PSYC W6

– Using the course materials as a guide, identify the treatment option(s) you would deploy in a specific disaster situation, explaining your rationale for the selection(s)
– In addition, discuss the population(s) the treatment will be used with and why this is the most appropriate choice for the population(s) identified.
350 words or more APA format
psychologyemergency
ATTACHED FILE(S)
289
16 Initial Behavioral
Health Response
The Conundrums of a State
Crisis Counseling Program
Julie L. Framingham
And.I.saw.Sisyphus.in.agonising.torment.trying.to.roll.a.huge.stone.to.the.top.of.a.hill..He.
would.brace.himself,.and.push.it.towards.the.summit.with.both.hands,.but.just.as.he.was.about.
to. heave. it. over. the. crest. its. weight. overcame. him,. and. then. down. again. to. the. plain. came.
bounding. that. pitiless. boulder.. He. would. wrestle. again,. and. lever. it. back,. while. the. sweat.
poured.from.his.limbs,.and.the.dust.swirled.round.his.head.
Bk XI: 593–640
The Odyssey
16.1  INTRODUCTION
In. the. wake. of. disaster,. state. agencies. frequently. play. a. crucial. role. in. the. immediate. response.
to. impacted. communities. by. determining. if. a. need. for. behavioral. health. services. exists,. and. by.
designing,.implementing,.and.managing.behavioral.health.programs..State.behavioral.health.agen-
cies. have. access. to. certain. federal. funding. resources. that. are. unavailable. to. other. organizations.
involved.in.disaster.response..This.chapter.will.focus.on.one.particular.federal.funding.resource,.
the.Federal.Emergency.Management.Agency’s.Crisis.Counseling.Program,.and.discuss.some.of.the.
challenges.encountered.in.designing,.implementing,.and.administering.the.program..In.illustration,.
the.experiences.of.state.behavioral.health.agency.staff.in.Florida.as.related.to.programs.developed.
around.Hurricane.Charley.and.subsequent.disasters.that.followed.from.the.period.of.2004.to.2007.
CONTENTS
16.1. Introduction…………………………………………………………………………………………………………… 289
16.2. The.Crisis.Counseling.Program……………………………………………………………………………….. 290
16.3. Assessing.the.Need.for.Crisis.Counseling.Program.Services……………………………………….. 291
16.4. The.State.Mental.Health.Authority’s.Response.to.Hurricane.Charley…………………………… 292
16.5. Public.Misconceptions…………………………………………………………………………………………….. 293
16.6. Temporary.Disaster.Employment……………………………………………………………………………… 295
16.7. Provider.Agency.Capacity……………………………………………………………………………………….. 296
16.8. Unemployment.Compensation………………………………………………………………………………….. 296
16.9. Conclusion…………………………………………………………………………………………………………….. 297
Notes…………………………………………………………………………………………………………………………….. 298
References……………………………………………………………………………………………………………………… 299
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EBSCO Publishing : eBook Collection (EBSCOhost) – printed on 5/10/2022 3:04 PM via AMERICAN PUBLIC UNIVERSITY SYSTEM
AN: 448580 ; Julie Framingham, Martell L. Teasley.; Behavioral Health Response to Disasters
Account: s7348467.main.ehost
290 Behavioral Health Response to Disasters
will.be.examined.a.Therefore,.select.issues.such.as.state.agency.funding,.program.continuity,.grants.
administration,.and.jurisdictional.concerns.encountered.by.program.staff.in.Florida.are.addressed,.
as.well.as.some.of.the.solutions.applied..Some.of.the.challenges.described.are.not.unique.to.Florida,.
however,.but.have.been.experienced.by.other.state.behavioral.health.agencies.as.well..Therefore,.it.is.
hoped.that.this.chapter.will.not.only.offer.some.insight.on.the.Crisis.Counseling.Program’s.potential.
obstacles,.but.encourage.other.state.behavioral.health.agencies.to.find.creative.means.to.resolve.the.
potential.barriers.to.administering.future.programs.
16.2  THE CRISIS COUNSELING PROGRAM
The. Crisis. Counseling. Assistance. and. Training. Program. (CCP. or. the. Crisis. Counseling.
Program).was.first.authorized.by.the.Disaster.Relief.Act.of.1974.(Pub..L..93-288),.later.amended.
by.Section.416.of.the.Robert.T..Stafford.Disaster.Relief.and.Emergency.Assistance.Act.of.1988.
(Stafford.Act;.Pub..L..100-707)..The.Stafford.Act.authorizes.the.president.of.the.United.States,.
through. a. disaster. declaration,. to. provide. states. and. U.S.. territories. with. a. wide. array. of. pub-
lic. and. individual. assistance. program. funds.. Pursuant. to. Title. 42,. Chapter. 68,. Subchapter. IV,.
Section.5183:.
The.President.is.authorized.to.provide.professional.counseling.services,.including.financial.assistance.
to. State. or. local. agencies. or. private. mental. health. organizations. to. provide. such. services. or. training.
of.disaster.workers,.to.victims.of.major.disasters.in.order.to.relieve.mental.health.problems.caused.or.
aggravated.by.such.major.disaster.or.its.aftermath.
The.CCP.is.jointly.administered.by.the.Federal.Emergency.Management.Agency.(FEMA).and.
the.U.S..Department.of.Health.and.Human.Services.(HHS),.Substance.Abuse.and.Mental.Health.
Services. Administration. (SAMHSA),. Center. for. Mental. Health. Services. (CMHS),. through. an.
interagency.agreement.(FEMA.Crisis Counseling.nd;.SAMHSA.nd)..CMHS.provides.training.
and.program.oversight,.as.well.as.monitoring.for.Regular.Services.Programs,.for.State.Mental.
Health.Authorities.(SMHA;.42.U.S.C..§.201)..In.Florida,.the.SMHA.is.the.Florida.Department.
of. Children. and. Families. (DCF).. DCF. has. the. responsibility. to. administer. mental. health. and.
substance.abuse.services.within.the.state.and.is.eligible.to.request.grant.funding.from.FEMA.for.
disaster.crisis.counseling.services.
Given.the.chronic.under-funding.of.many.state.mental.health.and.substance.abuse.services,.the.
CCP.is.an.essential.resource.for.SMHAs.to.assist.large.numbers.of.survivors.experiencing.psycho-
logical.distress.postdisaster..Sanctioned.CCP.activities.include.outreach,.counseling,.public.educa-
tion,.and.referrals.to.community.resources..Activities.are.intended.to.assist.survivors.to.understand.
their.situations.and.the.physical,.cognitive,.and.behavioral.reactions.that.can.result,.including.anxi-
ety,. fear,. anger,. grief,. hopelessness,. and. changes. in. sleep. patterns. or. appetite.. Crisis. counselors,.
sometimes. called. outreach. workers,. attempt. to. alleviate. adverse. stress. reactions. in. survivors. by.
providing.emotional.support..Using.active.listening,.they.help.validate.the.survivors’.reactions.and.
assist. them. to. understand. that. they. are. reacting. normally. to. an. abnormal. event. (SAMHSA. CCP.
Program.Guidance.nd)..Psychoeducation.is.a.key.component.of.the.CCP.and.has.been.demonstrated.
to. be. effective. in. a. number. of. trauma. contexts.. Psychoeducation. can. assist. individuals,. families,.
and.communities.by.normalizing.stress.reactions.and.ameliorating.distress,.and.encourage.support.
seeking,. resilience,. and. community. cooperation. (Layne. et. al.. 2008;. Jacobs,. Vernberg,. and. Lee.
2008;.Marbley.2007;.Naturale.2007;.Fremont.2004;.AACAP.2007)..
Crisis. counselors. also. help. survivors. review. their. recovery. options. and. teach. coping. skills.
and. relaxation. techniques,. among. other. nonclinical. interventions.. Crisis. counseling. activities. are.
short. term. and. community. based. and. occur. at. survivors’. homes,. schools,. places. of. employment,.
senior. centers,. and. community. centers,. among. other. sites. (SAMHSA. CCP. Program. Guidance.
nd)..Research.suggests.that.community.outreach.may.be.especially.helpful.for.reaching.out.to.and.
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291Initial Behavioral Health Response
empowering.certain.vulnerable.groups.after.disaster..These.groups.include.ethnic.minorities,.older.
adults,. individuals. with. mental. illness,. or. others. who. lack. social. support. systems. and. services,.
especially. when. delivered. by. indigenous,. trained. workers. (Norris. and. Alegria. 2005;. Elmore. and.
Brown.2007;.Person.and.Fuller.2007;.Hardiman.and.Jaffee.2008)..Further,.communications.with.
diverse.populations.in.the.community.assist.outreach.workers.to.overcome.biases.and.become.more.
culturally.aware.(Goodman.and.West-Olatunji.2009)..CMHS.expects.SMHAs.to.develop.CCPs.that.
acknowledge.the.diversity.of.the.communities.served.by.targeting.ethnic.and.racial.minorities.and.
hiring. indigenous. workers. who. reflect. the. community’s. demographic. makeup. whenever. possible.
(SAMHSA.CCP.Program.Guidance.nd).
16.3  ASSESSING THE NEED FOR CRISIS COUNSELING PROGRAM SERVICES
Two.funding.mechanisms.are.available.to.SMHAs.through.the.CCP:.(1). the.Immediate.Services.
Program,.which.provides.up.to.60.days.of.funding.for.disaster.crisis.counseling.services,.and.(2).the.
Regular.Services.Program,.which.provides.for.an.additional.nine.months.of.funding.(FEMA Crisis
Counseling.nd;.SAMHSA.nd)..The.date.of.the.presidential.disaster.declaration.is.the.start.date.for.
both. the. Immediate. Services. Program. and. Regular. Services. Program. (SAMHSA. CCP. Program.
Guidance.nd)..Between.2004.and.2007,.Florida’s.Immediate.Services.Program.grant.applications.
were.approved.quickly,.whereas.Regular.Services.Program.grant.applications.averaged.between.8.
and.22.weeks.for.review.and.approval.(Kimber.2007)..Requests.for.no-cost.extensions.(to.extend.the.
program.end.date.without.additional.funding).or.additional-cost.extensions.of.Immediate.Services.
Programs.were.therefore.necessary.to.avoid.services.disruption.
Given.the.copious.amount.of.information.that.needs.to.be.included.in.the.grant.applications,.
this.generally.means.weeks.to.months.of.extended.workdays.for.SMHA.staff.assessing.the.needs.
of.the.affected.communities,.gathering.the.data,.and.developing.the.plan.of.services.and.the.bud-
get..CMHS.requires.SMHAs.to.complete.the.CMHS.Needs.Assessment.Formula.for.Estimating.
Disaster. Mental. Health. Needs. (CMHS. Needs. Assessment;. included. in. the. grant. applications).
when.calculating.the.numbers.of.survivors.who.might.benefit.from.crisis.counseling..The.CMHS.
Needs.Assessment.follows.the.FEMA.damage.assessment.concept.and.includes.loss.categories.
of.numbers.of.dead,.hospitalized,.or.otherwise.reported.injured;.homes.with.minor.and.major.
damages,. or. totally. destroyed;. and. numbers. of. survivors. who. became. unemployed. as. a. result.
of. the. disaster.. Each. CCP. grant. application. was. developed. in. close. consultation. with. FEMA.
and.CMHS.project.officers.because.FEMA.damage.assessments.were.not.always.completed.for.
each. county,. or. they. were. completed. under. very. difficult. conditions,. making. it. impossible. to.
obtain.more.than.a.superficial.estimate.of.damages..FEMA.Individual.Assistance.applications.
for.each.county.are.also.helpful.data.for.assessing.crisis.counseling.needs,.but.CMHS.discour-
aged.use.of.these.data.if.using.the.FEMA.damage.assessment.methodology.due.to.the.potential.
for.duplication.
Consequently,.DCF.program.staff.had.to.be.resourceful.to.find.ways.to.include.other.loss.cat-
egories.or.data.sources.in.the.formula.that.would.be.acceptable.to.CMHS.and.FEMA.in.order.to.
provide.more.realistic.numbers.of.individuals.likely.to.benefit.from.crisis.counseling..Negotiation.
was.also.necessary.since.the.numbers.of.teams.and.team.members,.as.well.as.ratios.of.crisis.coun-
selors.to.team.leaders,.were.prescribed.based.on.the.numbers.of.survivors.calculated.to.benefit.from.
services.in.the.CMHS.Needs.Assessment..With.each.grant.application,.DCF.presented.the.unique.
aspects.of.the.impacted.counties.and.the.service.districts.responding.to.the.disaster.by.highlighting.
conditions.that.made.the.use.of.standardized.staffing.formulas.problematic..For.instance,.are.the.
impacted.counties.mostly.urban.or.rural?.In.the.latter.case,.teams.may.have.to.travel.much.greater.
distances.to.reach.survivors..Population.density.or.large.cultural.groups.could.also.be.reasonable.
grounds.to.deviate.from.expected.staffing.formulas..While.the.state.may.include.special.populations.
or.other.circumstances.in.other.sections.of.the.grant.application,.the.CMHS.Needs.Assessment is.
given.significant.weight.during.the.application.review.
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292 Behavioral Health Response to Disasters
16.4   THE STATE MENTAL HEALTH AUTHORITY’S 
RESPONSE TO HURRICANE CHARLEY
In.the.days.leading.up.to.the.landfall.of.Hurricane.Charley.in.August.2004,.personnel.in.the.Mental.
Health.Program.Office.at.DCF.were.busy.preparing.for.the.storm’s.arrival..The.National.Hurricane.
Center’s.tracking.and.prediction.graphic.models.suggested.that.the.hurricane.would.strike.Florida’s.
Gulf.Coast.somewhere.between.the.Fort.Myers.and.the.Tampa.Bay.areas.with.initial.reports.pre-
dicting.the.latter.being.the.most.likely.point.of.landfall.(NOAA.2006)..In.anticipation.of.Hurricane.
Charley’s.arrival,.then.Governor.Jeb.Bush.executed.Executive.Order.#04-182.on.August.11.declar-
ing.a.State.of.Emergency.(SLAF.nd).
On.Friday,.August.13,.2004,.Hurricane.Charley,.with.little.warning,.turned.suddenly.from.
its.greatly.anticipated.landfall.near.Tampa.Bay.and.slammed.into.the.southwest.coast.of.Florida.
at. Captiva. Island,. and. then. Port. Charlotte,. as. a. Category. 4. storm. with. winds. approaching.
150mph.(NOAA.2006)..It.was.the.strongest.hurricane.to.hit.the.United.States.since.Hurricane.
Andrew. in. 1992. (FDEP. nd).. It. was. also. the. first. time. Florida. had. been. struck. by. two. major.
storms. in. less. than. 36. hours. (Tropical. Storm. Bonnie. struck. northwest. Florida. on. August. 12;.
Avila. 2004;. FDEP. nd).. The. storm. then. continued. diagonally,. north. by. northeast,. across. the.
state,.before.exiting.near.Daytona.Beach.as.a.Category.2.hurricane..Almost.1.5.million.people.
evacuated. their. homes.. Tens. of. thousands. of. homes. and. businesses. were. damaged. or. totally.
destroyed. and. more. than. 2. million. residents. were. left. without. electricity.. Damages. exceeded.
$11. billion.. There. were. 24. hurricane-related. deaths. and. 792. injuries. (NOAA. nd).. Due. to. the.
enormity.of.the.disaster,.Governor.Bush.requested.federal.assistance.from.the.president,.who.
issued.a.Federal.Disaster.Declaration,.FEMA-1539,.the.same.day.(FEMA.Major Disaster.nd)..
Of. Florida’s. 67. counties,. 26. were. declared. disaster. areas. eligible. for. Individual. Assistance.
funding,.including.the.CCP.
It.had.been.several.years.since.the.state.of.Florida.had.experienced.a.major.disaster.or.had.the.
need. to. provide. crisis. counseling. for. survivors. trying. to. cope. with. the. emotional. aftermath. of. a.
storm..Nevertheless,.anticipating.there.would.be.a.need.for.such.a.response.to.Hurricane.Charley,.
the. Disaster. Behavioral. Health. Coordinator. and. other. key. DCF. leaders. began. discussions. about.
how.to.prepare.a.response.ahead.of.the.storm’s.arrival..They.formed.a.small.team.of.workers.con-
sisting.of.several.permanent.and.temporary.staff b.to.develop.the.response.
Fortunately,. there. were. a. few. team. members. who. had. developed. CCP. grant. applications. for.
prior. disasters.. DCF. was. also. contacted. by. federal. project. officers. with. offers. of. guidance. for.
developing. the. grant. application.. The. Disaster. Behavioral. Health. Coordinatorc. had. been. making.
preparations. throughout. the. preceding. year. by. obtaining. support. from. the. department’s. senior.
management. should. the. need. arise. to. provide. a. behavioral. health. response. to. a. disaster.. He. also.
cultivated.useful.contacts.at.other.state.agencies.and.nonprofit.organizations.that.could.offer.assis-
tance.during.or.postdisaster,.including.the.Florida.Department.of.Health,.the.Department.of.Elder.
Affairs,.the.State.Emergency.Operations.Center,.the.National.Organization.for.Victim.Assistance.
(NOVA),.and.Florida.Interfaith.Networking.in.Disasters.(FIND)..FIND.played.a.prominent.role.in.
the.Department’s.response.as.this.organization.was.able.to.put.the.DCF.in.contact.with.Lutheran.
