s, master’s, doctorate, and certification programs in just about any type of emergency management program with any type of focus you can imagine. You should understand that the content of these degrees varies quite a bit because as of yet there is no clear consensus on what all that “stuff” should be.
If you sought to earn an interdisciplinary bachelor’s degree with a major in emergency management from Western Carolina University, for example, your courses could range from International Terrorism to Crisis Communications to the Politics of Budgeting (Western Carolina University Emergency Management Institute, 2015).
However, as Nancy Freeman (2003) says, “My bachelor’s degree and graduate work is in the humanities, with an emphasis in interior design, history, and historic preservation, and you wouldn’t think that would be anything like what you’d need for this job, but I learned about architecture in that program, and I can read a building plan and know what ‘load bearings under initial impact’ means, and that is critically important when we are designing evacuation and safety plans. I also know how to do research and that is critically important in this job.”
Jerry Lane holds a master’s degree in community mental health. Jerry sort of wandered into this business by being an amateur radio operator and weather spotter. As Jerry says, “I’m kind of a rare breed. Most emergency managers don’t have a mental health background. They tend to be retired military and have a pretty good handle on how to handle logistics problems, which is indeed important in this job” (Lane, 2003).
Both of these directors have taken many courses through the Federal Emergency Management Association’s Emergency Management Institute, which has a campus in Emmitsburg, Maryland, and various correspondence and Internet courses. Besides critical incident stress debriefing and PTSD training, you might also be required to take Preparedness Planning in a Nuclear Crisis, Mortuary Services in Emergency Management, Hazardous Materials Basic Awareness, and Executive Analysis of Fire Service Organization and Emergency Management. If you are getting the idea that you had better be a Jack or Jill of all trades and a master of many, you are right!
There is a national certification process and an international association of emergency managers. In Florida, emergency managers must be certified through a combination of coursework, training, and work experience. They must also take 150 hours of education courses every 4 years to retain their certification. There is continuous ongoing training in management tools resources, new technology, and communications. There are two annual conferences managers are expected to attend, one of which covers general emergency preparedness. Lots of training exercises are developed at the national and state levels and then are brought down to the local level to be used in training exercises (Freeman, 2003). Still interested in this job?
What Do Emergency Managers Do? Certainly, disasters don’t happen every day. Does that mean that emergency managers sit around playing pinochle, drinking coffee, eating doughnuts, pitching horseshoes, and polishing the fire engine, waiting for something to happen? Local EMAs are in the business of preparing for, preventing, intervening in, and mitigating the effects of any and all kinds of disasters. To do that takes a great deal of planning and coordinating. Direct your attention to the matrix of city and county agencies and the support functions they engage in as primary or secondary supports in a disaster (see Figure 17.3). While you might think of roads, bridges, potable water, and sewage disposal as being critical, the last thing you might think of would be animal issues. But if you had severe flooding after a hurricane, animals—both alive and dead—would be a very real problem.
Planning for Disasters. There are two types of disasters: those that have prior warning time and those that do not. As a result, local EMAs have various disaster plans that are implemented in stages. Although there might be a very little warning in the case of a tornado or a chemical spill from a derailed train, hurricanes and forest fires generally do have a lead time for preparation. Nassau County has a very complex and lengthy hurricane plan that is divided into 10 stages. A brief description of those stages follows to give you an idea of just how involved this business is (Nassau County Emergency Management Department, 2003). For each stage, a particular action is noted and the re- sponsible section is designated to implement it. Those sections are emergency operation center (EOC) command, planning, logistics, operations, administration, recovery task force, and elected policy makers.
Awareness stage. 72–60 hours Estimated Land Fall (ELF) of hurricane. Activate emergency command center. Establish liaison with the National Weather Service, state department of emergency management, surrounding counties, media, utility services, law enforcement, and fire agencies. Conduct vulnerability analysis. Activate alert phone system. Prepare primary evacuation routes. Notify all gas and diesel wholesalers
to restock retail outlets within 12–24 hours. Test EOC
communications equipment.
Standby stage. 60–48 hours ELF. Activate emergency broadcast system. Notify amateur radio group to go on standby. Use local media and National Weather Service bulletins to advise boat owners, homeowners, drawbridge operators, and motel and hotel managers, and detail causeway and bridge closings and evacuation routes. Coordinate establishment of emergency worker shelters. Secure EMS ambulances, transport vehicles, oil spill trailers, and heavy equipment.
