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There is a real difference between providing crisis services for non-mentally ill persons and those with significant mental illness. Provided below is the first chapter of Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provided by the U.S. Department of Health and Human Services. This chapter provides an introduction to and overview of the text. This publication is a must read for anyone providing or anticipating providing mental health services during times of crisis. The complete text can be found at the end of this chapter.

Introduction to Crisis Counseling Programs and Services to Persons With Serious and Persistent Mental Illness

Tony Speier, Ph.D.

This document provides a brief guide for State and local mental health agency administrators and five detailed chapters for program planners and providers of direct services. The intent is not to suggest that persons with serious and persistent mental illness require separate disaster recovery programs, but that within the scope of such programs people with mental illness may require specialized strategies for accessing the services they need on the journey to recovery. Our goals are:

@ to educate State and local mental health administrators, planners, and providers about the needs of individuals with serious and persistent mental illness who experience a disaster;

@ to present practical suggestions for disaster preparedness, for structuring disaster response and programs that mobilize the strengths of survivors; and

@ to summarize some of the broader issues regarding disaster mental health service delivery to people with mental illness.

This chapter produces an overview of the basic principles that underscore disaster recovery programs and the core principle of community support systems that form the basis for services to people with serious and persistent mental illness. A brief summary of the major points found in each chapter, includes a quick reference for the most likely audience for each of the chapters.

Principles for Human Service Workers in Major Disasters

The foundation for much of the Federal and State response to disaster relief can be found in The NIMH Training Manual for Human Service Workers in Major Disasters (1978). This document acknowledges the presence of high risk groups who may require specialized crisis counseling services. Before discussing what distinguishes high-risk groups from the majority of disaster survivors, it is important to recognize the common needs expressed by almost all people who experience a disaster and the personal destruction it leaves behind.

Common Needs and Reactions

1. Concern for basic survival.

2. Grief over loss of loved ones or loss of prized possessions.

3. Separation anxiety centered on self and also expressed as fear for safety of significant others.

4. Regressive behaviors, e.g., reappearance of thumbsucking among children.

5. Relocation and isolation anxieties.

6. Need to express feelings about experiences during the disaster.

7. Need to feel one is a part of the community and its rehabilitation efforts.

8. Altruism and desire to help others.

Crisis counseling programs are designed to respond to these needs and reactions. Survivors are assisted through services that are typically developed around four key concepts: (1) the target population is primarily normal; (2) mental health labels must be avoided; (3) help must be offered in innovative ways; and (4) the program must be appropriate for the community. The most successful crisis programs address the common needs of survivors, use indigenous outreach workers and volunteers, and respond to the socio-demographic and cultural diversity of affected communities. These kinds of programs help those with special needs or increased vulnerability to environmental stressors maintain their pre-disaster level of social and functional well being.

With respect to people with serious and persistent mental illness, the underlying philosophy of most treatment and program intervention in the 1990’s emphasizes wellness and similarities between people with psychiatric disabilities and the general population. The background for this approach is the Community Support Program (CSP), which was established by the National Institute of Mental Health in 1978. Simply stated, the CSP philosophy and subsequent program initiatives emphasize the concepts of inclusion, wellness, and natural supports while deemphasizing segregated service systems, illness, and artificial social support systems. Anyone familiar with disaster counseling and CSP programs will recognize the similarities in philosophy and services emphasized both programs emphasize.

Consistent with this philosophy is the belief that people with serious and persistent mental illness are viewed as “people first”, whose needs and responses are typical of all human beings. In the unnatural situation brought on by a disaster, these people will have the same basic feelings and will react in much like the rest of the population. Some will experience despair and shock; others will respond by performing heroic deeds. An individual’s mental illness does not preclude mentally healthy responses and adaptive coping skills. However, in some instances the impact of one’s mental illness or its related symptoms may present a special challenge.

An example from the Louisiana Hurricane Andrew Regular Services Program (Speier and Balson, 1994) illustrates the special challenge to some individuals. From a sample of 1,005 persons with severe and persistent mental illness, 47 percent required assistance after the storm. A total of 45 percent of these people still needed assistance 9 months later. In relationship to their expressed needs, only 19 percent, or 191 of the 1,005, had actually received assistance from FEMA and 8.5 percent, or 88 persons, had received assistance from the American Red Cross. From the perspective of the Louisiana program, the types of requests and assistance provided were not necessarily different from those received or provided by outreach workers from the estimated 5,000 non-mental health clients who sought assistance. The unique aspect of this experience was the large number of people with mental illness who had legitimate storm-related needs that were not identified during the recovery phase.

People with long-term mental illnesses often are psychologically vulnerable to rapid, unplanned changes in their environment and have difficulty assimilating new environmental contingencies into their life space. As a result, these individuals may be reluctant to seek help or do not have the organizational skills necessary to access services from FEMA or other Federal agencies.

The unique quality of providing disaster relief services to persons with psychiatric disabilities is often simply a matter of determining how outreach programs can be successful in engaging these individuals. While the crucial feature is often to help disaster victims access services, it also becomes the responsibility of outreach teams to recognize the perceptual set, value system, and lifestyle of each individual they are trying to engage in services.