Disaster.Response.and.other.helpful.nongovernmental.organizations..Lutheran.Disaster.Response.
offered.to.host.daily.conference.calls.for.Florida’s.state.agencies.and.voluntary.organizations.to.help.
the.state.provide.an.adequate.level.of.coverage.for.behavioral.health.services.in.the.impacted.com-
munities.while.avoiding.duplication..These.calls.helped.establish.lasting.collaborative.partnerships.
by.fostering.candid.discussion.and.the.sharing.of.information.and.resources.among.the.participating.
agencies.
Before.Hurricane.Charley,.DCF.endeavored.to.increase.its.capacity.to.respond.to.disasters.by.
developing.and.training.a.volunteer.cadre..Long.experience.had.made.DCF’s.leadership.realize.
that.each.time.a.disaster.was.over.and.the.impacted.communities.had.returned.to.“normal,”.the.
staff.who.had.gained.experience.working.in.the.disaster.drifted.away.for.various.reasons..New.
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293Initial Behavioral Health Response
employment. opportunities,. relocation,. burnout,. or. disillusionment. after. prior. disaster. work,. or.
lack.of.supervisory.support,.were.recurring.grounds.for.later.nonparticipation.and.contributed.to.
a.chronic.loss.of.institutional.memory..The.agency.was.also.hamstrung.by.the.fact.that.disaster.
behavioral. health. preparedness. funding. from. the. Centers. for. Disease. Control. and. Prevention.
(CDC).and.the.Office.of.the.Assistant.Secretary.for.Preparedness.and.Response.(ASPR).is.ear-
marked.for.ESF.8,.Public.Health.and.Medical,.agencies..Under.the.National.Response.Framework,d.
ESF.8.agencies.are.tasked.to.provide.disaster.behavioral.health.services.e.In.Florida,.however,.the.
ESF.8.agency.is.the.Department.of.Health,.whereas.DCF.is.designated.as.an.ESF.6,.Mass.Care,.
agency..ESF.6.agencies.are.responsible.for.providing.disaster.crisis.counseling.(Sundararaman,.
Lister,.and.Williams.2006).f
Without. preparedness. funding,. DCF. did. not. have. the. resources. to. maintain. sufficient. staff.
year-round.to.prepare.for.future.disasters.and.sustain.its.knowledge.base..The.sustainment.prob-
lem.was.not,.however,.limited.to.headquarters.staff..It.was.common.throughout.the.DCF.system,.
including.its.contracted.community.agencies..Thus,.when.Hurricane.Charley.arrived,.DCF.found.
itself.in.the.same.predicament.as.before..In.fact,.the.department.was.to.reexperience.this.same.
dilemma.and.others.with.each.succeeding.hurricane.as.Hurricane.Charley.was.quickly.followed.
by.Hurricanes.Jeanne,.Francis,.and.Ivan.in.2004,.and.Hurricanes.Dennis,.Wilma,.and.Katrinag.
in.2005.
DCF.distributed.its.disaster.cadre.at.Disaster.Recovery.Centers,h.DCF.emergency.food.stamp.
locations,i.comfort.stations,.or.other.designated.sites.established.within.the.impacted.areas..The.
cadre.and.DCF’s.disaster.partners.provided.immediate.assistance.for.survivors.and.freed.SMHA.
staff.to.develop.the.grant.applications.to.secure.sufficient.federal.funding.for.recovery.services..
Cadre. members. brought. educational. materials. and. set. up. information. tables. within. the. sites..
They.provided.emotional.support,.listened.to.the.survivors’.disaster.experiences,.provided.them.
with. guidance. in. completing. FEMA. or. other. applications. for. assistance,. and. steered. them. to.
helping.resources..One.colleague.described.her.first.experience.as.a.crisis.counselor.in.a.Disaster.
Recovery.Center..She.stated.a.male.survivor.approached.her.while.she.was.standing.at.her.infor-
mation.table:
She.asked,.“How.may.I.help.you.sir?”.The.man.immediately.exploded.into.a.tirade.concerning.his.frus-
trations.with.the.disaster,.the.response.process,.and.the.bureaucratic.“red.tape”.that.impeded.obtaining.
the.assistance.that.he.desperately.needed..The.crisis.counselor’s.eyes.opened.wide.and.she.froze.in.fear..
After.a.couple.of.minutes,.however,.she.plucked.up.her.nerve.and.repeated.her.question.
“Sir,.how.can.I.help.you?”
Suddenly,.the.survivor.ceased.his.tirade,.took.a.deep.breath.and.looked.at.her.and.said,.“I.feel.much.
better.now..Thank.you!”.He.then.walked.off.without.asking.for.any.other.assistance.or.information.j
The. point. illustrated. here. is. that. crisis. counselors. provide. a. great. deal. of. emotional. support.
simply.by.listening.to.survivors’.stories..Survivors.may.not.need.much.more.than.having.someone.
listen.to.them.and/or.some.informational.materials.to.help.them.understand.their.reactions.to.the.
disaster.and.learn.more.adaptive.ways.to.cope.with.current.stressors.
16.5  PUBLIC MISCONCEPTIONS
In. fact,. the. term. crisis counseling. is. somewhat. misleading. since. all. CCP. services,. even. when.
delivered.by.licensed.behavioral.health.specialists,.are.nonclinical.in.nature..However,.the.disaster.
literature.suggests.that.the.majority.of.survivors.do.not.develop.long-term.posttraumatic.psychopa-
thology.(Gray,.Litz,.and.Maguen.2004;.Davidson.and.McFarlane.2006),.especially.in.the.absence.
of. extensive. property. damage,. injuries. and. loss. of. life,. or. human-caused. incidents. (Norris. et. al..
2001)..Consequently,.no.clinical.services.are.authorized.under.the.CCP.(SAMHSA.CCP.Program.
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294 Behavioral Health Response to Disasters
Guidance.nd)..Crisis.counselors.are.expected.to.refer.individuals.in.need.of.clinical.mental.health.or.
substance.abuse.treatment.to.preexisting.community.behavioral.health.agencies,.which.frequently.
have. long. waiting. lists. for. Medicaid-funded. services.. An. unfortunate. consequence. of. failing. to.
authorize.clinical.services.is.that,.of.those.individuals.who.do.go.on.to.develop.long-term.psycho-
logical.or.substance.use.disorders,.the.uninsured.and.under-insured.suffer.the.most.(Sundararaman,.
Lister,.and.Williams.2006).
The.fact.that.no.clinical.services.are.offered.in.the.CCP.appears.to.contradict.the.Stafford.Act’s.
language,.which.states.that.“professional.counseling”.may.be.offered.to.survivors.experiencing.
psychological.distress.postdisaster.(42.U.S.C..§.5183)..However,.it.has.been.left.up.to.CMHS.to.
determine.what.constitutes.professional.counseling.(Drury,.Scheeringa,.and.Zeanah.2008)..The.
FEMA. CCP. instead. relies. on. many. of. the. same. principles. used. in. the. Psychological. First. Aid.
model. developed. by. the. National. Child. Traumatic. Stress. Network. (NCTSN). and. the. National.
Center. for. Posttraumatic. Stress. Disorder. (NCPTSD),. which. many. organizations. have. endorsed.
as. a. preferred. intervention. for. response. to. emergencies. or. disasters. (Chapter. 10,. this. volume)..
Similar.to.the.CCP,.Psychological.First.Aid.is.used.in.diverse.community.settings.and.is.designed.
to.provide.disaster.survivors.with.nonclinical.assistance..Core.components.of.Psychological.First.
Aid. involve. engaging,. comforting,. and. stabilizing. survivors;. gathering. information. about. their.
needs. or. concerns. and. offering. practical. help. to. satisfy. those. needs;. connecting. survivors. to.
social.support.systems.and.community.resources;.and.providing.information.on.stress.reactions.
and.coping.(Brymer.et.al..2006).
Misconceptions.about.what.the.CCP.has.to.offer.survivors.has.led.to.a.number.of.misunderstand-
ings. with. the. media. and,. consequently,. with. the. public.. This. has. at. times. occurred. with. painful.
results,. not. just. for. Florida’s. DCF,. but. also. for. other. SMHAs. that. have. implemented. CCPs.. The.
media. have. sometimes. assumed. that. crisis. counseling. refers. to. clinical. counseling,. and. various.
news.stories.have.criticized.CCPs.for.failing.to.provide.clinical.services..For.example,.in.October.
2006,.the.New Orleans Times-Picayune.published.a.news.story.(Varney.2006).about.the.SMHA’s.
Louisiana.Spiritk.wherein.it.criticized.FEMA.for.not.allowing.CCP.funding.to.be.spent.on.“medical.
doctors”.and.instead.implied.it.was.being.spent.on.“muffins.and.coffee.”.The.article.further.stated.
that. research. concerning. the. CCP’s. effectiveness. is. lacking. and. an. expert. source. was. quoted. as.
suggesting.that.the.program.possibly.causes.more.harm.than.good.(Varney.2006)..The.fact.that.the.
trauma. expert. cited. in. the. story. referred. to. the. CCP’s. intervention. as. “psychological. debriefing”l.
suggests.he.was.unaware.that.the.CCP.does.not.permit.use.of.psychological.debriefing.(SAMHSA.
CCP.Program.Guidance.nd,.14),.which.indeed.has.come.under.fire.as.a.means.of.assisting.disaster.
survivors.and.has.been.discouraged.from.practice.by.some.researchers.(Rose.etal..1999;.Mayou,.
Ehlers,.and.Hobbs.2000;.Rose.et.al..2001;.Litz.et.al..2002;.NIMH.2002)..
It.is.true,.however,.that.there.have.been.few.studies.of.the.CCP.that.sought.to.examine.the.
program’s.effectiveness.(Elrod,.Hamblen,.and.Norris.2006;.Norris,.Hamblen,.and.Rosen.2009;.
Drury,. Scheeringa,. and. Zeanah. 2008).. Evaluating. the. CCP’s. effectiveness. has. been. difficult.
because,.unlike.clients.in.traditional.mental.health.systems,.crisis.counseling.services.are.short.
term.(CMHS.recommends.assessment.and.referral.after.three.visits;.SAMHSA.CCP.Program.
Guidance. nd,. 19). and. no. personally. identifying. information. is. retained.. Therefore,. it. is. not.
possible. to. obtain. pre-. and. posttest. measures. of. the. program’s. efficacy. in. ameliorating. post-
disaster.distress.(Norris,.Hamblen,.and.Rosen.2009;.Drury,.Scheeringa,.and.Zeanah.2008)..It.
is.also.true.that.FEMA.and.CMHS.have.allowed.SMHAs.wide.latitude.in.administering.CCPs..
CCPs.use.a.wide.variety.of.outreach.and.engagement.strategies.to.identify.survivors.who.might.
benefit. from. services.. In. October. 2006,. Florida’s. Hurricane. Wilma. and. Hurricane. Katrina.
Regular.Services.Programs.were.criticized.by.the.Fort.Lauderdale.Sun-Sentinel.(Kestin.2006a).
as.a.ridiculous.waste.of.taxpayer.money.because.of.the.staff.time.expended.on.what.the.paper.
alleged.to.be.frivolous,.ineffective.strategies.to.identify.and.engage.survivors..These.strategies.
included. dressing. in. costume. and. singing. songs. for. preschoolers.. The. news. story. featured. a.
performance.by.crisis.counselors.dressed.in.costumes.at.a.preschool.where.they.sang,.“Windy.
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295Initial Behavioral Health Response
Biggie.is.our.friend..Windy.Biggie.is.strong.wind..She.turns,.turns,.turns,.turns.around..She’s.
knocking.things.to.the.ground.”
The. story. also. discussed. how. CCP. funds. were. expended. on. staff. organizing. hurricane. bingo,.
puppet.shows,.and.yoga.for.various.organizations.as.a.way.to.try.to.identify.and.reach.out.to.sur-
vivors..The.crisis.counselors.interviewed.admitted.that.finding.survivors.who.might.really.benefit.
from. the. CCP. was. difficult. because,. despite. the. fact. that. the. program. is. FEMA. funded,. FEMA.
would.not.share.the.names.and.addresses.of.FEMA.aid.registrants.due.to.privacy.concerns.(Kestin.
2006a)..This.was.not.always.the.case,.however,.but.transpired.after.FEMA.instituted.a.policy.change.
in.the.late.1990s.due.to.privacy.concerns.(Elrod,.Hamblen,.and.Norris.2006).
Following. the. Sun-Sentinel’s. report,. The. Honorable. Susan. M.. Collins,. Chairman. of. the.
Committee. on. Homeland. Security. and. Governmental. Affairs,. requested. both. FEMA. and. HHS.
to. investigate. Project. H.O.P.E.’s. Hurricane. Wilma. and. Katrina. programs. to. determine. if. federal.
funding.was.being.wasted.(Department.of.Homeland.Security.2008).m.The.Sun-Sentinel.continued.
publishing. articles. critical. of. Florida’s. CCPs. over. the. next. few. months.. In. December. 2006,. the.
newspaper.reported.CCPs.administered.in.states.other.than.Florida.had.also.engaged.in.allegedly.
inappropriate. activities. (Kestin. 2006b).. The. article. referred. to. other. CCPs. (California,. Virginia,.
Wisconsin,.and.Colorado).offering.classes.on.crafts,.martial.arts,.canning.and.freezing.foods,.pro-
viding. massages,. haircuts,. and. gumbo. cook-offs,. among. other. engagement. strategies,. to. identify.
survivors. and. offer. crisis. counseling. services. (Kestin. 2006b).. Later,. in. January. 2007,. the. Sun-
Sentinel. (Kestin. 2007). reported. that. Rep.. Tom. Feeney,. R-Oviedo,. and. Rep.. Mario. Diaz-Balart,.
R-Miami,.intended.to.file.a.bill.to.prevent.future.federal.disaster.funding.from.being.spent.on.crisis.
counseling.activities.ensuring.that.“no.disaster.relief.funds.are.used.for.any.type.of.crisis.counsel-
ing,.recreation.or.self-esteem.building.classes.or.instruction,.including.but.not.limited.to.dance.and.
exercise.classes,.bingo,.gardening.workshops,.puppet.shows.or.theater.productions.”.FEMA’s.initial.
response.to.Sen..Collins.in.December.2008.found.that.Project.H.O.P.E..was.spending.its.funding.on.
“reasonable.and.approved.items.and.activities”.under.federal.guidelines.(Kestin.2007;.Department.
of.Homeland.Security.2008)..FEMA’s.final.report.of.its.findings.was.not.released.until.September.
2008.(Department.of.Homeland.Security.2008)..Suffice.it.to.say.that.there.is.a.genuine.need.to.cre-
ate.a.more.realistic.public.perception.of.crisis.counseling.
16.6  TEMPORARY DISASTER EMPLOYMENT
From. 2004. to. 2007,. DCF. had. to. overcome. many. challenges. to. the. program,. and. the. unfavor-
able.media.coverage.of.the.Fort.Lauderdale.Sun-Sentinel.was.just.one.head.of.the.hydra..Other.
barriers. to. the. CCP. included. the. use. of. temporary. disaster. workers. and. unemployment. com-
pensation.issues..Until.2006,.DCF.used.two.options.for.hiring.disaster.teams:.the.teams.were.
either.contracted.through.community.behavioral.health.agencies,.or.they.were.hired.directly.as.
temporary.departmental.staff.by.the.service.districts.in.the.impacted.areas..Contracting.through.
a. community. agency. meant. the. workers. could. receive. certain. fringe. benefits. that. temporary.
departmental. disaster. staff. members. were. not. given.. No. line. item. expenses. for. vacation. or.
sick.leave,.pension.or.unemployment.benefits.were.included.in.the.CCP.budgets.for.temporary.
departmentalworkers.
The.decision.to.hire.teams.as.temporary.departmental.staff.or.on.contract.was.left.up.to.indi-
vidual. DCF. service. district. managers.. Some. of. the. service. districts. elected. to. hire. CCP. teams.
directly.rather.than.contract.them.out.to.community.behavioral.health.agencies..A.disadvantage.
to.this.hiring.method.was.that.the.district.supervisors.were.then.responsible.for.supervising.many.
more.staff,.which.could.be.quite.challenging..Direct.control.and.close.monitoring.of.team.activi-
ties.by.the.DCF.service.districts,.and.a.relatively.quick.hiring.process,.on.the.other.hand,.were.
distinct.advantages.to.hiring.temporary.departmental.workers..Even.when.there.is.a.gubernato-
rial.declaration.of.emergency,.which.waives.normal.state.procurement.regulations.(F.S..252.36),.
the.contract.execution.process.can.be.very.time.consuming..Further,.some.service.districts.did.
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296 Behavioral Health Response to Disasters
not.have.any.providers.that.were.willing.or.had.the.capacity.to.host.large.teams.of.disaster.out-
reach.workers.
16.7  PROVIDER AGENCY CAPACITY
Since.no.indirect.costs.are.permitted.in.the.CCP.(SAMHSA.CCP.Program.Guidance.nd),.con-
tracting. CCP. teams. can. present. a. significant. hardship. on. community. agencies. that. are. already.
financially.strained..Contracted.community.agencies.are.therefore.forced.to.provide.supervision,.
financial. management,. and. frequently,. office. space,. free. of. charge.. Nevertheless,. a. number. of.
agencies. agreed. to. host. teams. citing. reasons. such. as. goodwill. for. their. communities. and. con-
cern.that.untreated.postdisaster.distress.can.develop.into.long-term.mental.illness..In.the.latter.
instance,.this.means.that.more.people.might.eventually.become.long-term.clients.of.an.already.
beleaguered.and.overburdened.health.care.system..Some.of.Florida’s.contracted.agencies,.how-
ever,.simply.did.not.have.the.capacity.to.sustain.teams,.which.DCF.discovered.in.a.very.painful.
circumstance.