Decision stage. 48–45 ELF. Activate traffic control plan and emergency transport plan. Declare state of emergency and activate county emergency plan. Recommend/ order evacuation. Designate nonessential businesses to close. Coordinate decision-making actions and link all municipalities, law enforcement agencies, fire districts, utility companies, hospitals, and medical care facilities with State Division of Emergency Management and the National Hurricane Center.
Preparation stage. 45–36 ELF. Begin implementing evacuation plans for “at risk” populations such as mobile homes, people with special needs, tourists, campers, people without transportation, and low-lying areas. Activate all EOC communication systems. Announce public closings. Implement 24-hour operation of fleet management garage and fueling resources. Activate emergency transportation plan. Prepare shelters for opening.
Evacuation stage. 36–4 ELF. Issue evacuation orders. Identify areas at risk. Announce shelter openings and transportation pickup points. Request National Weather Service to broadcast information on road closures. Activate/coordinate shutdown of electric power services. Maintain communications with public shelters, emergency worker family shelters, special care centers, emergency transportation, area hospitals, animal emergency care facilities, power, water, sewage, utilities, fire districts, law enforcement, and public works. Begin preplanning post storm activities.
Storm/emergency stage. Monitor storm/emergency characteristics. Continue preplanning post storm activities. Continue communications with other agencies.
Immediate emergency stage. Commence local emergency response activities. Determine long-term human service needs, including mental health care counseling. Determine information and referral services. Assess temporary housing needs. Distribute resources: food, water, clothing, and cleanup kits. Activate recovery task force and review damage reports. Recommend implementation of appropriate moratoriums and adoption of emergency resolutions and ordinances. Determine if curfew is needed. Activate Damage Assessment Teams. Monitor public health conditions.
Evaluation stage. Determine if primary threat still exists. Conduct/coordinate initial impact assessment effort. Reaffirm and/or reestablish communications with all shelters, hospitals, towns, state emergency operations, law enforcement, public works, fire districts, and surrounding counties. Enact emergency resolutions. Determine initial mutual
aid requirements and request assistance from state EOC. Discuss emergency ordinances to be enacted. Issue news media releases. Establish times for briefings/planning meetings. Report accidents to date and update status. Assess damage to areas with existing or potential hazardous materials. Summarize current operational activities underway. Discuss current strategy. Review human resource needs. Determine additional resources needed. Implement rest and rotation policies for emergency workers. Assess logistics of transportation routes opened, distribution sites, feeding procedures, and available sleeping facilities.
Reconstruction stage. Perform long-term activities or projects focused on improving or strengthening community’s economy. Complete restoration of services. Dispose of debris and allocate resources to cleanup chores. Focus on community recovery planning, building and construction issues, and environmental/ecological issues. Continue/complete human services delivery assistance of information and referral, resource distribution, health care delivery, mental health care counseling, and transportation assistance. Complete activities for presidential disaster declaration. Perform hazard mitigation projects to reduce community’s susceptibility and vulnerability to hurricanes. Repair, replace, modify, or relocate public facilities in hazard-prone areas.
Restoration stage. Perform assessment of community needs and economic damage. Address the following restoration issues: economic and job base assessment, community recovery planning, building and construction issues, public information and citizen
outreach, and environmental issues and ecological concerns. Provide health care delivery for both pre- and postdisaster needs, including home health-care management and case referral. Put mental health care counseling into operation. Determine victims’ counseling needs by triage assessment. Determine training needs for mental health professions on disaster-related issues. Place mental health professions/ CISD team members on community assessment teams. Determine where counseling services will operate. Determine transportation needs to public feeding sites, shelters, and disaster service sites. Reestablish and implement public transportation service. Chore service needs assessment for cleanup. Determine needs and coordinate with volunteer groups for debris cleanup, interior home cleanup, window repair, etc. Coordinate with FEMA to set up Disaster Field Office and Disaster Application Centers. Assist in establishing temporary housing sites. Establish a federal public assistance office to coordinate all disaster relief efforts to clients. Participate in interagency hazard mitigation team and hazard mitigation survey activities. Complete after- evacuation report and county incident report. Critique the management of the storm emergency.