People with mental illness have the same basic needs as the general population. However, the stress associated with the impact of the disaster and its aftermath may result in stress reactions that should not automatically be attributed to an exacerbation of mental illness. The unique features of addressing the disaster-related needs of mental health consumers have to do with the service engagement process. They include a competent understanding and awareness of how these individuals perceive the services being offered, and how aspects of one’s mental illness may make some individuals reluctant to seek help. The programs and activities discussed in the sections that follow illustrate how helping systems can be mobilized and how people, including those with serious mental illness, recover from stressful disaster related experiences. Emphasis is placed on preplanning activities for organizing and mobilizing resources, and recognizing the strengths people with psychiatric disabilities need in the disaster recovery process.

Chapter Summaries

These summaries offer a quick reference to the information in chapters that follow.

Chapter 2: State Mental Health Authority (SMHA)

This chapter gives State mental health program directors an overview of the role of the public mental health system in disaster response operations, with special emphasis on preplanning activities essential to mobilizing agency resources.

State and local mental health program agencies typically function along parallel lines of authority and responsibility. Emergency situations require rapid and integrated agency responses.

SMHAs must plan and organize their disaster response operations before the disaster. Administrative policy development occurring concurrently with direct service responses are ill-advised and often confuseCrather than simplifyCthe response effort.

Disaster response planning requires the SMHA to understand the structure of State government, the mission and function of social and human agencies, and the responsibilities of local governments.

State emergency operations plans and the mental health response should be organizationally integrated, and direct responses must be well coordinated. The SMHA must assist responders and survivors during all phases of the disaster event and its aftermath.

The rapidly evolving nature of disaster events require a flexible mental health response. Quick implementation of preplanned administrative procedures assures availability of crisis counselors and crisis counseling services.

Chapter 3: Local Mental Health Authorities

Local mental health authorities, whose missions include providing services and resources to people with serious and persistent mental illnesses and providing mental health assistance to survivors and disaster, will find this chapter useful in assuring that the special needs of those with mental illness are met after a major disaster.

People with mental illness have the same basic needs as the general population following a major disasterCsafety, shelter, food, social supportCbut they may have other special needs.

Programs designed to meet these special needs should not be anymore stigmatized than programs for other special populations, such as children, the frail elderly, or people with special language or cultural needs.

People with mental illness have the same capacity to “rise to the occasion” and perform heroically in the aftermath of a disaster as the general population. Many demonstrate an increased ability to handle this stress without decompensation from their primary illness.

Though the local mental health authority is responsible for reestablishing general mental health services to this population, it is also important to provide special disaster services and interventions for those with special needs, either through crisis counseling services for the general population or those specifically provided at mental health service sites.

Disaster mental health training should be provided to therapists, case managers, and care coordinators as well as to consumers, families, board-and-care home operators, single-room-occupancy hotel managers and consumers who operate satellite housing programs. Preparedness training should be provided to consumers.

Recognition should be given to staff members who continue to provide routine clinical services to people with mental illness as well as to those staff who provide disaster response services.

Chapter 4: Community Mental Health Centers

This chapter will help CMHC managers, program directors, clinical staff, and consumers prepare for, and recover from, a disaster experience.

Making disaster planning as a part of an ongoing psychiatric rehabilitation program is a way to educate staff and consumers about preparedness, response, and recovery. Consumers can develop the curriculum and train their peers.

Staff must address disaster-related needs of consumers, provide opportunities for group work to share experiences and resolve the painful aspects of the experience, and provide opportunities for consumers to serve the larger community in its recovery.

Chapter 5: Crisis Counseling Program

This chapter is written for those who design, administer, or work in crisis counseling programs. It describes the crisis counseling programs funded by FEMA and monitored by CMHS. It also addresses how these programs may, within the scope of their intent, respond to the needs of this population.

Establish predisaster plans, agreements, and relationships among State Mental Health Authority, local mental health provider agencies, State emergency management agencies, and FEMA will help ensure rapid, effective disaster mental health response and timely implementation of the Crisis Counseling Program.

CMHS staff may be contacted for help with developing the Crisis Counseling Program and negotiating the bureaucratic maze of State and Federal agencies. States that have recently implemented successful Crisis Counseling Program also can be consulted.

The disaster mental health needs of people with mental illness will be similar to those of the general population; it must be assumed that these needs cannot be met by traditional mental health and psychiatric programs.

The service concepts of “the three A’s”Cavailability, accessibility, and acceptabilityCshould be incorporated into all crisis counseling services. Adjustments may need to be made for survivors with mental illness.

The Crisis Counseling Program function should be broadly applied. It must provide direct services for survivors; training and consultation for disaster workers, CMHC staff, and other providers of services; and crisis counseling and support with CMHC and other staff who are also disaster survivors.

Chapter 6: Psychosocial Rehabilitation Programs and Consumer Empowerment

This chapter is for providers of mental health services, consumers of those services, and their family members. It outlines the experiences of members of Fellowship House, a clubhouse program that experienced Hurricane Andrew.

Developing and maintaining a community support network is vital to the ability to access needed resources during a disaster. Using social group work as a methodology prepares consumers and staff for the teamwork needed to weather an emergency. The sense of community and ownership of the clubhouse by consumers and staff plays a major role in recovery from a disaster.

Involving consumers in preparing for and recovering from a disaster provides needed human resources and makes good rehabilitative sense. Principles of psychiatric rehabilitation are as effective in a disaster as in normal times.

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