In.2006,.DCF’s.contract.with.a.small.agency.in.southwest.Florida.had.to.be.terminated.abruptly.
because.it.could.not.handle.the.expenses.for.the.large.number.of.CCP.staff.on.its.payroll..Unable.to.
meet.its.payroll.obligations,.the.agency.reached.a.point.where.it.was.giving.staff.only.half.of.their.
paychecks.or.no.paychecks.at.all..The.team.members.were.understandably.anxious.and.alarmed..
The.funding.shortfall.was.attributed.in.large.part.to.the.agency’s.cost.reimbursement-based.con-
tracts,.the.payment.methodology.used.by.DCF.to.ensure.compliance.with.the.CCP.prohibition.on.
indirect.costs..The.state’s.cost.reimbursementn.methodology,.however,.can.seem.bewildering.since.
it.requires.copious.amounts.of.documentation.to.demonstrate.that.monies.were.spent.on.approved.
items.and.activities..It.was.sometimes.several.months.before.providers.were.reimbursed.for.their.
CCP.expenses..The.service.district.eventually.hired.the.teams.directly.as.temporary.departmental.
staff.. Thus,. Florida. joined. ranks. with. other. states. that. have. experienced. similar. reimbursement.
problems.according.to.one.study.of.state.disaster.crisis.counseling.programs.(Elrod,.Hamblin,.and.
Norris.2006).
16.8  UNEMPLOYMENT COMPENSATION
As.temporary.departmental.workers,.the.staff.from.the.aforementioned.agency.were.paid.wages.
but. no. fringe. benefits,. including. unemployment. compensation,. because,. under. Florida. law,.
employees.hired.to.serve.on.a.temporary.basis.“in.case.of.fire,.storm,.snow,.earthquake,.flood,.
or.similar.emergency”.are.exempt.[F.S..443.1216.(4)(c)3]..At.that.time,.almost.half.of.the.CCP’s.
450. workers. were. hired. as. temporary. departmental. staff.. Despite. awareness. of. the. temporary.
nature. of. the. work,. some. of. these. temporary. staff. submitted. claims. for. benefits. to. the. state’s.
employment.security.agency.after.the.grants.ended..DCF.service.districts.fought.these.claims,.
and.at.least.some.of.the.cases.were.denied.on.appeal.by.state.employment.security.adjudicators.o.
Consequently,.it.came.as.quite.a.shock.when.DCF.discovered.that.federal.law.did.not.exclude.its.
temporary.departmental.workers.from.unemployment.benefits..In.fact,.only.very.short-term.and.
immediate.activities.such.as.firefighting,.storm.debris.removal,.public.works,.and.similar.activi-
ties.that.must.be.performed.to.avoid.further.harm.to.individuals,.property,.or.the.environment,.
meet. the. exclusion.. Disasters,. on. the. other. hand,. suggest. extensive. devastation. and. suffering,.
which.require.services.long.after.the.need.for.immediate.action.has.ceased..Therefore,.person-
nel.engaged.in.such.activities.may.not.be.excluded.from.unemployment.compensation.benefits.
(Kilbane.1997).
Consequently,. DCF. had. to. request. permission. from. FEMA. and. CMHS. to. allow. grant. bud-
get. adjustments. to. accommodate. unemployment. compensation. for. temporary. disaster. work-
ers..Due.to.DCF’s.unemployment.compensation.rate.setting.methodology,.however,.forecasting.
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297Initial Behavioral Health Response
these. expenses. accurately. was. very. difficult.. As. a. “reimbursing”. employer. (F.S.. 443.1313),. the.
Department.had.to.reimburse.the.state.employment.security.agency.dollar.for.dollar.on.all.actual.
individual.claims.paid..In.contrast,.most.community.agencies.have.established.unemployment.tax.
rates.that.could.be.easily.budgeted.into.the.CCP.grants.for.reimbursement.of.claims.p.Fortunately,.
there.were.sufficient.unspent.grant.funds.available.to.cover.all.of.the.estimated.claims.and.DCF.
received.approval.from.FEMA.and.CMHS.to.adjust.CCP.budgets.accordingly..There.was,.how-
ever,.the.possibility.that.individual.unemployment.compensation.expenses.could.arise.after.the.
end.of.the.grants’.service.period,.a.circumstance.that.would.unlikely.be.remedied.by.FEMA.and.
CMHS,.and.had.to.receive.approval.from.the.Florida.Legislative.Budget.Commission.(LBC;.F.S..
11.90).. This. is. necessary. because. the. Florida. Appropriations. Act. (Chapter. 216,. F.S.). provides.
funding.for.state.agencies.to.pay.routine.expenses.only.and.does.not.anticipate.special.funding.
for.infrequent.programs.like.the.CCP..Needless.to.say,.after.the.turmoil.and.frustration.of.dealing.
with.the.unemployment.compensation.issue,.DCF.elected.to.contract.all.field-based.CCP.services.
from.that.point.forward.
Indeed,.the.very.existence.of.the.CCP.hinged.on.the.Department’s.ability.to.obtain.spending.
authority. because. each. Notice. of. Grant. Award. (NOGA). required. approval. from. either. the. state.
legislature,.which.convenes.annually.in.the.spring,.or.the.LBC,.which.typically.meets.only.a.few.
times.each.year.(Kimber.2007,.7)..Since.the.statutory.exemption.from.state.procurement.regula-
tions.in.a.state.of.emergency.expires.after.60.days.(F.S..252.36),.DCF.frequently.required.urgent.
assistance.from.the.state.emergency.management.agency.and.the.governor’s.office.to.ensure.the.
CCP. was. explicitly. authorized. in. any. extended. executive. orders.. Further,. receipt. of. a. Regular.
Services. Program. NOGA. requires. the. state. to. terminate. its. Immediate. Services. Program. right.
away.(SAMHSA.CCP.Program.Guidance.nd)..This.requirement.poses.another.conundrum.since.
budget. authority. requests. must. be. presented. to. the. LBC. at. least. one. month. before. it. convenes,.
accompanied. by. substantiating. documentation. of. need. (i.e.,. the. NOGA. or. other. official. federal.
communication. of. grant. approval;. Kimber. 2007).. Consequently,. DCF. personnel. were. often. in.
a.state.of.panic.to.get.budget.authority.requests.for.new.Regular.Services.Programs.to.the.LBC.
before. the. Immediate. Services. Programs. ended.. The. absence. of. budget. authority. would. have.
forced.DCF.to.stop.the.CCP.at.a.crucial.time.in.the.postdisaster.recovery.period.and.deprive.sur-
vivors.of.the.emotional.and.educational.supports.they.needed.to.deal.with.the.disaster’s.aftermath.
(Kimber.2007,.7).
16.9  CONCLUSION
The.issues.discussed.in.this.chapter.represent.a.sampling.of.those.experienced.by.Florida’s.SMHA.
staff.as.they.were.attempting.to.develop.and.manage.CCPs.during.the.2004–2007.hurricane.sea-
sons..Since.then,.Florida’s.SMHA.has.developed.zero-dollar.funded.contracts.within.a.provider.
network. consisting. of. 12. community. behavioral. health. agencies. (DCF. nd).. This. network. now.
covers.62.of.Florida’s.67.counties..The.zero-dollar.contracts.can.be.easily.amended.after.the.state.
receives.a.grant.award.following.a.major.disaster.declaration.to.immediately.begin.implementing.
a. CCP,. thereby. substantially. reducing. the. time. needed. to. execute. contracts.. This. development.
was. largely. due. to. the. ingenuity. and. technical. skills. of. the. current. Disaster. Behavioral. Health.
Coordinator.. The. SMHA. still. endeavors. to. maintain. a. functional. disaster. cadre. for. immediate.
response.
Beginning.with.Tropical.Storm.Fay.in.2007,.Florida’s.DCF.and.other.state.SMHAs.have.been.
granted. limited. access. to. FEMA’s. disaster. assistance. registry.. This. has. allowed. CCP. teams. to.
focus. their. outreach. during. the. Immediate. Services. Program. with. known. survivors. potentially.
in.need.of.crisis.counseling..During.the.Regular.Services.Programs,.the.teams.can.attempt.con-
tact.with.any.survivors.missed.previously.or.recontact.other.registrants.who.may.still.need.crisis.
counseling.or.referrals.to.recovery.resources.q.Without.confirmation,.it.is.difficult.to.determine.if.
this.change.in.information.sharing.is.due.to.the.negative.media.publicity.mentioned.earlier.or.if.it.
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298 Behavioral Health Response to Disasters
is.the.result.of.resourceful.individuals.who.have.learned.ways.to.work.with.existing.policies.and.
regulations.
There.are.several.lessons.to.take.away.from.this.chapter.to.inform.future.crisis.counseling.pro-
grams..First,.personnel.tasked.with.implementing.disaster.crisis.counseling.services.should.expect.
delays.and.recognize.that.there.may.be.“extra.costs”.to.administering.crisis.counseling.programs..
SMHAs.need.to.ensure.disaster.cadres.are.maintained.and.trained,.and.that.cooperative.relation-
ships.with.disaster.partners.are.in.place.before.a.disaster.occurs.because.federal.assistance.may.be.
delayed.or.difficult.to.obtain..State.behavioral.health.agencies.should.also.maintain.records,.current.
disaster.plans,.standard.operating.procedures.and.checklists,.and.conduct.disaster.exercises.to.miti-
gate.against.institutional.memory.loss..Furthermore,.program.advertising.should.include.funding.
for.public.“attitude.shaping”.to.explain.not.only.how.behavioral.health.services.can.assist.survivors.
in.postdisaster.recovery,.but.provide.a.rationale.for.services.limitations..Finally,.while.state.statutes.
and.agency.policies.may.differ,.the.solutions.to.program.challenges.often.lay.hidden.within.them..It.
sometimes.takes.resourceful.and.dedicated.personnel.to.tease.out.the.solutions.in.order.to.overcome.
program.barriers.
NOTES
. a.. As.Director.of.Federal.Disaster.Behavioral.Health.Projects.with.the.Florida.Department.of.Children.
and. Families. from. 2005. through. 2008,. the. author. managed. the. Crisis. Counseling. Program. grants.
and. Project. Recovery,. a. program. funded. by. the. Substance. Abuse. and. Mental. Health. Services.
Administration.
. b.. These.temporary.disaster.staff.included.contract.and.Other-Personal-Services.(OPS).workers..Pursuant.
to.Florida.Statutes.(F.S.),.Chapter.110.131,.OPS.staff.may.be.hired.by.state.agencies.to.work.on.a.tem-
porary.basis.and.are.not.entitled.to.the.benefits.of.permanent.state.employees.
. c.. Charles.M..Kimber.served.as.the.Disaster.Behavioral.Health.coordinator.at.the.Florida.Department.of.
Children.and.Families.until.his.death.in.August.2007.
. d.. Homeland. Security. Presidential. Directive. 5,. Management. of. Domestic. Incidents,. established. the.
National.Response.Plan.on.February.28,.2003..It.was.amended.on.March.22,.2008,.and.renamed.
the. National. Response. Framework.. See. http://www.fema.gov/emergency/nrf/. for. additional.
information.
. e.. See.the.Florida.Comprehensive.Emergency.Management.Plan,.Appendix.VIII,.at.http://www.floridadi-
saster.org/documents/CEMP/2010/ESF%208.pdf.
. f.. See.the.Florida.Comprehensive.Emergency.Management.Plan,.Appendix.VI,.at.http://www.floridadisas-
ter.org/documents/CEMP/2010/ESF%206.pdf..
. g.. The. department. operated. a. Katrina. Evacuee. CCP. (Immediate. Services. Program,. with. extension,. and.
Regular.Services.Program).from.September.2005.to.December.2006.
. h.. See.FEMA’s.web.page,.About DRCs,.at.http://www.fema.gov/assistance/opendrcs.shtm..
. i.. Besides.being.the.SMHA,.the.department.is.also.responsible.for.administering.the.Temporary.Assistance.
for. Needy. Families. (TANF). program.. See. the. U.S.. Department. of. Health. and. Human. Services,.
Administration. for. Children. &. Families. for. more. information. about. this. federally. funded. program. at.
http://www.acf.hhs.gov/programs/ofa/.
. j.. Thanks.to.Marilyn.Juengst,.former.CCP.program.manager,.who.shared.this.experience.with.the.author.
. k.. The.Louisiana.SMHA’s.name.for.the.CCP;.each.state.brands.its.CCP.differently.
. l.. Psychological.debriefing.generally.refers.to.Critical.Incident.Stress.Debriefing.(CISD;.Mitchell.1983),.
which. was. initially. designed. to. ameliorate. adverse. psychological. sequelae. in. “first. responders”. after.
traumatic.events..It.was.designed.to.diffuse.the.intensity.of.acute.stress.reactions,.which,.in.turn,.reduces.
the.risk.of.long-term.mental.disorders..
. m.. Florida’s.CCP.is.branded.under.the.name.of.Project.H.O.P.E..(“Helping.Our.People.in.Emergencies”).
. n.. Cost. reimbursement. allows. the. state. to. reimburse. providers. for. actual. expenditures. incurred,. based.
on. a. line. item. budget,. which. makes. it. possible. to. demonstrate. that. all. expenditures. were. allowable.
expenses.
. o.. The.author.spoke.with.several.adjudication.officers.in.2006.who.heard.the.appeals.of.temporary.depart-
mental.staff.employed.in.the.department’s.CCPs..These.officers.cited.Florida.Statute.443.1216.(4)(c)3.as.
the.basis.for.the.exclusion.
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299Initial Behavioral Health Response
. p.. Nevertheless,.laying.off.numerous.contracted.staff.at.the.end.of.a.CCP.may.negatively.impact.the.con-
tributing.employer’s.unemployment.compensation.tax.rate.in.future.quarters.
. q.. A.heartfelt.thanks.to.James.(Jimmers).Micallef,.DCF’s.current.Disaster.Behavioral.Health.Coordinator,.
for.sharing.information.about.recent.developments.in.Florida’s.CCPs.
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301
17 Long-Term Mental Health
Treatment for Adult
Disaster Survivors
Jessica L. Hamblen, Erin Barnett, and Fran H. Norris
17.1  INTRODUCTION
The. impact. of. major. disasters. on. mental. health. is. well. understood.. Posttraumatic. stress. disorder.
(PTSD).is.the.most.commonly.studied.mental.health.problem.observed.in.these.studies.(Norris.and.
Elrod.2006;.Norris.et.al..2002)..Prevalence.rates.range.from.30.percent.to.40.percent.among.direct.
victims,. 10. percent. to. 20. percent. among. rescue. workers,. and. 5. percent. to. 10. percent. among. the.
general.population.(Galea,.Nandi,.and.Vlahov.2005).
In.this.chapter.we.review.long-term.mental.health.treatments.for.adult.disaster.survivors..Bryant.
and. Litz. (2009). distinguished. intermediate. or. long-term. interventions. designed. to. prevent. or. treat.
psychopathological.responses.from.immediate.or.short-term.interventions.designed.to.promote.safety.
and.stabilization..They.made.the.important.point.that.the.decision.about.which.intervention.to.imple-
ment.is.not.based.on.the.amount.of.time.that.has.passed,.but.rather.on.the.degree.of.ongoing.threat.and.
stability.(Bryant.and.Litz.2009)..A.survivor.who.is.worried.about.the.life.of.a.loved.one,.caring.for.an.
injured.family.member,.homelessness,.or.being.unemployed.cannot.focus.on.his.or.her.own.mental.
health. needs.. Thus,. a. World. Trade. Center. survivor. might. be. ready. for. long-term. treatment. several.
months.after.the.attack.while.a.Katrina.survivor.might.not.be.ready.for.close.to.a.year.because.
the.infrastructure.in.Louisiana.was.severely.disrupted.due.to.the.massive.flooding.after.Katrina.
CONTENTS
17.1. Introduction…………………………………………………………………………………………………………… 301
17.2. Long-Term.Treatments…………………………………………………………………………………………….. 302
17.2.1. PTSD.Treatment………………………………………………………………………………………….. 302
17.2.2. CBT.for.Disaster-Related.PTSD…………………………………………………………………….. 304
17.2.3. Disaster-Specific.Treatments…………………………………………………………………………. 305
17.2.4. Considering.Comorbidity……………………………………………………………………………… 306
17.2.5. Treatment.Summary…………………………………………………………………………………….. 307
17.3. Barriers.to.Care……………………………………………………………………………………………………… 308
17.3.1. Utilization.of.Mental.Health.Services…………………………………………………………….. 308
17.3.1.1. Utilization.Rates…………………………………………………………………………….. 308
17.3.1.2. Variables.Related.to.Utilization………………………………………………………… 308
17.3.1.3. Utilization.of.At-Risk.Groups…………………………………………………………… 309
17.3.1.4. Recommendations.for.Improving.Utilization……………………………………… 310
17.3.2. Treatment.Dissemination………………………………………………………………………………. 310
17.3.2.1. Recommendations.for.Improving.Dissemination………………………………… 312
17.4. Summary.and.Conclusions………………………………………………………………………………………. 312
References……………………………………………………………………………………………………………………… 313
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AN: 448580 ; Julie Framingham, Martell L. Teasley.; Behavioral Health Response to Disasters
Account: s7348467.main.ehost
302 Behavioral Health Response to Disasters
The.best.information.on.effective.treatments.for.disaster.comes.from.the.strong.treatment.out-
come. literature. on. PTSD.. Although. only. a. minority. of. these. studies. include. disaster. samples,.
thisbroader.literature.has.been.shown.to.generalize.across.trauma.types..Additional.information.
comes. from. the. small. but. emerging. literature. on. disaster-specific. treatments.. We. review. each. of.
these.areas.with.a.focus.on.interventions.appropriate.for.long-term.recovery..We.consider.issues.of.
comorbidity.and.how.conditions.such.as.depression,.substance.abuse,.and.grief.can.be.addressed..