Throughout the unfolding stages of the disaster, constant needs assessment should occur. A community mental health needs assessment formula (Flynn, 2003, p. 23) that constantly updates the dead, hospitalized, nonhospitalized injured, homes destroyed, homes with major and minor damage, unemployed due to job loss, and other losses will give a good indication of the potential numbers of people in need of crisis counsel- ing services. The same community-wide assessment should continuously occur in regard to mental health (Katz, 2011). Nancy Freeman was asked when she would know that the crisis is over. She stated, tongue in cheek, that she’d know because no one had called and everyone had found his or her dog and Aunt Nellie. In reality, the immediate crisis is considered passed when everyone’s safety is assured from any effects of the di- saster, public works are back in operation, and services are returning to normal. That’s when the EOC can get a doughnut and some sleep!
The foregoing plan for hurricanes can be adapted to any kind of disaster, whether natural or human- made. While timelines may be very compressed or in some instances operations may start at the emergency stage, the format is replicable with just about any kind of community-wide crisis. Although local EMAs have very little preparation time for other types of disas- ters, they do not stand idly by waiting for something to happen. Continuous interagency tabletop exer- cises give them practice in responding to a variety of potential disasters. Assessment of particularly vital and vulnerable public sites, ranging from water treat- ment plants to nursing homes, is made to determine what needs and weak points there may be. Jerry Lane spends a fair amount of time working with individual agencies to develop their own internal disaster plans to fit with the overall one that the local EMA has.
Mental Health Components of Local EMAs
Any local mental health clinic should have a prototype disaster response plan (Lane, 2003). While each community will have variations due to its own particular regional and state systems of men- tal health delivery, geographic locale, and popula- tion differences, they should generally follow along with what Hartsough (1982) has outlined for mental health agencies’ typical response to a disaster.
The following points are abstracted from Hartsough (1982) and Lane (2003). First of all, the centers must have a plan that assumes that they may be victims themselves and have breakdowns in com- munications; loss of or inability to find staff; loss of equipment, supplies, and records; inability of staff to cope with loss; and problems recognizing their functional limits. The mental health center must be prepared to provide services in two situations—a lo- calized but traumatic event and a large-scale disas- ter. A localized event can be responded to without affecting operations to any great degree. A disaster will most likely disrupt operations to some degree, while drastically increasing the demand for services. A clear chain of command with redundancy features is mandatory. There should be an assessment of population groups in the area with regard to high- risk groups such as children, non-English-speaking, elderly, and low socioeconomic groups. Interagency cooperative agreements should be made. A specific mental health liaison person should be named to the local EOC.
Predisaster training encompasses development of outreach programs that target “normal people acting normally in an abnormal situation.” Training spe- cifically targets practitioners who have not had for- mal training in outreach or who historically perform poorly when they have to rely on their formal train- ing. Consideration should be given to sending local clinicians to Red Cross training. Drills and tabletop exercises should be developed and conducted in coor- dination with the local EOC.
Personnel. Volunteers who would function as reserve crisis counselors should be recruited and trained in crisis intervention skills. Specified workers should be selected for multidisciplinary crisis response teams. A chief of operations should be nominated and will be the individual actually running the disaster response. There should also be an emergency preparedness coordinator who will be responsible for planning and preparation prior to a disaster and will function as a consultant to the chief of operations during an actual emergency. This person will be the liaison to the local EOC.
An outside clinical consultant should be retained to assess the physical and mental condition of the staff. A command-and-control and communications center should be established and staffed by a team leader and other staff necessary for it to function ef- fectively. A historian should keep an ongoing journal of activities that occur as a result of the disaster. The decisions, events, problems, and information should include details, names and addresses, times, and is- sues that can later be used for debriefings, psychologi- cal autopsies, system improvements, grant requests, or reimbursement.
A personnel liaison will assist the chief of oper- ations in assessing, making, and tracking staff and volunteer assignments. A media/information liaison will provide information to the media and local gov- ernment, develop press releases, and distribute gen- eral information regarding service delivery. Staff may be made available to the local EOC to provide psycho- logical support.
Transdisaster (0–14 Days). The mental health unit needs to initiate immediate mental health services when the disaster occurs; restore services to clients served during normal times; act as the disaster mental health advisor to the local government; provide out- reach programs and coordinate resources for the de- livery of disaster mental health services from the Red Cross, NOVA, FEMA, and other religious and philan- thropic organizations; coordinate the responses of any contractors for services with particular emphasis on evacuation of residential facilities; target specific areas, such as evacuation centers, emergency relief centers, and FEMA “one-stop” service centers; provide support services for disaster workers; and assist with mental health emergencies in hospitals with victims requiring medical or psychiatric care.