We.end.with.a.review.of.barriers.to.care.and.what.factors.might.prevent.survivors.from.utilizing.
effective.treatments.and.clinicians.from.delivering.them..We.pay.specific.attention.to.cultural.and.
socioeconomic.barriers.
17.2  LONG-TERM TREATMENTS
17.2.1  pTsd TreaTMenT
Several.clinical.practice.guidelines.from.different.federal.agencies,.professional.organizations,.and.
countries.offer.recommendations.for.the.treatment.of.PTSD.(Australian.Centre.for.Posttraumatic.
Mental. Health. 2007;. Foa,. Keane,. and. Friedman. 2009;. National. Collaborating. Centre. for. Mental.
Health.2005;.Ursano.et.al..2004;.VA/DoD.Clinical.Practice.Guideline.Working.Group.2003)..The.
Institute.of.Medicine.(IOM).also.recently.published.a.report.evaluating.the.evidence.on.PTSD.treat-
ment.(Institute.of.Medicine.2008)..The.guidelines.unanimously.recommend.cognitive.behavioral.
therapies.as.the.most.effective.treatment.for.PTSD.
Cognitive. behavioral. treatments. (CBTs). typically. include. a. number. of. components,. including.
psychoeducation,.anxiety.management,.exposure,.and.cognitive.strategies..Exposure.and.cognitive.
restructuring.are.thought.to.be.the.most.effective.components..Exposure.involves.having.survivors.
repeatedly.reexperience.their.traumatic.event.by.confronting.feared.situations.by.imagining.their.
traumatic.event.(imaginal.exposure).and/or.by.entering.previously.avoided.situations.that.elicit.fear.
(in vivo.exposure)..Cognitive.strategies.have.a.primary.focus.on.challenging.and.modifying.mal-
adaptive.beliefs.related.to.the.trauma..We.will.review.exposure.interventions.first,.followed.by.the.
cognitive.ones..Many.cognitive.behavioral.treatments.include.both.components.or.aspects.of.both.
components.
There. is. strong. evidence. for. exposure. therapy’s. effectiveness. in. a. wide. range. of. populations,.
including.those.who.have.experienced.sexual.assault,.childhood.sexual.abuse,.motor.vehicle.acci-
dents,.crime,.and.mixed.trauma.samples.(e.g.,.Bryant.et.al..2003;.Cloitre.et.al..2002;.Foa.et.al..1999;.
Foa.et.al..2005;.Blanchard.et.al..2003;.Marks.et.al..1998;.Schnurr.et.al..2007)..Further,.although.
study.samples.have.included.mainly.middle-aged.survivors,.exposure.therapies.have.been.found.to.
be.effective.in.women.and.men.of.various.racial.backgrounds.(Cloitre.et.al..2002;.Foa.et.al..1999;.
Foa.et.al..2005;.Schnurr.et.al..2007)..Of.these.various.approaches,.prolonged.exposure.(PE),.devel-
oped.by.Edna.Foa,.has.received.the.most.attention..In.Foa’s.first.trial,.PE,.stress.inoculation.training.
(SIT),.and.to.a.lesser.extent.supportive.counseling.were.all.more.effective.in.reducing.PTSD,.rape-
related.distress,.anxiety,.and.depression.than.a.waitlist.control.in.a.small.sample.of.45.female.sexual.
assault.survivors.(Foa.et.al..1991).
In.an.attempt.to.optimize.the.effects.of.exposure,.PE.was.combined.with.other.effective.treat-
ments.in.the.next.two.trials..Unexpectedly,.the.combined.treatments.fared.worse..In.the.first,.PE.
alone.was.more.effective.than.the.combination.of.PE.plus.SIT,.SIT.alone,.or.a.waitlist.control.(Foa.
et.al..1999).on.symptoms.of.PTSD,.depression,.and.anxiety..The.authors.concluded.that.the.com-
bination.of.PE.plus.SIT,.which.was.expected.to.be.superior,.may.have.overloaded.the.client.with.
techniques.since.SIT.included.a.variety.of.techniques.
In. response. to. the. previous. study,. in. the. next. trial. a. single. technique,. cognitive. restructuring.
(CR),. was. added.. One. hundred. seventy-one. female. survivors. of. sexual. assault,. physical. assault,.
or.childhood.sexual.abuse.were.randomized.to.PE.alone,.PE.plus.CR,.or.waitlist.(Foa.et.al..2005)..
While.both.active.treatments.were.superior.to.waitlist.on.PTSD.and.depression,.again.the.combined.
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303Long-Term Mental Health Treatment for Adult Disaster Survivors
treatment.was.no.more.effective.than.PE.alone..The.authors.offered.two.possible.explanations.(Foa.
et. al.. 2005).. The. first. was. that. the. effect. of. equating. treatments. reduced. the. necessary. dose. of.
PE..That.is,.in.order.to.equate.the.amount.of.time.in.the.two.active.treatments.the.dose.of.PE.was.
reduced.and.may.not.have.reached.a.therapeutic.level..A.second.suggestion.was.that.the.approaches.
included.similar.elements,.and.therefore.the.effect.of.combining.elements.amounts.to.switching.one.
effective.element.for.another.
Other.investigators.who.have.added.a.novel.component.to.an.exposure.treatment.in.an.effort.to.
optimize.the.treatment.have.found.similar.results.(e.g.,.Arntz,.Tiesema,.and.Kindt.2007;.Cloitre.et.al..
2002;.Falsetti,.Resnick,.and.Davis.2008;.Glynn.et.al..1999)..For.example,.behavioral.family.therapy.
following.exposure.therapy.added.nothing.to.exposure.therapy.alone.in.terms.of.PTSD.improve-
ment.(Glynn.et.al..1999)..In.addition,.imagery.rescripting.(or.modifying.an.image.to.decrease.dis-
tress),. in. conjunction. with. imaginal. exposure,. added. nothing. to. imaginal. exposure. alone. (Arntz.
etal..2007)..These.findings.suggest.that.the.novel.components.were.not.necessary.
Several.others.have.evaluated.PE.and.found.it.effective.(e.g.,.Schnurr.et.al..2007;.Taylor.et.al..
2003).. For. example,. in. a. recent. multisite. randomized. controlled. trial. of. PE. with. female. veterans.
and. active-duty. personnel. with. PTSD,. women. who. received. PE. experienced. a. greater. reduction.
of. PTSD. symptoms. and. were. less. likely. to. meet. diagnostic. criteria. for. PTSD. relative. to. women.
who.received.present-centered.therapy.(Schnurr.et.al..2007)..In.another.investigation.(Resick.et.al..
2002),.PE.alone.was.compared.to.a.cognitive.intervention,.Cognitive.Processing.Therapy.(CPT),.
and.a.waitlist.control..Both.PE.and.CPT.were.superior.to.waitlist,.but.there.were.few.differences.
between.the.active.treatments.
Exposure.has.also.been.compared.to.eye.movement.desensitization.and.reprocessing.(EMDR),.
a.CBT.that.involves.engaging.in.imaginal.exposure.to.a.trauma.while.simultaneously.performing.
saccadic.eye.movements..Several.clinical.practice.guidelines.list.EMDR.as.an.effective.treatment..
Two.well-controlled.studies.compared.EMDR.to.PE..One.study.(Rothbaum,.Astin,.and.Marsteller.
2005).found.equivalent.results.while.the.other.found.PE.to.be.superior.(Taylor.et.al..2003)..However,.
although.studies.support.the.effectiveness.of.EMDR,.additional.research.has.raised.questions.about.
the. mechanism. of. action.. There. is. growing. evidence. that. the. theorized. eye. movements. are. an.
unnecessary.component.(Davidson.and.Parker.2001),.which.suggests.that.the.mechanism.for.action.
might.be.the.exposure.component.
Although.widely.researched,.prolonged.exposure.is.not.the.only.form.of.exposure.therapy..Others.
have.used.imaginal.and.in.vivo.exposure.with.and.without.cognitive.components.with.equal.success.
(e.g.,.Arntz.et.al..2007;.Blanchard.et.al..2003;.Glynn.et.al..1999;.Marks.et.al..1998)..Thus,.exposure.
is. effective. in. various. forms. and. with. a. range. of. trauma. types.. Exposure. therapy. for. PTSD. also.
seems.to.have.a.significant.effect.on.reducing.comorbid.depression.and.anxiety..However,.add-ons.
to.exposure.do.not.appear.to.boost.its.effectiveness.
Cognitive.interventions.also.are.widely.supported.in.treatment.guidelines.(Duffy,.Gillespie,.and.
Clark.2007;.Ehlers.et.al..2005;.Marks.et.al..1998;.Mueser.et.al..2008)..CPT.(Resick.and.Schnicke.
1996),. one. of. the. most. well-researched. cognitive. approaches,. has. a. primary. focus. on. challeng-
ing.and.modifying.maladaptive.beliefs.related.to.the.trauma,.but.also.includes.a.written.exposure.
component.. Developed. by. Patricia. Resick,. CPT. was. initially. shown. to. be. as. effective. as. PE. and.
more.effective.in.treating.PTSD,.depression,.and.guilt.than.a.minimal.attention.control.condition.
in. a. study. of. 171. female. sexual. assault. survivors. (Resick. et. al.. 2002).. CPT. has. also. been. shown.
to. be. effective. for. male. and. female. veterans. with. military-related. PTSD. (Monson. et. al.. 2006)..
Sixty.veterans.were.randomized.to.CPT.or.a.waitlist..Intention-to-treat.analyses.revealed.significant.
improvements.in.PTSD.and.comorbid.symptoms.in.the.CPT.condition.compared.with.the.waitlist.
condition..After.treatment,.40.percent.of.the.CPT.group.no.longer.met.criteria.for.PTSD.
In. contrast. to. the. study. of. PE,. once. CPT. was. shown. to. be. effective,. the. treatment. developers.
conducted.a.dismantling.study.to.determine.the.relative.utility.of.the.full.protocol.compared.with.
its.components:.cognitive.therapy.and.written.exposure.(Resick.et.al..2008)..All.three.treatments.
resulted.in.significant.improvement. in.PTSD..However,.cognitive.therapy.alone.resulted.in.faster.
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304 Behavioral Health Response to Disasters
improvement.than.written.exposure,.with.the.effects.of.the.full.protocol.falling.in.between.(Resick.
et.al..2008).
Just. as. there. are. various. approaches. to. exposure,. there. are. also. different. forms. of. cognitive.
therapy..For.example,.Ehlers.and.Clark.developed.a.cognitive.therapy.for.PTSD.that.involves.three.
goals:.(1).modifying.excessively.negative.appraisals,.(2).correcting.disturbances.in.autobiographi-
cal. memory,. and. (3). removing. problematic. behavioral. and. cognitive. strategies. (Ehlers. and. Clark.
2000)..In.a.small,.randomized.controlled.trial,.28.survivors.of.accident,.assault,.or.witnessing.death.
improved. significantly. more.on.PTSD,. depression,.and.anxiety.in.cognitive.therapy. compared. to.
waitlist.(Ehlers.et.al..2005)..Mueser.and.Rosenberg.(Mueser.et.al..2004).developed.a.CR.for.PTSD.
program.that.includes.education,.breathing.retraining,.and.CR.taught.as.a.general.self-management.
skill.for.dealing.with.any.negative.feeling.rather.than.solely.using.it.to.target.trauma-related.cogni-
tions.. Results. showed. that. CR. was. more. effective. than. usual. care. for. treating. PTSD,. depression,.
and. anxiety. in. people. with. severe. mental. illness,. including. borderline. personality. disorder. and.
psychotic.disorders.(Mueser.et.al..2008).
In. sum,. like. exposure-based.treatments,. there. is. strong. support. for. the. effectiveness. of. cogni-
tive.therapy..Cognitive.interventions.have.been.evaluated.in.women.and.men,.sexual.assault.survi-
vors,.veterans,.people.with.severe.mental.illness,.and.mixed.trauma.samples,.and.with.a.variety.of.
approaches..However,.aside.from.the.CPT.dismantling.study.(Resick.et.al..2008),.racial.diversity.
has.been.limited,.and.each.study.sample.consists.primarily.of.middle-aged.survivors..Nevertheless,.
these.treatments.appear.to.target.depression.and.anxiety.in.addition.to.PTSD..
Currently,. there. is. more. consistent. support. for. CBT. than. for. medications. in. the. treatment. of.
PTSD..In.fact,.there.is.some.disagreement.among.the.clinical.practice.guidelines.as.to.whether.phar-
macotherapy.should.be.considered.a.frontline.treatment.for.PTSD.(see.Friedman.2008)..However,.
at.times.survivors.may.choose.a.medication.over.psychotherapy.or.may.want.a.combination.of.both..
Two.selective.serotonin.reuptake.inhibitors.(SSRIs),.sertraline.and.paroxetine,.have.been.approved.
by.the.U.S..Food.and.Drug.Administration.for.the.treatment.of.PTSD..Both.have.been.evaluated.
in.multisite.randomized.controlled.trials.with.survivors.(Brady.et.al..2000;.Davidson,.Pearlstein,.
etal..2001;.Davidson,.Rothbaum,.et.al..2001;.Marshall.et.al..2001).with.positive.results..There.is.
also.a.positive.trial.of.the.SSRI.fluoxetine.(Martenyi.et.al..2002)..However,.negative.trials.have.been.
reported.as.well.(Friedman.et.al..2007;.Martenyi,.Brown,.and.Caldwell.2007).and.the.results.for.
medications.are.typically.less.impressive.than.those.found.with.CBT.(see.Friedman,.Davidson,.and.
Stein.2009.for.a.review.of.medications.for.PTSD).
17.2.2  cBT for disasTer-relaTed pTsd
A.few.studies.have.evaluated.treatment.for.disaster-related.PTSD..In.early.studies.with.earthquake.
survivors. in. Turkey,. Basoglu. and. colleagues. found. that. one. to. two. sessions. of. CBT. or. exposure.
to. artificial. tremors. in. an. earthquake. simulator. significantly. reduced. PTSD. symptoms. (Basoglu,.
Livanou,.and.Salcioglu.2003;.Basoglu.et.al..2003)..Two.later.randomized.controlled.trials.involved.
a.single-session.exposure.intervention.compared.to.either.a.wait-list.control.or.repeated.assessment.
(Basoglu,.Salcioglu,.and.Livanou.2007;.Basoglu.et.al..2005)..Findings.suggested.the.single-session.
behavioral.treatment.given.approximately.three.years.post-disaster.produced.a.substantial.decrease.
in.PTSD.symptoms..Given.the.promising.implications.of.this.trial.for.expedient.and.cost-effective.
treatment,.these.results.are.in.need.of.replication.
In. other. preliminary. work,. Gillespie. and. colleagues. (Gillespie. et. al.. 2002). studied. the. effec-
tiveness.of.Ehlers.and.Clark’s.cognitive.therapy.in.91.survivors.of.a.bombing.in.Northern.Ireland.
10months.post-bombing..All.survivors.had.PTSD.related.to.the.bombing..After.treatment,.the.sur-
vivors.had.significant.improvement.in.PTSD,.depression,.and.general.health..In.response.to.these.
promising.results,.the.research.team.randomized.58.survivors.of.terrorism.and.other.civil.conflict.
to.either.cognitive.therapy.or.waitlist.(Duffy.et.al..2007)..At.posttreatment,.participants.in.cognitive.
therapy. demonstrated. significantly. greater. improvement. in. self-reported. PTSD,. depression,. and.
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305Long-Term Mental Health Treatment for Adult Disaster Survivors
functioning.than.those.in.the.waitlist.with.continued.improvement.in.those.who.received.additional.
sessions.(Duffy.et.al..2007)
A. third. research. team. focused. on. providing. treatment. to. survivors. and. disaster. workers. from.
the.World.Trade.Center..One.study.utilized.a.quasi-experimental.design.in.which.survivors.were.
assigned. to. a. virtual. reality. or. a. matched. waitlist. control. group.. Results. indicated. significant.
improvement.in.PTSD.in.the.virtual.reality.group.compared.to.waitlist.(Difede,.Cukor.et.al..2007)..
In. the. other. study,. 31. disaster. workers. were. randomized. to. CBT. or. “treatment. as. usual”. (TAU;.
Difede,.Malta.et.al..2007)..CBT.included.psychoeducation,.breathing.retraining,.imaginal.and.in.
vivo. exposure,. cognitive. reprocessing,. and. relapse. prevention.. TAU. included. an. assessment. with.
referral. for. PTSD. treatment. with. a. community. provider.. Over. half. of. the. CBT. and. an. eighth. of.
the.TAU.participants.dropped.out.of.treatment..For.those.who.completed.treatment,.participants.in.
CBT.showed.significant.improvement.in.PTSD.relative.to.those.in.TAU,.although.no.participants.
followed. through. on. the. referral.. Intention-to-treat. analyses. yielded. no. significant. effects,. likely.
because.of.the.high.dropout.rate.