Postdisaster (15–365 Days). Evaluate and assess the need for postdisaster services; implement prepared
immediate services grant and prepare regular services grant if a presidential disaster is declared; establish linkages with American Red Cross mental health workers to hand off clients requiring longer-term care; monitor for long-term psychological effects; educate the public regarding disaster-related psycho- logical phenomena; evaluate program response, both short and long term; perform psychological autopsy on total crisis response and debrief workers.
In the foregoing sections of this chapter you have read about the overall composition of disaster plan- ning and infrastructure. In an ideal world, even in a world of disasters, all of this runs smoothly. While 9/11 certainly had its share of chaos and confusion (Halpern & Tramontin, 2007, pp. 171–197; Kaul & Welzant, 2005; Norris et al., 2006), order came out of that maelstrom fairly quickly, and everybody thought they had learned a lot of lessons. Then along came hurricane Katrina and everything got turned upside down.
What Happened with Katrina?
In any disaster there is invariably an attempt to fix blame. If blame can be fixed, then people may start to believe that the impossible, out-of-control, insane, unbelievable, chaotic, and unfathomable event can be contained, made sense of as to the reasons it oc- curred, and a sense of control regained as to what went wrong and how it can be made right the next time. In that sense hurricane Katrina is no different from mul- titudes of other natural disasters that have hit other countries. Indeed, in comparison to typhoons and earthquakes that have plagued Asia and the Middle East, it is a relatively small event, and certainly so in regard to loss of life. Yet the recriminations from hur- ricane Katrina are unending and rub raw nerves from the standpoints of socioeconomic, racial, political, and even interstate rivalries. While it is expected, rightly or wrongly, that there will be disasters in countries like Bangladesh, it “cannot happen” in the United States. We pride ourselves on controlling our destiny through science and industry, up to and including controlling nature. After Katrina, apparently not!
This is not an exposition about who’s to blame or what’s to blame. The emerging facts suggest that there is plenty of blame to pass around and share. However, what Anahita Gheytanchi and her associates (2007) have compiled is worth reporting as a way of looking at how the various systems within a disaster ecosystem operate, or in the case of hurricane Katrina . . . don’t! Gheytanchi and her associates report 12 key failures of response.
1. Lack of efficient communication. The sine qua non of disaster mitigation is communication. Both within and between the primary and super me- sosystems, communication failed. At least four separate command structures were operating in Katrina’s aftermath: two command structures in FEMA and two military command structures. That’s at least two too many and resulted in crossed communications, duplicated or incomplete efforts, and generally clouded decision-making.
2. Poor coordination plans. Coordination is about moving assets to where they are most needed. The inability to coordinate relief efforts ranged from not utilizing one of the finest hospital ships in the world, the USS Bataan, which sat idly offshore, to an inability of FEMA to find buses and drivers and move people out of the Superdome, to hundreds of trucks filled with ice sitting idly in Memphis freight yards with no place to go, to thousands of house trailers sitting in Arkansas when they were desperately needed in Mississippi and Louisiana.
3. Ambiguous authority relationships. The Department of Homeland Security remained on a “pull” basis, which means that the state had to request federal assets, rather than a “push” basis, which means that assets would be immediately made available to the state. The National Response Plan Cata- strophic Incident Annex (NPR-CIA) should have been invoked prior to landfall, but in fact was never invoked. The prevarication and waffling by Louisiana state and local governments on instituting mandatory evacuation because of the cost, even though they were getting intense pressure from federal authorities to do so, caused severe problems that culminated in the Superdome fiasco.
4. Who’s in charge? Factious political fights plagued relief efforts. The shifting of blame from the mayor of New Orleans to the governor of Louisiana to the president of the United States settled nothing. Lessons from previous hurricanes about coordination among federal, state, and local governments have not been learned or at least not been put into practice. Laws that govern the use of the armed forces in the continental United States also severely hamstring efforts to quickly deploy military personnel and need to be changed.
5. Counterterrorism versus all-hazards response. Money, staff, and other assets have been drained out of FEMA and moved to Homeland Security efforts to combat terrorism. A natural disaster the size of Hurricane Katrina dwarfs any terrorist attack up to a nuclear detonation or release of the plague. Yet Homeland Security funded disaster preparedness for terrorism as opposed to natural disasters at a 7-to-1 ratio pre-Katrina.
6. Ambiguous training standards and lack of preparation. Across the board, training and experience with disasters were lacking. While the FEMA training to become a certified LEMA manager sounds good, the reality is that the training requirements to become an emergency manager and become certified were cumbersome and difficult to complete. Standards for accreditation of response agencies were also vague and not tied to any performance-based evidence.
7. Where is the “learning” in lessons learned? A multiagency hurricane exercise that very closely resembled Katrina was completed prior to the storm. Outcomes closely paralleled what happened. Yet the failure of local and state governments to follow up and take advantage of the exercise doomed it to collect dust on the shelf. This is not the first instance of failure to heed learning from the past. Putting into practice all the procedures necessary to stave off a disaster like Katrina is difficult, costly, and time-consuming; it demands expertise and interagency cooperation at the local level and vertical integration with state and federal agencies. Tackling the logistical and tactical problems involved in implementing those procedures takes a backseat when the danger is not imminent.
8. Performance assessment was not integrated into the process. In an evidence-based world, continuous performance assessment should be built into disaster relief efforts, but that is not the case. Performance evaluation is especially lacking in mental health provision. An assessment device that provides benchmarks and rubrics to gauge how relief is proceeding and how well it is going is sorely needed so that best practice models may be generated. There was discussion about that after 9/11, but it still hadn’t happened 7 years later. To this day there still is no clear way of systematically evaluating the services rendered (Watson, Brymer, & Bonanno, 2011).
9. The geography of poverty. Are race and socioeconomic status response factors? While race became a factor because the majority of the poor in New Orleans were black, the fact is that disaster plans as they are currently formulated put the poor, the elderly, the sick, and other disenfranchised individuals who are not financially or physically able to evacuate, relocate, or rebuild at extreme risk without regard to race, creed, color, national origin, religion, sexual preference, or any other distinctive human quality.
10. Rumor and chaos. Urban legend and rumor, the bane of any disaster, ran rampant in New Orleans. No, clearly designated official spokesperson appeared, giving clear, unconflicted, factual messages that could be believed. Exaggeration by elected officials of armed violence was given airtime by the media, and these rumors then turned into “facts” and took on a life of their own. At its best rumor served to warn people and put them on their guard. At its worst, it turned into a self-fulfilling prophecy that slowed rescue efforts. Concrete, factual, up-to-the-minute information by an official spokesperson with both face and content validity was essentially absent. Above all else, an ironclad rule in any disaster is that one highly valid, knowledgeable spokesperson gives facts out in a timely manner and dispels rumors as they arise.
11. Personal and community preparedness. There was clearly a sharp divide between what happened in Louisiana and Mississippi regarding recovery efforts. Both states suffered an equal amount of catastrophic devastation along their coast. However, for whatever reasons, and there are many variables to be examined, Mississippi was more resilient. Whether most of its people had better resources and support systems is a different question from whether they were prepared. However, that question needs to be examined carefully, for both physical and psychological differences and perhaps even cultural differences that were demonstrated and heavily influenced long-term outcomes in the two states.
12. Disaster mental health and the role of mental health professionals. What works for reducing mental health problems in people afflicted by a disaster like Katrina is still not clear, and a great deal of research needs to be done to find out what evidence-based practices do work. Critical incident stress debriefing (CISD), which has been used and most certainly abused as a panacea, appears not to be the ultimate answer. Further, attributions that label survivors as suffering from a mental illness don’t work very well either. The preferred operating mode now is the use of psychological first aid and social support (Watson, Brymer, & Bonanno, 2011). Self-efficacy models
that foster self-reliance, coping, and problem- solving skills, focus on individual needs, seek to extinguish PTSD at early onset, and concentrate on functional recovery rather than looking for pathology seem to hold promise (Ruzek, 2006).
Psychological First Aid and Psychosocial Support as Applied to Disaster Survivors
As detailed in Chapter 1, the National Institute of Mental Health (2002) defines psychological first aid (PFA) as establishing safety of the client, reducing stress-related symptoms, providing rest and physical recuperation, and linking clients to critical resources and social support systems. Psychological first aid has now been adapted and modified from its initial use by Raphael (1977) into a first-order, evidence-based ap- proach to working with survivors of mass disasters (Brymer et al., 2006; Hobfoll et al., 2007). It may be taught to paraprofessionals and nonprofessionals. For example, it is one of the training modules (CERT, 2011) that volunteer CERT workers get as part of their search and rescue work training.