In. another. study. of. World. Trade. Center. victims,. therapists. at. an. outpatient. clinic. were. taught.
Skills.Training.in.Affective.and.Interpersonal.Regulation/Modified.Prolonged.Exposure.(STAIR/
MPE),.a.CBT.that.adds.affect.regulation.and.interpersonal.skills.into.a.prolonged.exposure.treat-
ment.. Significant. decreases. in. PTSD,. depression,. and. social. adjustment. were. observed. and. were.
similar.to.results.found.in.a.randomized.controlled.trial.of.the.same.treatment.(Levitt.et.al..2007).
One.other.study.is.worth.mentioning.for.its.novelty.in.responding.to.disaster..The.study.involved.
a.public.mental.health.program.initiated.in.response.to.the.London.bombings..The.program.involved.
two.components,.screening.and.treatment.(Brewin.et.al..2008)..Extensive.efforts.were.made.to.iden-
tify. and. screen. individuals. involved. in. the. bombings. to. identify. either. preexisting. mental. health.
problems.or.mental.health.problems.stemming.from.the.bombings..If.new.problems.were.identified,.
individuals.could.either.be.referred.for.immediate.trauma-focused.treatment.or.monitored.to.deter-
mine.if.the.problem.would.resolve.on.its.own.and.then.referred.if.necessary..Treatment.resources.
included. existing. programs. that. utilized. licensed. clinical. psychologists. offering. trauma-focused.
CBT. or. EMDR.. Therapists. were. supervised. by. specialists,. and. treatment. and. travel. costs. were.
reimbursed.
The. program. screened. 596. individuals,. 346. of. whom. received. a. more-detailed. assessment. to.
determine. whether. a. referral. was. indicated.. PTSD. was. the. predominant. diagnosis.. Seventy-four.
percent. were. referred. for. treatment,. while. 26. percent. were. judged. to. require. monitoring. only..
Preliminary. outcome. data. were. available. for. 82. individuals,. 72. of. whom. completed. treatment..
Treatment.yielded.large-effect.sizes.for.PTSD.and.depression.(Brewin.et.al..2008).
Overall,.there.is.a.strong.and.growing.literature.supporting.the.use.of.cognitive.behavioral.treat-
ments.for.disaster-related.PTSD..These.treatments.have.been.used.with.survivors.of.terrorism.and.
natural. disaster.. In. each. trial,. survivors. who. receive. CBT. improve. relative. to. waitlist. conditions..
Importantly,.improvements.are.regularly.seen.in.depression,.anxiety,.and.functioning.in.addition.to.
PTSD..These.findings.do,.however,.need.to.be.extended.to.diverse.populations,.as.most.of.the.survi-
vors.studied.were.middle-aged.women.(Basoglu.et.al..2007;.Basoglu.et.al..2005;.Brewin.et.al..2008;.
Gillespie.et.al..2002;.Levitt.et.al..2007)..Many.authors.did.not.report.racial/ethnic.backgrounds.of.
their.samples.
17.2.3  disasTer-specific TreaTMenTs
To. our. knowledge,. our. Hamblen. and. colleagues. (Hamblen. et. al.. 2006). are. the. only. ones. to.
develop. a. treatment. for. the. long-term. response. that. is. focused. more. broadly. on. postdisaster.
distress.rather.than.PTSD.specifically..Postdisaster.distress.encompasses.a.range.of.cognitive,.
emotional,.and.behavioral.reactions.to.disaster,.including.symptoms.of.PTSD,.depression,.stress.
vulnerability,. and. functional. difficulties.. Postdisaster. distress. is. not. a. psychiatric. diagnosis..
Within.certain.limits,.distress.is.perfectly.natural.and.normal.and.can.be.expected.to.improve.
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306 Behavioral Health Response to Disasters
on.its.own..Sometimes,.however,.this.distress.becomes.severe.and/or.prolonged.enough.to.inter-
fere.with.quality.of.life.
There.are.several.advantages.to.this.approach.(Hamblen.et.al..2006)..First,.it.could.assist.indi-
viduals.who.present.with.other.primary.reactions,.such.as.depression,.mixed.conditions,.or.sub-
clinical.conditions..Although.the.PTSD.treatment.studies.reviewed.previously.demonstrate.effects.
beyond.PTSD,.disaster.survivors.without.a.primary.PTSD.diagnosis.are.excluded.from.these.treat-
ments..Second,.a.treatment.focused.on.postdisaster.distress.or.stress.is.potentially.more.acceptable.
to.survivors.who.may.be.suffering.from.mental.health.problems.for.the.first.time..Finally,.a.single.
treatment.focused.on.distress.as.opposed.to.diagnosis.reduces.the.need.for.extensive.assessment.
and.can.be.disseminated.to.community.clinicians.through.a.single.training.(rather.than.through.
multiple.trainings.for.disorders).and.increases.the.feasibility.of.the.treatment’s.use.in.community.
settings.
Cognitive. Behavioral. Therapy. for. Postdisaster. Distress. (CBT-PD;. Hamblen. et. al.. 2006). is. a.
manualized.disaster-specific.intervention.that.has.a.primary.focus.on.identifying.and.challenging.
maladaptive.disaster-related.beliefs..It.includes.psychoeducation,.breathing.retraining,.behavioral.
activation,.and.cognitive.restructuring..Evaluation.was.minimal.in.the.first.pilots.of.the.approach,.
taking.place.in.New.York.after.the.World.Trade.Center.bombings.(Donahue.etal..2006).and.in.
Florida. after. the. 2004. Hurricanes. Bonnie,. Charley,. Frances,. Ivan,. and. Jeanne. (Hamblen. and.
Norris.2007),.but.preliminary.results.were.promising..In.a.subsequent.study.employing.a.quasi-
experimental.repeated.measures.design,.88.racially.diverse.adult.survivors.of.Hurricane.Katrina.
were.given.CBT-PD.and.were.assessed.at.referral,.pretreatment,.intermediate.treatment,.and.post-
treatment.(Hamblen.etal..2009)..The.overall.pre-posteffect.size.was.1.4.in.intention-to-treat.anal-
yses,.demonstrating.CBT-PD.resulted.in.large.and.significant.improvements.in.distress..Benefits.
were.maintained.at.five-month.follow-up.
17.2.4  considering coMorBidiTy
Although.PTSD.is.the.most.common.mental.health.problem.after.disaster,.depression,.anxiety,.and.
increased. substance. use. are. frequent. as. well.. Depending. on. the. nature. of. the. disaster,. prolonged.
grief. can. also. be. an. area. of. concern. if. there. was. significant. loss. of. life.. In. our. opinion,. depres-
sion.and.anxiety.can.often.be.addressed.as.part.of.the.PTSD.treatment..As.reviewed.before,.most.
CBTs.for.PTSD.also.significantly.reduce.depression.and.anxiety..Similarly,.medications.effective.
for.PTSD.also.target.symptoms.of.anxiety.and.depression.
Substance.abuse.problems.are.another.area.of.concern.after.disaster.(see.Chapter.18,.this.vol-
ume,.for.more.on.this.topic)..After.a.disaster,.survivors.may.relapse.or.use.more.heavily.than.before.
the.disaster,.but.new.onset.substance.abuse.problems.are.rare.(North.et.al..1999)..A.series.of.studies.
on. the. use. of. cigarettes,. alcohol,. and. marijuana. among. New. York. City. residents. after. the. World.
Trade. Center. attack. demonstrated. an. increase. in. substance. use. immediately. following. the. attack.
(Vlahov.et.al..2002);.however,.it.was.still.true.that.the.percentage.of.new.onset.cases.was.relatively.
small.(2.2percent).compared.to.the.number.of.new.onset.cases.of.PTSD.(Vlahov.et.al..2006).
Few.treatments.exist.to.treat.comorbid.PTSD.and.substance.use..The.most.popular.treatment.is.
Seeking.Safety.(SS)..SS.is.a.present-focused.therapy.that.focuses.on.teaching.coping.skills.that.are.
relevant.to.both.PTSD.and.substance.use..There.are.25.topics.that.address.cognitive,.behavioral,.
interpersonal,.and.case.management.issues..Data.from.two.large.randomized.controlled.trials.of.SS.
both. demonstrated. significant. reductions. in. PTSD. symptoms,. but. SS. was. no. more. effective. than.
either.active.control.condition.(relapse.prevention.or.women’s.health.education).in.reducing.PTSD.
symptoms..Outcomes.related.to.substance.use.were.inconsistent..While.both.SS.and.relapse.preven-
tion.resulted.in.improved.substance.outcomes.in.the.first.study,.there.was.no.effect.of.SS.or.women’s.
health.education.on.substance.use.in.the.second.study.(Hien.et.al..2004;.Hien.et.al..2009)..Thus,.at.
this.point.the.literature.does.not.support.its.use.as.a.PTSD.or.substance.abuse.treatment,.although.it.
may.be.an.effective.treatment.engagement.strategy.
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307Long-Term Mental Health Treatment for Adult Disaster Survivors
Two. models. have. been. proposed. to. account. for. the. association. between. PTSD. and. SUD.
(Jacobsen,.Southwick,.and.Kosten.2001)..In.one.case,.the.PTSD.is.primary.and.patients.drink.to.
cope.with.PTSD.symptoms..In.the.other.case,.SUD.is.primary.and.patients’.substance.use.places.
them. in. risky. environments. where. they. are. more. likely. to. be. traumatized.. Data. support. the. first.
model. (Chilcoat. and. Breslau. 1998a,. 1998b),. sometimes. called. the. self-medication. theory,. where.
patients.use.substances.to.manage.their.PTSD.symptoms..Given.the.state.of.the.literature.and.the.
proposed.relationship.between.PTSD.and.substance.use,.our.current.recommendation.is.that.when.
possible,. individuals. with. substance. abuse. problems. should. be. included. in. cognitive. behavioral.
treatments. for. PTSD.. Pilot. work. under. way. suggests. that. both. PE. and. CPT. can. be. effective. in.
treating.PTSD.in.people.with.the.comorbid.condition.and.may.reduce.substance.use.as.well.(E..Foa.
personal.communication,.October.14,.2009;.K..Chard.personal.communication,.October.6,.2009).
Prolonged.grief.is.a.condition.that.can.be.observed.after.trauma.when.there.is.a.major.loss,.such.
as.the.death.of.a.spouse.or.child..Prolonged.grief.has.also.been.called.complicated.grief.or.traumatic.
grief.(Prigerson.et.al..2009)..Prolonged.grief.is.more.persistent,.consuming,.and.debilitating.than.is.
normal.grief..Now.under.evaluation.for.inclusion.in.the.Diagnostic and Statistical Manual,.5th.ed..
(APA,.in.press),.prolonged.grief.disorder.describes.a.severe.condition.wherein.the.bereaved.person.
has. experienced. both. separation. distress,. characterized. as. an. intense. yearning. for. the. deceased.
person,.and.a.high.co-occurring.frequency.of.cognitive,.emotional,.or.behavioral.symptoms.such.as.
avoidance,.shock,.confusion,.trouble.accepting.loss,.difficulty.trusting.others,.bitterness,.difficulty.
moving.on,.emotional.numbness,.and.sense.of.meaninglessness..Symptoms.must.persist.for.at.least.
six.months.and.result.in.significant.functional.impairment.(Prigerson.et.al..2009).
Although. prolonged. grief. disorder. shares. some. symptoms. with. depression. and. anxiety. (most.
notably.PTSD),.it.has.repeatedly.been.shown.to.differentiate.from.the.two.(Prigerson.et.al..2009)..
Few.treatments.exist.for.prolonged.grief;.we.were.able.to.identify.only.one.randomized.controlled.
trial..Shear.and.colleagues.developed.a.complicated.grief.treatment.that.includes.both.interpersonal.
psychotherapy. (IPT). components. for. the. depressive. symptoms. and. cognitive. behavioral. therapy.
components. for. the. intrusive. and. avoidant. symptoms. (Shear. et. al.. 2005).. IPT. focuses. on. helping.
patients.arrive.at.a.more.realistic.assessment.of.the.relationship.with.the.deceased.and.identifying.
positive.and.negative.aspects.of.the.relationship..Cognitive.behavioral.therapy.includes.both.in.vivo.
and.imaginal.exposure..The.patient.is.asked.to.complete.a.“revisiting”.exercise.in.which.they.tell.
the.story.of.the.deceased’s.death..They.are.also.asked.to.have.an.imaginary.conversation.with.the.
deceased.in.which.the.patient.asks.questions.and.then.takes.on.the.role.of.the.deceased.to.answer..In.
a.randomized.controlled.trial.comparing.the.complicated.grief.treatment.to.IPT.alone,.51.percent.of.
participants.in.the.complicated.grief.treatment.responded.to.the.treatment.compared.to.28.percent.
of.participants.in.IPT.alone.(Shear.et.al..2005).
While.the.results.of.the.trial.were.promising,.more.than.half.of.participants.in.the.grief.treatment.
continued.to.present.with.symptoms.following.the.treatment..In.addition,.only.a.minority.of.deaths.
were.from.unnatural.causes.such.as.a.natural.disaster.or.terrorism..Thus,.it.is.not.clear.whether.par-
ticipants.who.were.grieving.from.“traumatic”.deaths.would.respond.similarly..Another.limitation.
was.that.while.almost.half.of.participants.had.current.PTSD,.PTSD.was.not.assessed.as.an.outcome.
measure..Thus,.it.is.impossible.to.determine.if.the.grief.treatment.targeted.the.PTSD.symptoms.as.
well..It.may.be.that.when.loss.of.life.is.due.to.a.traumatic.event,.a.PTSD-specific.treatment.may.be.
indicated.
17.2.5  TreaTMenT suMMary
The. previous. treatment. review. should. help. inform. clinicians. and. policy. makers. on. the. range. of.
treatments.that.are.available.following.disaster..There.is.a.strong.evidence.base.for.using.cognitive.
behavioral.treatments.for.PTSD.and.a.growing.one.in.support.of.their.use.with.disaster.survivors,.
although.findings.need.to.be.extended.to.diverse.populations,.particularly.to.the.young,.the.elderly,.
and.members.of.racial.minority.groups..These.treatments.are.highly.effective.for.PTSD,.but.also.
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308 Behavioral Health Response to Disasters
often. treat. comorbid. problems.. Novel. treatment. approaches. are. also. in. development. for. use. with.
survivors. with. postdisaster. distress. who. may. either. not. have. PTSD. or. may. be. resistant. to. being.
labeled. with. a. mental. disorder.. Finally,. researchers. are. starting. to. consider. how. to. provide. more.
integrated.care.for.some.conditions.such.as.substance.abuse.and.prolonged.grief.
17.3  BARRIERS TO CARE
In.the.second.half.of.the.chapter,.we.turn.to.barriers.to.care..Even.if.we.can.identify.the.best.treat-
ments.for.the.long-term.response.to.disaster,.they.are.only.effective.if.survivors.access.them.and.
providers.deliver.them.with.efficacy..We.begin.by.defining.the.relevant.concepts..By.utilization,.
we.mean.connecting.with.and.using.available.services;.retention.refers.to.completing.an.adequate.
“dose”.of.an.intervention.so.improvements.are.possible..Other.important.concepts.include.“need”.
and. “demand”. for. mental. health. services.. We. believe. that. at. times. these. constructs. are. used.
interchangeably.when.they.really.should.be.considered.distinct..At.the.population.level,.need.can.
be. defined. as. the. number. of. individuals. directly. affected. by. a. disaster. who. could. benefit. from.
receiving.mental.health.services..However,.it.has.repeatedly.been.shown.that.not.all.people.who.
need.services.seek.them..Thus,.we.define.demand.as.those.individuals.who.actually.seek.mental.
health.care.
The.distinction.between.need.and.demand.is.important.because.some.researchers.have.asserted.
that.mental.health.“needs”.following.disasters.often.exceed.the.services.available.in.a.community.
(Marshall.et.al..2006)..Some.researchers.have.also.predicted.that.optimal.mental.health.response.
programs,.those.predicted.to.have.high.recovery.rates.and.avert.long-term.public.health.costs,.would.
exceed.available.providers.(Schoenbaum.et.al..2009)..However,.the.ways.in.which.need.has.been.
defined.in.the.literature.likely.includes.many.individuals.who.will.neither.desire.nor.seek.care..In.
our. experience,. demand. is. rarely. equivalent. to. need,. and. only. a. small. portion. of. those. who. may.
need.services.ever.demand.them..However,.there.are.many.barriers.to.utilization.
17.3.1  uTilizaTion of MenTal healTh serVices
17.3.1.1  Utilization Rates
It.is.no.surprise.that.disasters.are.followed.by.increases.in.psychological.symptoms.(Norris.etal..
2002). and. that. many. who. likely. need. or. demand. services. do. not. receive. care.. For. example,.
researchers. estimated. that. six. months. after. Hurricane. Katrina,. 31. percent. of. individuals. living.
in.the.areas.affected.by.the.hurricane.acquired.mental.health.disorders.(need);.yet.only.one-third.
(32 percent). of. these. individuals. had. utilized. services. (Wang. et. al.. 2007).. Following. the. 9/11.
terrorist. attacks,. estimates. of. between. 11. percent. and. 36. percent. of. those. with. mental. health.
disorders. sought. mental. health. care. (DeLisi. et. al.. 2003;. Stuber. et. al.. 2006).. Further,. among.
individuals.who.do.demand.and.enroll.in.services,.retention.rates.are.poor..Wang.et.al..reported.
that.64.percent.attended.only.one.or.two.visits.to.health.or.mental.health.care.agencies.follow-
ing. Hurricane. Katrina.. Similarly,. 55. percent. of. those. enrolled. in. a. cognitive-behavioral. treat-
ment.study.following.Hurricane.Katrina.did.not.complete.treatment.(Hamblen.et.al..2009),.even.
thought.the.treatment.was.free.and.offered.in.many.convenient.locations..The.high.proportion.of.
individuals.who.need.care.yet.do.not.seek.or.receive.it.is.alarming.considering.the.public.health.
relevance.of.psychiatric.conditions.after.disasters,.such.as.PTSD,.major.depression,.and.anxiety.
(Norris.et.al..2002).
17.3.1.2  Variables Related to Utilization
Recent.investigations.in.postdisaster.contexts.have.begun.to.uncover.factors.that.relate.to.utiliza-
tion..Because.the.literature.often.does.not.distinguish.between.need.and.demand,.we.will.attempt.
to.disentangle.these.concepts.throughout.our.discussion..Anderson’s.Behavioral.Model.of.health.
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309Long-Term Mental Health Treatment for Adult Disaster Survivors
care.utilization.(Andersen.and.Newman.1973).has.been.applied.and.validated.in.numerous.stud-
ies. of. trauma. and. disaster. victims. (Anderson. 1995;. Elhai. and. Ford. 2009;. Koenen. et al.. 2003)..
The.model.outlines.three.factors.that.impact.utilization:.need,.predisposing.factors,.and.enabling.
factors.. In. this. model,. need. refers. to. both. perceived. need. for. help. and. severity. of. symptoms..
Predisposing. factors. include. historical. or. sociodemographic. characteristics.. Enabling. factors.
encompass.access.to.resources.and.availability.of.interventions..In.a.recent.meta-analysis.of.25.
studies.investigating.utilization.of.mental.health.services.after.disasters,.Elhai.and.Ford.(2009).
found.that.the.need.variables.of.severity.of.PTSD,.depression,.and.anxiety.had.the.largest.bear-
ings. on. utilization.. The. predisposing. variables. of. more. stressful. life. events,. more. exposure. to.
trauma.and.disaster,.and.being.middle-aged.were.also.positively.related.to.utilization..Enabling.
factors.were.not.strongly.related.to.utilization,.although,.notably,.these.variables.were.the.least.
likely.to.be.included.in.studies.
Although. enabling. factors. did. not. strongly. relate. to. utilization. in. the. meta-analysis,. raising.
awareness.and.increasing.availability.of.psychological.care.is.an.obvious.important.step.following.
disasters..Survivors.cannot.utilize.treatment.unless.they.are.aware.of.it.and.it.is.available.to.them..
To.this.end,.large-scale.mental.health.response.programs.have.been.implemented.in.the.wake.of.
disasters..One.such.program.following.the.9/11.World.Trade.Center.attacks,.Project.Liberty,.spent.
$9.4.million.on.marketing.in.the.three.months.following.the.event.(Frank.et.al..2006)..Researchers.
reported.that.24.percent.of.New.York.City.inhabitants.were.aware.of.the.project..However,.aware-
ness. was. not. enough. to. improve. utilization.. Of. those. who. were. aware,. 67. percent. had. a. good.
impression. of. the. project,. yet. only. 23. percent. reported. they. would. call. the. hotline. for. services.
(estimate.of.demand;.Rudenstine.et.al..2003)..Higher.socioeconomic.status.was.related.to.aware-
ness. of. the. program,. whereas. indications. of. underprivileged. status. (e.g.,. racial. minority,. lower.
income,.immigrant),.as.well.as.severity.of.PTSD.symptoms.(need),.were.positively.related.to.esti-
mated.demand.
In. an. effort. to. further. assess. whether. mental. health. needs. were. met. following. the. 9/11. World.
Trade. Center. attacks,. a. random. digit. dial. phone. survey. was. initiated. in. the. NYC. metropolitan.
area.six.months.following.the.attack.(Stuber.et.al..2006)..Seventeen.percent.of.those.with.probable.
PTSD.or.depression.(need).considered.mental.health.treatment..Of.those.with.probable.diagnoses.
who.considered.but.did.not.seek.care,.the.most.frequently.reported.barriers.included.believing.that.
other.people.needed.the.help.more.than.they.did.(58.percent),.perceptions.of.not.having.enough.time.
(42.percent).and.money.(39.percent),.perceived.stigma.associated.with.having.a.mental.illness.(27.
percent),.lack.of.knowledge.of.services.(17.percent),.and.preferences.to.take.care.of.the.problems.
on.their.own.or.with.the.help.of.family.(14.percent)..Prior.emotional.problems.and.sexual.abuse,.
previous.mental.health.services,.and.current.physical.health.problems.increased.the.likelihood.of.
utilization.(Stuber.et.al..2006).
Other. investigators. have. found. that. many. people. who. need. mental. health. care. do. not. utilize.
services.because.they.do.not.know.or.do.not.believe.that.effective.treatments.are.available.(Pietrzak.
etal..2009)..In.our.experience,.the.competing.demands.and.stressors.that.accompany.disasters,.such.
as.property.damage,.displacement,.and.financial.and.resource.loss,.also.serve.as.significant.barriers.
to.mental.health.care.utilization.
17.3.1.3  Utilization of At-Risk Groups
Although.being.a.member.of.an.underprivileged.or.minority.group.(racial.minority,.physical.dis-
ability,.etc.).did.not.significantly.relate.to.utilization.in.Elhai.and.Ford’s.(2009).meta-analysis,.much.
attention. has. been. focused. on. the. vulnerability. of. at-risk. groups.. Some. research. has. shown. that.
not.only.are.marginalized.groups.at.greater.risk.for.psychiatric.problems.following.disasters.than.
nonmarginalized.groups,.they.also.have.unequal.access.to.information.about.impending.disasters.
and.are.treated.differently.during.relief.efforts.(Stough.2009)..For.example,.statistics.show.that.the.
elderly. and. persons. with. disabilities. in. institutions. are. overrepresented. among. disaster. fatalities.
(Cook.and.Elmore.2009)..As.a.result,.recent.attention.has.been.given.to.the.complexities.of.disaster.
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310 Behavioral Health Response to Disasters
preparedness,. response,. and. recovery. for. long-term. care. facilities. (Dosa. et. al.. 2008;. Hyer. et. al..
2006).
In. addition,. professionals. argue. that. members. of. marginalized. groups. have. more. barriers. to.
recovery.than.do.able-bodied.and.able-minded.persons.and.are.at.higher.risk.for.postdisaster.psy-
chiatric.problems.(Hawkins.et.al..2009;.Stough.2009)..Researchers.assert.that.this.increased.risk.is.
accounted.for.by.an.interaction.of.various.pre-,.peri-,.and.postdisaster.factors,.including.important.
socioeconomic. and. sociocultural. variables. (Hawkins. et. al.. 2009).. For. example,. key. differences.
between.groups.exist.in.terms.of.risk.perceptions,.disaster.preparation,.prior.traumatic.experiences,.
cultural.beliefs.(e.g.,.external.locus.of.control,.mistrust.of.professionals),.and.help-seeking.behaviors.
(e.g.,.use.of.family.or.kin.rather.than.professionals)..Taken.together.with.the.reality.that.marginal-
ized. communities. often. have. weaker. infrastructures. to. support. interventions. and. less. access. to.
culturally. competent. interventions. and. resources. (e.g.,. documents. and. services. only. provided. in.
English),.we.can.glean.a.clearer.picture.of.why.these.groups.might.not.utilize.mental.health.services.
(Hawkins.et.al..2009).
17.3.1.4  Recommendations for Improving Utilization
It.is.our.belief.that.it.is.not.enough.just.to.set.up.a.disaster.treatment.program.and.hope.that.survivors.
will.access.it..Even.the.most.expensive.media.campaigns.fail.to.enroll.the.majority.of.survivors.in.
need.of.treatment..Special.attention.must.be.paid.to.identifying.those.survivors.in.the.greatest.need.
of.services.and.finding.ways.of.making.the.treatments.more.acceptable.to.these.groups..We.sug-
gest.that.disaster.treatment.programs.work.with.social.service.and.crisis.agencies.to.determine:.the.
groups.most.in.need,.appropriate.outreach.strategies.to.reach.these.groups,.and.unique.barriers.to.
care.for.these.groups..Marketing.and.recruitment.should.also.aim.to.make.individuals.aware.that.
there.are.enough.services.to.go.around.and.that.they.personally.deserve.treatment..Individuals.also.
need.to.be.informed.that.mental.health.care.is.often.of.no.cost.to.them.following.disasters;.govern-
ment.and.grant-funded.programs.are.put.into.place.due.to.the.expected.mental.health.problems.that.
can.occur.
The.needs.of.special.populations.should.be.considered.as.well..For.example,.following.the.World.
Trade.Center.attack,.a.special.effort.was.made.to.reach.out.to.undocumented.workers.who.may.have.
been.working.in.the.World.Trade.Center..In.addition,.materials.had.to.be.translated.into.multiple.
languages.in.order.to.make.the.treatments.acceptable.to.non-English-speaking.survivors..Similarly,.
in.Florida.the.elderly.were.a.population.of.concern.after.the.2004.hurricanes..Older.adults.are.often.
not.able.to.come.to.the.therapist.for.an.office.visit.and.may.require.more.time.to.comprehend.the.
treatment.material..More.generally.as.a.field,.we.need.to.understand.more.about.why.individuals.
underutilize.and.drop.out.of.treatment..Investigators.are.encouraged.to.consider.this.research.ques-
tion.when.designing.studies.and.analyzing.outcomes.
17.3.2  TreaTMenT disseMinaTion
Even.if.effective.treatments.exist.and.survivors.want.to.access.them,.both.systemic.and.clinician.
barriers.may.exist. Several.unique.systemic.issues.arise.when.attempting.to.disseminate.effective.
treatments.in.the.wake.of.disaster.(see.Marshall.et.al..2006.for.review)..Treatments.are.often.imple-
mented.through.a.community.response,.which.brings.with.it.distinctive.systems.issues.regarding.
referral.and.treatment.delivery..Training.programs.often.need.to.be.implemented.quickly,.inexpen-
sively,.and.to.many.providers.with.a.range.of.backgrounds..There.is.often.less.time.to.offer.com-
prehensive.didactics.and.supervision.to.providers.than.in.other.training.contexts..Further,.effective.
treatments.compete.with.other.types.of.interventions,.and.service.planners.and.organizations.may.
fail. to. work. together,. experience. communication. problems,. feel. ambivalent. toward. trainers. who.
might.be.considered.“outsiders,”.and.have.limited.funding.and.resources.(Norris.et.al..2005).
Clinician.barriers.can.exist.both.in.terms.of.training.needs.and.in.terms.of.resistance.to.deliver-
ing.the.identified.treatments..With.respect.to.training,.a.review.of.the.CBT.dissemination.literature.
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311Long-Term Mental Health Treatment for Adult Disaster Survivors
in-.and.outside.of.the.postdisaster.context.indicates.that.community-based.therapists.can.be.trained.
to. implement. effective. treatments. in. local. crisis. and. community. agencies.. Rape. crisis. counsel-
ors,. community. mental. health. clinicians,. and. school-based. counselors. have. been. shown. to. be.
able.to.learn.specific.CBT.interventions.and.to.provide.them.with.good.outcome.(Foa.et.al..2005;.
Gillespieet.al..2002;.Stein.et.al..2003)..Together.these.studies.indicate.that.it.may.be.possible.to.
train. clinicians. in. a. variety. of. nonacademic. settings. to. provide. effective. manualized. CBT. treat-
ments.for.PTSD.
Only. two. studies. report. on. training. therapists. to. provide. CBT. following. a. disaster.. The. first.
involved.a.two-day.training.of.PE.to.more.than.100.frontline.clinicians.following.the.9/11.World.
Trade.Center.attacks.(Marshall.et.al..2006)..Results.from.the.pretraining.assessment.indicated.that.
therapists.were.moderately.favorable.regarding.the.active.components.of.the.treatment,.but.felt.that.
they.lacked.the.skill.to.adequately.deliver.the.exposure.treatment..No.posttraining.assessment.was.
completed.
The.second.study.involved.a.two-day.training.of.community.clinicians.in.Baton.Rouge,.Louisiana,.
to.deliver.CBT-PD.following.Hurricane.Katrina.(Hamblen.et.al..2010)..Results.indicated.that.the.
training.was.effective.in.educating.therapists.about.CBT-PD..Therapists,.especially.those.who.were.
not.already.at.the.maximum.score.at.pretraining,.showed.significant.improvements.in.their.ratings.
of. the. importance. of. various. elements. of. CBT. in. therapy,. their. knowledge. and. understanding. of.
those.elements,.and.their.confidence.that.they.could.use.them.effectively.
These.studies.indicate.that.it.may.be.possible.to.train.community-based.clinicians.in.manu-
alized.interventions.for.PTSD.or.postdisaster.distress..A.large.number.of.therapists.from.dif-
ferent. agencies. were. taught. to. deliver. these. interventions. with. relatively. little. training. and.
significantly.less.intensive.supervision.than.in.a.typical.randomized.controlled.trial..The.two.
disaster. studies. also. support. the. success. of. “just-in-time”. trainings. of. evidence-based. CBT.
interventions. that. can. be. implemented. in. the. aftermath. of. a. disaster. (Hamblen. et. al.. 2010;.
Marshall.et.al..2006).
Another.barrier.to.treatment.can.be.resistance.on.the.part.of.the.clinician..Many.clinicians.are.
reluctant.to.delivering.manualized.treatments,.either.because.they.think.they.do.not.“fit”.their.
clients.or.they.believe.that.their.clinical.techniques.and.interventions.are.more.effective.(Addis,.
Wade,.and.Hatgis.1999)..Therefore,.a.training.goal.should.be.helping.clinicians.understand.that.
most. CBTs. are. quite. adaptive. to. specific. client. presentations. and. can. be. tailored. to. meet. the.
specific.client.needs..The.cognitive.and.behavioral.components.of.the.treatments.are.focused.on.
the.unique.issues.of.the.client..No.two.clients.will.ever.receive.the.exact.same.treatment.because.
it.is.their.own.values,.beliefs,.and.fears.that.shape.the.treatment..It.may.also.be.that.manuals.can.
be.used.more.flexibly.than.once.thought..Two.disaster.treatment.models.have.been.used.flexibly.
with. success.. One. such. model. is. specialized. crisis. counseling. services. (SCCS),. a. team-based.
program.that.was.implemented.as.part.of.Project.Recovery.following.Hurricane.Katrina.(Jones.
et. al.. 2009).. SCCS. is. a. blend. of. CBT,. solution-focused,. and. person-centered. approaches. that.
involves. flexible,. stand-alone. sessions.. Clinicians. could. identify. what. techniques. they. wanted.
to.implement.in.each.session..Not.only.were.satisfaction.ratings.high.and.outcomes.promising,.
researchers. found. that. master’s. level. clinicians. with. various. backgrounds. could. be. effectively.
trained.in.the.approach.
The. other. model. is. a. flexible. application. of. STAIR/MPE. (reviewed. previously;. Levitt. et. al..
2007).. In. this. model,. therapists. received. limited. training. and. had. little. or. no. CBT. experience..
They.were.encouraged.to.follow.the.manual,.but.to.use.it.flexibly.as.determined.by.their.judgment..
This.included.skipping.sessions,.repeating.sessions,.ending.before.the.full.16.sessions,.and.adding.
nonprotocol.sessions.if.a.crisis.needed.to.be.addressed..On.average,.therapists.delivered.one.extra.
session.of.STAIR.and.one.extra.session.of.MPE,.with.one.additional.nonprotocol.session.(Levitt.
et al.. 2007).. This. study. suggests. that. strict. adherence. to. manuals. may. not. be. necessary. and. that.
training.should.help.clinicians.understand.the.rationale.for.each.treatment.component.so.that.they.
can.determine.the.best.pacing.of.the.intervention.
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312 Behavioral Health Response to Disasters
17.3.2.1  Recommendations for Improving Dissemination
Lack. of. training. is. one. barrier. to. care. that. can. be. overcome.. Evidence. suggests. that. community.
clinicians.can.learn.to.deliver.these.treatments,.but.most.will.require.training..While.training.cli-
nicians.in.advance.of.a.disaster.has.advantages,.we.believe.this.is.not.realistic..First,.community.
mental.health.centers.do.not.have.the.resources.to.send.clinicians.to.trainings.if.they.may.not.be.
needed..Second,.clinicians’.skills.will.likely.deteriorate.if.they.do.not.have.the.option.to.treat.clients.
immediately.after.the.training..Therefore,.we.recommend.“just-in-time”.training..We.also.suggest.
that.there.may.be.some.advantages.to.training.clinicians.in.a.model.like.CBT-PD.that.requires.only.
a.single.training.but.is.effective.for.a.range.of.postdisaster.responses.and.disorders,.rather.than.tak-
ing.the.time.to.train.clinicians.in.two.or.more.effective.treatments,.such.as.one.for.PTSD.and.one.
for.depression.
Finally,.it.is.important.for.administrators.to.understand.that.just.because.clinicians.receive.train-
ing.in.effective.treatments,.this.does.not.ensure.that.they.will.utilize.those.treatments..Significant.
attention. must. be. directed. at. helping. clinicians. understand. how. these. treatments. can. be. specifi-
cally.tailored.to.respond.to.their.client’s.unique.needs.while.still.keeping.faithful.to.the.manual..A.
remaining.empirical.question.is.the.extent.to.which.clinicians.can.go.off.protocol.without.reducing.
treatment.effectiveness.