Psychological first aid as it is applied in a disaster is designed to reduce distress, generate short- and long- term adaptive functioning, and link survivors with additional services (Watson, Brymer, & Bonanno, 2011). The Field Operations Guide for Psychological First Aid developed by the National Child Traumatic Stress Network and the National Center for PTSD (NCTSN/ NCPTSD, 2006) is considered state-of-the art in that regard (Webber, Mascari, & Runte, 2010). Delivery of PFA includes a number of core actions (NCTSN/ NCPTSD, 2006): make initial respectful contact by a warm engaging presence; gather and provide in- formation in regard to supports needed to deal with immediate physical and safety concerns; provide and direct people in regard to practical assistance needed; provide for their safety and comfort both from a phys- ical and psychological standpoint by linking them with social services; teach them basic coping skills if requested; and get information and help that will connect them to social supports, such as reuniting them with family and other social groups with which they are involved.
The job of CFA workers is not to attempt to engage in therapy or elicit details of the tragedy; rather, it is to reduce acute psychological distress by their sup- portive and compassionate presence through basic active listening and responding skills (Everly & Flynn, 2005). Initiating contact involves the notion of “just being there” or “compassionate loitering” (Webber, Mascari, & Runte, 2010), which emphasizes careful observation, a nonintrusive presence, and caring, re- spectful contact. One example is the crisis workers who were available in the dining halls of Virginia Tech residence facilities and classrooms immediately after the shootings there. Volunteers had handouts on normal reactions to tragedies, self-care tips about trauma, and resource lists. Workers were instructed to engage and support students who seemed to be struggling by a respectful, nonintrusive introduction as a way to offer their support. They wore purple arm- bands to identify their presence. They reported that students initially would not speak to them, but as time went by and students started coming to terms with their grief, they would stop by and thank them for being there (Lawson, Bodenhorn, & Welfare, 2010).
Even doing the foregoing may not be necessary as most people are pretty resilient after a disaster (Hobfoll et al., 2007). As indicated in Chapter 2, Culturally Effective Helping in Crisis, insistence on participating in “psychotherapy” may be met with anger and extreme resistance. In support of the con- cept of voluntary participation, Bonanno, Westphal, and Mancini (2011) found that a one-size-fits-all intervention might hold no advantage over, and could even undermine, the self-efficacy and resiliency of sur- vivors. For many others, PFA may be both necessary and sufficient. Finally, for some few others, PFA may be necessary but not sufficient.
When More Than PFA Is Needed
It was first thought that severity of exposure to the event and severity of postevent stress and adversity would be the greatest factors indicating the need for more in-depth intervention for serious and chronic psychological problems (Norris, 2006). However, since 9/11 it is clear that degree of exposure or prox- imity to the attacks does not explain all of the persons presenting with severe psychological problems after a disaster. An individual waving an American flag for hours and hours over an interstate highway 1,000 miles from the impact sites, and refusing to come down for safety, is one example among literally thou- sands of individuals across the country who “lost it” after 9/11 and needed something more than PFA. In other words, vicarious traumatization through expo- sure to merely seeing or hearing about disaster events could instigate maladaptive psychological respond- ing. As a consequence, Watson, Brymer, and Bonanno (2011) have compiled a laundry list from their own and a number of other researchers that total 22 risk factors for adults and 13 for children. We believe it doesn’t make a lot of sense to try to go through that list and winnow out significant variables. What we do believe in is knowing how to use the Triage Assess- ment Form in this book. People scoring 20 or more are going to need something more than PFA for sure; they are going to need someone to monitor them closely until they regain some precrisis equilibrium and most likely should not be turned loose on their own. People in the high 20s, who are potentially lethal to themselves or others either by intended commission of unsafe acts or unintended omissions of activities needed to keep them safe, should not be turned loose. People in the high teens will most likely profit from PFA and a good deal of on-site psychosocial support so that they don’t escalate into the 20s. People in the low teens are probably ideal candidates for PFA. Any- body in the single digits on the TAF probably needs to counsel us!
The Current State of Affairs
The problem with this latter approach, however, is twofold. First, it assumes that a large enough number of practitioners have the necessary crisis intervention skills to do this. If mental health practitioners are not available, then paraprofessionals or laypersons like those who operate in Community Emergency Response Teams (CERTs) and are taught psycho- logical first aid as part of their training may be ini- tial providers of psychological support. That may be stretching it a bit. With all due respect to CERT vol- unteers, we spend a lot of time teaching these “first aid” techniques to graduate students. They are not easy to implement, particularly when faced with a person in crisis, and we wonder if the estimated learn- ing time of 1 hour and 15 minutes (including video) will be sufficient (CERT, 2011).