17.4  SUMMARY AND CONCLUSIONS
In.this.chapter.we.reviewed.the.literature.on.the.range.of.long-term.treatments.available.after.a.
disaster.and.on.issues.that.may.prevent.survivors.from.receiving.these.treatments..There.is.a.sub-
stantial.literature.supporting.the.use.of.CBT.for.PTSD,.the.condition.most.commonly.observed.
after.a.disaster..These.studies.include.a.few.studies.of.CBT.for.disaster-related.PTSD..We.also.
reviewed. the. literature. on. CBT-PD,. a. treatment. that. can. be. delivered. more. broadly. to. survi-
vors.with.postdisaster.distress..The.ultimate.decision.regarding.which.treatment.to.choose.may.
depend.most.on.a.program’s.specific.goals.or.needs..For.example,.a.statewide.crisis.counseling.
program.may.well.want.to.treat.everyone.who.is.significantly.upset.by.the.disaster..Therefore,.
CBT-PD.may.be.the.right.choice..Conversely,.a.local.treatment.center.or.program.may.want.to.
offer.services.to.only.those.who.are.most.severely.impaired.and.may.therefore.choose.a.PTSD.
treatment.
The.review.on.barriers.to.care.reveals.a.complex.literature..There.are.many.factors.and.levels.to.
contend.with..We.focused.primarily.on.survivor-level.barriers.and.clinician.barriers..For.survivors.
to. seek. care,. they. must. first. recognize. they. have. a. problem;. second,. know. that. help. is. available;.
and.third,.access.the.help..We.suggest.that.it.is.critical.to.provide.outreach.to.at-risk.groups.and.to.
specifically.address.unique.barriers.to.care.for.these.groups.
With.respect.to.clinician.barriers,.we.focused.on.training.and.resistance..It.appears.that.clini-
cians.can.be.trained.to.use.these.interventions..The.bigger.question.is.how.to.most.efficiently.con-
duct.the.training..It.is.likely.that.large-scale.trainings.in.advance.of.a.disaster.are.not.feasible.and.
clinicians.would.likely.need.a.refresher.course.just.prior.to.delivering.them..Thus.we.recommend.
just-in-time.training.and.raise.the.issue.whether.it.is.necessary.to.train.clinicians.in.more.than.one.
approach..Obtaining.trainers.may.be.another.barrier..One.possible.solution.is.to.provide.the.training.
over.the.Internet.or.by.video-.or.teleconferencing.
A.more.radical.suggestion.is.to.provide.the.therapy.itself.over.the.Internet..These.options.are.low.
cost,.have.the.potential.to.reach.large.numbers.of.survivors,.and.can.be.interactive.and.personalized.
(Ruggiero.et.al..2006)..Moreover,.individuals.may.be.more.apt.to.use.the.Internet.than.a.therapist.
due. to. stigma. associated. with. seeking. therapy.. These. programs. can. also. be. easily. revised,. may.
reduce.the.burden.on.CBT.clinicians,.gain.high.satisfaction.ratings,.and.obtain.successful.outcomes.
(Litz.et.al..2007;.Ruggiero.et.al..2006)..However,.currently.there.is.not.enough.data.to.recommend.
this.option.as.a.primary.treatment.strategy.
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313Long-Term Mental Health Treatment for Adult Disaster Survivors
Finally,.clinicians’.resistance.to.providing.these.treatments.must.be.addressed..The.goal.of.dis-
semination.is.to.change.clinicians’.behaviors.in.order.to.effectively.implement.treatments.(Marshall.
et.al..2006)..Training.research.has.shown.that.targeting.clinicians’.expected.values.of.the.outcome,.
beliefs.about.existing.norms,.and.self-efficacy.through.didactics,.demonstrations,.and.role-playing.
is.crucial.(Marshall.et.al..2006)..This.research.also.demonstrates.low.favorability.ratings.toward.
using.a.manual,.as.well.as.fears.that.clients.will.decompensate.in.trauma-focused.models.(Marshall.
et.al..2006;.Cahill.et.al..2006;.Becker.et.al..2004)..Thus.these.specific.points.must.be.addressed.as.
part.of.the.training.
To.convey.the.importance.of.using.treatments.that.are.supported.by.science,.administrators.and.
trainers.could.use.a.metaphor.from.the.medical.field.to.emphasize.the.importance.of.using.effective.
treatments:.“If.your.loved.one.was.ill.and.research.showed.that.one.medication.was.more.helpful.
than.another,.would.you.choose.the.less.effective.one?”.Finally,.to.motivate.clinicians.to.use.effec-
tive.treatments,.some.have.advocated.for.policy.change.in.managed.health.care.organizations.such.
that.effective.treatments.are.reimbursed.at.a.higher.rate.than.interventions.without.an.evidence.base.
(K..Mueser,.personal.communications,.November.20,.2009).
A. final. clinician. barrier. unique. to. disasters. is. that. clinicians. are. likely. to. share. in. the. experi-
ence.of.the.disaster.with.the.survivor.seeking.care,.which.we.have.found.to.create.special.issues.in.
training. and. implementation. (Hamblen. et. al.. 2009).. Although. these. collective. experiences. might.
increase.empathy,.it.might.decrease.clinician.objectivity..For.example,.local.clinicians.might.have.
difficulty.challenging.distorted.beliefs.around.the.likelihood.of.future.disasters.or.whether.things.
will.ever.improve.because.they.may.struggle.with.these.very.same.beliefs..When.they.have.shared.
the.client’s.experience,.clinicians.are.more.likely.to.engage.in.self-disclosure.and.are.more.easily.
led.off.topic.during.sessions..These.issues.can.be.addressed.effectively.if.they.are.acknowledged.
in.training..In.conclusion,.effective.long-term.treatments.exist.for.disaster.survivors..However,.to.
optimize.these.treatments.we.need.to.make.sure.that.survivors.are.aware.of.them.and.that.they.are.
delivered.in.ways.that.make.them.accessible.and.acceptable..Special.attention.must.be.paid.to.at-
risk.or.marginalized.groups..Finally,.training.considerations.should.include.when.and.how.to.train.
clinicians,.as.well.as.how.best.to.reduce.resistance.to.delivering.the.treatments.
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319
18 Disaster and Substance
Abuse Services
Dee S. Owens, Brian McKernan,and Julie L. Framingham
CONTENTS
18.1. Introduction…………………………………………………………………………………………………………… 320
18.2. .Literature.Review.of.the.Epidemiology.of.Substance.Use,.Abuse,.and.Dependence.
Postdisaster……………………………………………………………………………………………………………. 320
18.3. Dynamics.of.Substance.Abuse.Postdisaster……………………………………………………………….. 321
18.3.1. Increase.of.Substance.Use.in.the.General.Population.to.Cope.with.Stress…………… 321
18.3.2. .Persons.Nearing.Substance.Abuse.or.Dependence.Cross.the.Line……………………… 321
18.3.3. Persons.in.Active.Addiction.Increase.Use.of.Substances…………………………………… 322
18.3.4. Persons.in.Recovery.Experience.Relapse………………………………………………………… 322
18.3.5. .Persons.Experiencing.Posttraumatic.Stress.Disorder.or.Depressive.Symptoms.
Increase.Use.of.Substances……………………………………………………………………………. 322
18.3.6. .Persons.in.Other.At-Risk.Groups,.Such.as.First.Responders,.Increase.Use.of.
Substances………………………………………………………………………………………………….. 322
18.3.7. Complex.Dynamics……………………………………………………………………………………… 323
18.3.7.1. .National.Survey.on.Drug.Use.and.Health.Shows.Increase.in.
Useamong.Hurricane.Katrina.and.Rita.Evacuees.Compared.to.
ThoseWho.Remained…………………………………………………………………….. 323
18.3.7.2. Changes.in.Drug.Distribution.Networks.Postdisaster………………………….. 323
18.3.7.3. Localized.versus.Regional.Devastation……………………………………………… 323
18.4. .Disaster.Impact.on.Substance.Abuse.and.Prevention.Treatment.Infrastructure………………. 323
18.4.1. Impact.of.9/11.Attack.on.Lower.Manhattan.Opioid.Treatment.Providers……………. 324
18.4.1.1. Impact.of.Hurricane.Katrina.on.Methadone.Provision.in.the.South………. 324
18.4.2. .Impact.of.2005.Hurricanes.on.Gulf.Coast.Substance.Abuse.Prevention.and.
Treatment.Providers……………………………………………………………………………………… 324
18.4.3. Loss.or.Disruption.of.Recovery.Networks………………………………………………………. 325
18.5. At-Risk.Populations………………………………………………………………………………………………… 325
18.5.1. Disaster.Survivors.Who.Are.in.Early.Recovery………………………………………………. 325
18.5.2. Survivors.Experiencing.Disaster-Related.Mental.Health.Symptoms…………………… 325
18.5.3. First.Responders………………………………………………………………………………………….. 325
18.5.4. Adolescent.Youth…………………………………………………………………………………………. 326
18.6. Case.Studies…………………………………………………………………………………………………………… 326
18.6.1. Iowa.Disaster.Response………………………………………………………………………………… 327
18.6.1.1. 2008:.Catastrophic.Floods……………………………………………………………….. 327
18.6.2. Colorado.Disaster.Response………………………………………………………………………….. 329
18.6.2.1. 2008:.Severe.Storms.and.Tornadoes………………………………………………….. 329
18.6.2.2. 2005:.Hurricane.Katrina………………………………………………………………….. 329
18.6.2.3. 2002:.Wildfires………………………………………………………………………………. 330
18.6.3. Massachusetts.Disaster.Response…………………………………………………………………… 331
18.6.3.1. 2008:.Hurricane.Katrina.Evacuees.and.Response……………………………….. 331
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AN: 448580 ; Julie Framingham, Martell L. Teasley.; Behavioral Health Response to Disasters
Account: s7348467.main.ehost
320 Behavioral Health Response to Disasters
18.1  INTRODUCTION
This. chapter. will. use. a. multifaceted. approach. to. bring. the. reader. up. to. date. with. recent.
research. on. the. effects. of. disaster. on. survivors. with. substance. use. problems.. The. subject. of.
substance.abuse.has.been.the.focus.of.relatively.few.empirical.studies.in.comparison.to.other.
areas.of.disaster.research,.including.disaster.mental.health,.which.is.also.a.burgeoning.field.
of.study..Much.of.the.serious.research.on.substance.use.postdisaster.occurred.within.the.past.
decade,. since. the. terrorist. attacks. of. September. 11,. 2001. (9/11),. and. again. after. observing.
the.devastating.impacts.of.Hurricane.Katrina.on.August.29,.2005,.along.the.U.S..Gulf.Coast..
Some. of. these. research. findings. are. discussed. within. this. chapter.. Additionally,. the. field.
observations. of. three. different. states’. substance. abuse. responses. to. disasters. are. presented..
Together,.both.the.scholarly.studies.and.the.anecdotal.state.reports.yield.a.number.of.consid-
erations. for. disaster. planners. and. responders.. We. will. discuss. some. of. these. considerations.
and.how.they.informed.several.important.state.and.federal.disaster.substance.abuse.initiatives.
during.the.past.several.years..While.the.precise.relationship.between.disasters.and.substance.
use.is.still.not.fully.understood,.the.topic.nevertheless.merits.more.serious.consideration.and.
should.be.addressed.in.the.local.or.state.jurisdiction’s.overall.behavioral.health.planning.and.
response.to.disasters.
18.2   LITERATURE REVIEW OF THE EPIDEMIOLOGY OF SUBSTANCE 
USE, ABUSE, AND DEPENDENCE POSTDISASTER
As.the.study.of.alcohol.and.other.drug.use.after.disaster.is.an.emergent.field,.there.is.growing.
evidence.that.survivors.of.disaster.increase.use.of.alcohol.and/or.other.drugs,.and.that,.for.cer-
tain.populations,.this.phenomenon.is.especially.ill.advised..While.many.survivors.may.“go.to.
the.bars”.more.and.drink.to.relieve.stress,.those.who.have.existing.substance.use.disorders.are.
making.potentially.life-threatening.choices.by.doing.so..Most.methodologically.sound.studies.
about.alcohol.and.other.drug.use.have.shown.some.increase.or.deviance.in.use.after.a.disaster..
For.example,.almost.30.percent.of.988.New.York.City.residents.surveyed.reported.an.increase.
in.the.use.of.alcohol,.cigarettes,.and.marijuana.soon.after.the.9/11.attack.on.the.World.Trade.
Center.. Alcohol. consumption. reported. the. largest. increase. with. 24.6. percent,. followed. by.
cigarettes.at.9.7.percent,.and.3.2.percent.for.marijuana.(Vlahov.et.al..2002)..Other.studies.of.
2,368.and.1,681.New.York.City.adults.conducted.at.one.and.two.years,.respectively,.after.the.
World. Trade. Center. attack,. report. sustained. increases. in. alcohol. consumption. (10. percent).
and. alcohol. dependence. after. disaster. exposure,. while. an. increase. in. binge. drinking. was.
observed. at. one. year. postdisaster. (Boscarino,. Adams,. and. Galea. 2006;. Adams,. Boscarino,.
and.Galea2006)..Wu.and.colleagues.(2006).demonstrate.that.of.2,731.New.York.City.public.
high.school.students.surveyed,.10.9.percent.increased.their.consumption.of.alcohol..Although.
5.4.percent.also.reported.an.increase.in.cigarette.smoking.after.9/11,.this.increase.was.attrib-
uted. more. to. the. students’. self-reports. of. past. trauma. experiences. and. posttraumatic. stress.
disorder.than.to.disaster.exposure.(Wu.et.al..2006)..Increased.alcohol.consumption.is.noted.
18.7. Lessons.Learned…………………………………………………………………………………………………….. 332
18.8. National.Developments……………………………………………………………………………………………. 333
18.8.1. Disaster.Substance.Abuse.Planning……………………………………………………………….. 333
18.8.2. Digital.Access.to.Medication………………………………………………………………………… 334
18.8.3. Disaster.Substance.Abuse.Preparedness.and.Response.Coordination…………………. 334
18.9. Conclusion…………………………………………………………………………………………………………….. 334
Notes…………………………………………………………………………………………………………………………….. 334
References……………………………………………………………………………………………………………………… 335
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321Disaster and Substance Abuse Services
among. 13. percent. of. the. survivors. of. the. attack. on. the. Pentagon. as. well. (n. =. 77;. Grieger,.
Fullerton,.and.Ursano.2003).
The. effects. of. terrorism. on. drinking. are. also. noted. by. researchers. who. find. that. binge/.
intoxication.drinking.postdisaster.is.increased.not.only.by.a.lack.of.social-bonding.variables,.such.
as.parenthood,.but.even.political.factors,.such.as.higher.alerts.for.terrorism.(Richman.et.al..2009)..
Furthermore,. a. meta-analysis. by. Dimaggio,. Galea,. and. Li. (2009). supports. that. terrorism. influ-
ences. substance. use. and. abuse. by. survivors. and. other. groups. affected.. Specifically,. and. using.
Bayesian.techniques,.this.analysis.of.31.population-based.studies.finds.that.in.the.first.two.years.
after. a. terrorist. event,. 7.3. percent. of. a. population. will. increase. alcohol. use,. with. a. 20. percent.
probability.that.at.least.14.percent.of.that.population.will.increase.use..Similarly,.6.8.percent.of.an.
affected.group.will.increase.smoking.behaviors,.while.drug.use.(including.prescriptions.and.illicit.
substances).will.rise.16.3.percent..
Studies.of.adolescent.survivors.of.Hurricanes.Katrina.and.Rita.also.demonstrated.a.connection.
between.disaster.exposure.and.increased.substance.use.and.abuse.(Flory.et.al..2009;.Rohrbach.et.
al.. 2009).. Furthermore,. other. types. of. disasters,. such. as. the. 1998. Swissair. Flight. 111. disaster. in.
Saint.Margaret’s.Bay,.Nova.Scotia,.Canada,.the.Mount.St..Helens.volcanic.eruption.in.1980,.and.
the.Herald.of.Free.Enterprise.disaster.in.1987,.demonstrated.similar.increases.in.substance.use.and.
abuse.(Stewart.et.al..2004;.Adams.and.Adams.1984;.Joseph.et.al..1993).
Although.these.studies.support.that.disaster.survivors.may.increase.their.consumption.of.alco-
hol,.tobacco,.and.other.substances,.not.all.do..One.study.of.the.Great.Hanshin.Earthquake.in.Japan,.
for.instance,.found.that.alcohol.use.was.10–20.percent.lower.than.anticipated.postdisaster.(Shimizu.
et. al.. 2000).. Some. research. (Valdez. et. al.. 2009). seems. to. demonstrate. a. lower. immediate. use. of.
illicit. drugs. but. higher. alcohol. sales,. indicating. a. likely. disruption. of. drug-supply. networks. after.
disaster..These.seeming.disparities.are.replicated.by.other.disaster.studies,.such.as.those.about.first.
responders,.where.some.are.seen.to.be.resilient.while.others.are.“more.symptomatic.than.unexposed.
comparison.groups”.(North.et.al..2002a,.172)..In.fact,.studies.have.found.higher.rates.of.predisaster.
alcohol-use. disorder. among. firefighters,. a. population. that. self-selects. for. traumatic. work. but. that.
seems.to.cope.by.drinking.alcohol.(Boxer.and.Wild.1993;.North.et.al..2002b)..While.these.studies.
are.more.equivocal.concerning.the.increase.of.substance.use.postdisaster,.they.nevertheless.illus-
trate. that. disaster. services. should. include. substance. abuse. as. an. important. portion. of. behavioral.
health.planning.and.response.