You will soon hear from a licensed professional counselor who was deployed in Louisiana post- Katrina. This counselor has extensive training and practice in crisis intervention. She is still the excep- tion rather than the rule. Given her background and training, she struggled and reevaluated her therapeu- tic worldview as she went through her tour of duty. Her story is not much different from that of many oth- ers who were there with her. While the American Red Cross crisis counseling training program has trained thousands of practitioners, that resource was clearly not enough for hurricane Katrina. The Red Cross and government agencies were forced to suspend their standards and bring in any licensed counselor, psy- chologist, social worker, psychiatric nurse, or psychia- trist they could get their hands on.
FEMA’s crisis counseling assistance and train- ing program (CCA-TP) is available to state mental health authorities once an area has been declared a disaster area by the president. That is a lot like clos- ing the barn door after the horse has escaped. Way too many things are happening to stop and say, “OK, we now have a large, metastasizing disaster on our hands; let’s do some training!” This training oc- curred in Memphis approximately a month after Katrina. To say it was mostly useless is being kind. We believe that training should come prior to any catastrophic event and follow-up refresher courses should go with it. After a congressional inquiry into this program’s problems in south Florida, a critical review of it was instigated and a number of worth- while recommendations were made to tighten it and beef it up—particularly in regard to coordination ac- tivities (Department of Homeland Security, 2008). None of those recommendations, however, made clear whether a municipality can actually get train- ing prior to a disaster.
Young and his associates (Young, 2006; Young et al., 2006) have developed a comprehensive predisas- ter training program that holds much promise. It has a conceptual framework that differentiates natural and human-caused disaster and examines effects on both individuals and communities. It has both prac- titioner and administrative training components and specific modules on high-risk client populations and interfaces with other organizations. This fine pro- gram is time consuming, most likely expensive, and requires trainers who have expertise in both disaster mental health practice and administration. Those are difficult commodities to find.
Consistent and comprehensive training for mental health providers in crisis intervention as they matricu- late through professional training programs has been piecemeal at best (Coke-Weatherly, 2005), as clearly de- scribed by Roberts (2005). That appears to be chang- ing to some extent. The Council for Accreditation of Counseling and Related Educational Programs and the National Association of School Psychologists both require the teaching of crisis intervention in their ac- crediting criteria. While that may now be seen as nec- essary, it remains to be seen whether what is taught will be sufficient. Other professional accreditation agencies appear to make the provision of crisis inter- vention training voluntary.
Most certainly, Katrina was a megacrisis that had metastasizing effects far beyond its geographic landfall and a physical scope that had never before been expe- rienced, with disenfranchised people shipped all over the United States. The terrorist attack on 9/11 probably had the widest range of vicarious psychological effects ever experienced in the United States, with the possi- ble exception of the Japanese attack on Pearl Harbor. A number of national committees issuing from both 9/11 and Katrina have made numerous recommendations in regard to the provision of crisis services to individu- als following these human-made and natural disasters. These recommendations have been summarized by Watson, Brymer, and Bonanno (2011) in their article on postdisaster psychological intervention since 9/11.
1. Be proactive ahead of time with pragmatic, flex- ible plans that match appropriate services to each phase of the recovery period.
2. Promote a sense of safety, connectedness, calm, hope, and efficacy.
3. Participate in groups with stakeholders to coordi- nate and learn from others, minimize duplication, and mend gaps in service.
4. Be culturally sensitive and consider human rights. 5. Be willing to undergo evaluation and open to
scrutiny of practices. 6. Stay up to date on evidence-based practices. 7. Maximize participation by local populations and
find and use local resources and capabilities. 8. Integrate activities and programs into larger systems to reduce stand-alone services, reach more people,
and be more sustainable over time and space. 9. Use a stepped approach that focuses early efforts on practical help and pragmatic support, with psychological first aid for a generally resilient
population. 10. Use triage assessment and focused care for those
with specialized needs who require increased lev-
els of intervention. 11. Provide technological assistance, consultation,
and training to local providers. 12. Conduct needs assessment of the community
with ongoing monitoring of services and program
evaluation. 13. Support community-based cultural rituals,
memorial services, and spiritual healing practices.
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