18.3  DYNAMICS OF SUBSTANCE ABUSE POSTDISASTER
18.3.1  increase of suBsTance use in The general populaTion To cope WiTh sTress
A.meta-analysis.was.conducted.by.Fran.Norris.(2005).including.not.only.United.States.data,.
but.also.research.from.34.other.countries,.developing.and.developed,.and.including.132.natu-
ral. and. human-caused. disasters.. The. study. shows. that. some. populations. do. increase. the. use.
of. alcohol,. other. drugs,. and. cigarettes,. especially. those. who. demonstrate. comorbidity. with.
other.disorders..Fifteen.percent.of.survivors.of.a.1994.shooting.in.a.Texas.cafeteria.said.they.
used.alcohol.to.cope.with.stress.(North.et.al..1994),.but.the.extent.to.which.alcohol.is.used.as.
self-medication.can.be.difficult.to.determine,.as.can.the.relationship.between.alcohol.use.and.
stressors.in.general.
18.3.2   persons nearing suBsTance aBuse or dependence cross The line
In.New.York.City.after.9/11,.a.constant.refrain.was.that.many.who.were.borderline.alcoholics.had.
“crossed.the.line,”.drinking.to.excess.to.cope.and.then.becoming.dependent.upon.alcohol.for.daily.
functioning.(Frank.and.Owens.2002)..This.area.deserves.more.research.so.core.indicators.of.addic-
tion.following.disaster.can.be.identified.
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322 Behavioral Health Response to Disasters
18.3.3  persons in acTiVe addicTion increase use of suBsTances
A. characteristic. of. addiction. is. an. increase. in. use. of. the. substance. over. time,. until. such. time. as.
either.recovery.or.early.death.or.disability.occurs..There.is.no.reason.to.believe.that.a.stressor.the.
size.of.a.disaster,.be.it.natural.or.human.caused,.would.be.any.different.in.its.outcomes..Frank.and.
Owens. (2002). found. that. 9/11. New. York. City. street. survivors. and. clients. were. requesting. more.
benzodiazepines.from.their.doctors.(50),.while.Stewart.(1996).and.Adams.and.Adams.(1984).found.
that.driving-while-intoxicated.(DWI).rates.rise.after.disaster.
18.3.4  persons in recoVery experience relapse
Relapse,.a.clinical.worsening.of.symptoms.(Norris.2005,.3),.increases.upon.exposure.to.disaster..
After. 9/11. in. New. York. City,. staff. of. substance. abuse. treatment. facilities. who. were. in. recovery.
sometimes.relapsed,.and.many.left.their.jobs.entirely.(Frank.and.Owens.2002,.19),.while.police,.
firefighters,.and.other.responders,.such.as.teachers.in.affected.schools,.in.recovery.were.relapsing.
(18).. A. focus. group. of. providers. conducted. by. Rowe. and. Liddle. (2008). found. that,. of. Hurricane.
Katrina.adolescent.disaster.survivors,.over.half.of.the.youth.in.drug-abuse-treatment.programs.had.
relapsed.during.the.hurricane.and.evacuation..The.Midwestern.floods.of.1993.caused.20.percent.of.
those.who.were.in.recovery.from.alcohol-use.disorders.to.use.alcohol.to.cope.after.the.floods.(North.
et.al..2004)..Zywiak.and.colleagues.reported.in.2003.that.relapse.among.patients.who.were.detoxi-
fied.prior.to.9/11.increased.by.42.percent,.while.a.recent.analysis.by.North.and.colleagues.(2011).
found.that.survivors.of.disaster.in.recovery.were.four.times.more.likely.to.drink.than.were.survivors.
without.a.previous.addiction..Clearly,.persons.in.recovery,.especially.those.in.early.recovery,.are.in.
danger.of.relapsing.back.to.the.addictive.substance.after.disaster.
18.3.5   persons experiencing posTTrauMaTic sTress disorder or 
depressiVe syMpToMs increase use of suBsTances
Posttraumatic. stress. disorder. (PTSD). is. a. known. outcome. in. disasters,. but. how. this. diagnosis.
relates. to. substance. use. deserves. further. study.. In. Oklahoma. City,. alcohol-use. disorder. among.
firefighters. was. correlated. with. less. satisfaction. at. work,. higher. PTSD-related. impairment. in.
job.performance.and.personal.relationships,.and.use.of.alcohol.as.a.coping.mechanism.after.the.
bombing. (North. et. al.. 2002a).. Vlahov. and. colleagues. (2002). postulate. that. substance. use. after.
disaster.may.rise.for.several.reasons,.including.the.increase.in.need.to.cope.with.stress.or.relax;.
nervousness.from.withdrawal.symptoms.or.self-medication,.especially.by.those.with.PTSD;.and.
a.vicious.cycle.of.substance.use.to.treat.symptoms,.which.in.fact.exacerbates.them.and.prolongs.
use.. Norris. (2005). notes. that. the. most. observed. condition. after. disaster. is. PTSD,. followed. by.
depression,.and.these.are.made.worse.by.proximity.of.exposure.to.the.disaster.and.by.the.disaster.
type,.with.mass.violence.causing.the.most.severe.impairment..Norris.also.discusses.substance.use.
in.this.context.as.possibly.increased.because.those.affected.already.had.substance.use.disorders.
or.other.psychological.disorders.(3)..It.is.clear.that.PTSD.and.substance.use.are.related;.exactly.
what.that.relationship.might.be.is.yet.to.be.fully.determined.by.research..According.to.Adams.
and.colleagues.(2006),.understanding.the.relationship.between.substance.use.and.PTSD.is.crucial.
because.substance.use.“may.hinder.the.resolution.of.psychological.distress.and.the.treatment.of.
psychological.problems”.(205).
18.3.6   persons in oTher aT-risk groups, such as firsT 
responders, increase use of suBsTances
Frank.and.Owens.(2002).found.that.police.and.fire.recovery.workers.were.noted.by.treatment.pro-
viders.to.be.increasing.alcohol.use,.in.part.due.to.survivor.guilt.(50–51)..Before.and.after.Oklahoma.
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323Disaster and Substance Abuse Services
City,.there.is.a.body.of.literature.that.documents.the.resilience.of.first.responders,.who.“self-select”.
for.this.work.(Boxer.and.Wild.1993;.North.2002a.and.2002b;.Frank.and.Owens.2002).along.with.
an.admonition.that.drinking.as.a.coping.mechanism.is.significantly.associated.with.poor.outcomes..
For.example,.those.Oklahoma.City.firefighters.who.drank.to.cope.had.four.times.the.alcohol-use.
disorders.than.did.others.(North.et.al..2002a,.174;.see.Section.18.5.3.for.further.information).
18.3.7  coMplex dynaMics
18.3.7.1   National Survey on Drug Use and Health Shows Increase in Use among 
Hurricane Katrina and Rita Evacuees Compared to Those Who Remained
The. National. Survey. on. Drug. Use. and. Health. reported. on. January. 31,. 2008,. that. although. there.
were.no.significant.overall.increases.in.illicit.drug.use.or.binge.alcohol.use.(and.an.actual.decrease.
in.marijuana.use).among.the.Gulf.Coast.areas.that.were.hit.by.Hurricanes.Katrina.and.then.Rita,.
there.were.higher.rates.of.use.in.all.categories.for.adults.who.were.displaced.from.their.homes.for.
at.least.two.weeks.(SAMHSA.2008,.1)..Female.caregivers.who.were.living.in.Federal.Emergency.
Management.Agency.(FEMA).trailers.or.hotels.reported.depression.and.anxiety.(68.percent);.they.
were. some. of. the. 1.5. million. people. who. were. displaced. for. longer. than. two. weeks. (SAMHSA.
2008,.2)..Clearly,.loss.of.residence.is.a.major.stressor.that.is.related.to.substance.use.
18.3.7.2  Changes in Drug Distribution Networks Postdisaster
Valdez. and. colleagues. (2009). demonstrate. that. patterns. of. drug. use. by. the. population. studied.
(poverty,. minority. race,. previous. substance. use,. displaced. to. Houston. from. New. Orleans). were.
disrupted.because.the.usual.illicit.drug.markets.were.destroyed.or.inaccessible,.and.new.markets.
in. Houston. supplied. different. drugs.. As. a. result,. overall. use. of. illicit. drugs. dropped,. despite. an.
overall.increase.in.substance.use.(Valdez.et.al..2009,.23)..The.NSDUH.Report.(SAMHSA.2008).
shows. that,. although. use. continued. to. rise. in. other. areas. of. the. country,. the. Gulf. states. showed.
decreases.in.the.use.of.illicit.drugs,.marijuana,.illegal.use.of.prescriptions,.binge.alcohol.use,.and.
cigarette. use. (Tables. 5. and. 6,. p.. 6).. Lack. of. availability. of. all. drugs. certainly. played. into. these.
numbers,.as.there.was.no.electricity.or.automobile.gas.in.much.of.the.region.for.weeks,.so.stores.
that.sell.legal.drugs.were.generally.not.open.
18.3.7.3  Localized versus Regional Devastation
Because.there.was.widespread.and.total.hurricane.destruction.in.many.of.the.Gulf.Coast.areas,.but.
especially.from.Biloxi,.Mississippi,.to.beyond.New.Orleans,.Louisiana,.by.Katrina,.and.from.Lake.
Charles,.Louisiana,.past.Beaumont,.Texas,.by.Rita,.no.local.help.was.available.for.immediate.call-
out.(SAMHSA.2008,.3)..Interstates.in.Mississippi.all.the.way.north.to.Jackson.were.covered.with.
trees,.gas.was.unavailable,.and.cell.towers.were.toppled.or.overloaded..Disaster.planning.ought.to.
take.these.considerations.into.account.when.devising.plans.for.agencies.and.clients,.especially.in.
areas.prone.to.natural.disaster.
18.4   DISASTER IMPACT ON SUBSTANCE ABUSE AND 
PREVENTION TREATMENT INFRASTRUCTURE
New.York.City.substance.abuse.treatment.systems.experienced.extraordinary.breaks.in.service.
delivery.after.the.attacks.of.9/11..For.example,.everything.below.14th.and.Houston.Streets.was.
closed.to.all.clients.and.residents—everyone.except.responders—for.a.long.period.of.time;.those.
providers.who.did.not.have.their.offices.destroyed.outright.were.nonetheless.faced.with.cremains.
and. ash. six. inches. deep,. with. elevators. that. would. not. work,. and. with. respiratory. issues. upon.
return..The.Frank.and.Owens.(2002).report.available.from.the.SAMHSA.Center.for.Substance.
Abuse. Treatment. entitled. “The. Impact. of. the. World. Trade. Center. Disaster. on. Treatment. and.
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324 Behavioral Health Response to Disasters
Prevention. Services. for. Alcohol. and. Other. Drug. Abuse. in. New. York”. is. a. lengthy. report. that.
describes.what.it.is.like.to.have.infrastructure.destroyed.or.so.ruined.that.it.takes.three.months.to.
even.consider.moving.back.in..What.about.records?.Communication.with.staff?.Client.services?.
The.report,.complete.with.focus.group.results,.describes.lessons.learned.for.providers.and.pro-
grams,. for. state/counties/cities,. and. makes. recommendations. for. the. future.. Examples. include.
provision. of. alternative. communication. systems;. cross-disciplinary,. comprehensive. planning;.
fiscal. rules. for. quick. resource. allocation;. and. specialized. disaster. and. response. training. for. all.
behavioral.health.providers.
18.4.1  iMpacT of 9/11 aTTack on loWer ManhaTTan opioid TreaTMenT proViders
As. noted. in. the. previously. mentioned. report,. lower. Manhattan. opioid. treatment. providers. were.
either. inaccessible. or. wiped. out. by. the. collapse. of. the. twin. towers.. Those. who. would. normally.
provide. services. ran. for. their. lives,. often. alongside. their. clients,. and. they. would. not. be. allowed.
back.for.a.long.time..Clients.were.not.required.to.carry.identification.so.were.technically.unable.
to. get. “guest”. doses. of. their. medicine. at. other. clinics—but. these. were. extraordinary. times.. The.
state.agency.quickly.told.remaining.providers.to.guest-dose.these.clients.after.asking.the.client.how.
much.the.dosage.was.to.be,.which.they.did,.and.there.was.not.one.documented.case.of.abuse.of.this.
guest-dosing.privilege,.which.is.extraordinary.in.itself..This.gap.in.the.system.was.quickly.studied.
and.filled;.there.are.now.protocols.for.guest-dosing.that.were.shared.nationally.so.that.others.could.
benefit.from.the.experience.of.the.New.York.City.providers.
18.4.1.1  Impact of Hurricane Katrina on Methadone Provision in the South
With. the. mental. health. and. substance. abuse. treatment. systems. destroyed. along. the. Gulf. Coast,.
provision. of. methadone. medication. proved. to. be. difficult,. at. best.. Many. displaced. persons. in.
Louisiana. went. to. Baton. Rouge,. where. Tulane. Medical. School. staff. also. relocated.. These. staff.
provided.doses.to.clients,.but.only.after.reassessing.their.needs,.as.most.clients.did.not.know.or.
have.their.dosage.amounts,.and.records.were.nonexistent.(Winstead.and.Legeai.2007)..In.fact,.at.
eight.months.after.the.disaster,.only.1.percent.of.evacuees.to.Houston.were.found.to.use.metha-
done.as.a.street.drug,.with.19.percent.preferring.marijuana.to.relieve.physical.and.emotional.pain.
(Valdez. et. al.. 2009,. 19).. The. systems. were. not. set. up. to. deal. with. total. displacement. for. many.
months—few.are.
18.4.2   iMpacT of 2005 hurricanes on gulf coasT suBsTance 
aBuse preVenTion and TreaTMenT proViders
Mental.health.and.substance.abuse.services.to.veterans.were.significantly.disrupted.due.to.destruc-
tion. of. Veterans. Affairs. facilities. in. Gulfport,. Mississippi,. and. the. closing. of. the. facility. in. New.
Orleans.after.Katrina;.interestingly,.the.Biloxi,.Mississippi,.facility.remained.open,.despite.the.utter.
destruction.in.that.area.(Druss,.Henderson,.and.Rosenheck.2007,.155),.and.provided.services.to.the.
Gulfport.displaced.veterans.
The. Gulf. Coast. Mental. Health. Center. system. in. southern. Mississippi. was. destroyed. by. the.
storm,.and.a.team.of.Indiana.state.police,.conservation.officers.(complete.with.swamp.buggies),.
National.Guard.(including.gasoline.and.MREsa),.and.medical.and.mental.health.professionals.was.
deployed.to.Biloxi.within.four.days.of.the.hit.by.Hurricane.Katrina.under.a.state-to-state.emer-
gency.management.assistance.compact.(EMACb)..The.mental.health.professionals.functioned.as.a.
temporary.replacement.for.the.community.mental.health.center,.providing.resources.and.helping.
clients.to.obtain.service.when.possible..The.Indiana.group.changed.its.personnel.every.two.weeks.
to. avoid. burnout,. for. a. period. of. six. weeks,. until. the. system. could. resume. functionality.. In. this.
way,.clients.were.able.to.access.some.services,.and.medications.could.be.obtained.for.those.who.
needed.them.
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325Disaster and Substance Abuse Services
18.4.3  loss or disrupTion of recoVery neTWorks
In.New.York.City,.many.lower.Manhattan.Alcoholics.Anonymous.(AA).and.other.peers-in-recovery.
meetings.were.lost,.both.people.and.places,.but.the.Ground.Zero.workers.set.up.two.daily.meetings.
that.people.could.attend.(see.Section.18.5.3.for.more.information)..In.Biloxi,.Mississippi,.personnel.
on. the. ground. within. one. week,. this. author. included,. were. told. that. the. recovery. network. pulled.
together,.went.out.to.find.its.members,.and.reestablished.meetings.as.it.could..This.was.self-help.in.
the.truest.sense.of.the.term..Since.these.meetings.are.set.up.by.members,.the.recovery.networks,.
although.lost,.seemed.to.reestablish.themselves.quickly..The.offices.of.Alcoholics.Anonymous.are.
in.New.York.City,.and,.while.not.displaced,.the.staff.there.were.affected.like.anyone.else..The.AA
Grapevine,. the. international. publication. of. AA,. discussed. the. story. in. January. 2002,. and. talked.
about.the.hardhats.and.boots.at.the.Group.at.Ground.Zero.(S.,.Richard.2002)..These.informal.net-
works.were.disrupted.or.lost,.but.the.spirit.of.self-help.caused.them.to.regroup.and.come.together.
again.in.support.of.members.who.needed.ongoing.support.
18.5  AT-RISK POPULATIONS
While.most.at-risk.populations.have.been.discussed.in.a.general.manner,.certain.of.these.deserve.
special.mention.
18.5.1  disasTer surViVors Who are in early recoVery
From. a. substance. abuse. treatment. perspective,. those. who. are. in. the. first. six. months. of. recovery.
from. substance. use. disorders. are. very. vulnerable. to. relapse,. or. the. reinitiation. of. use. of. the. par-
ticular.addictive.substance..Disasters,.especially.those.that.are.human.caused.and.have.culpability.
associated.with.them,.can.and.do.push.those.newly.in.recovery.to.relapse,.or.“go.back.out”.(Frank.
and.Owens.2002)..These.persons.will.need.extra.attention.and.care.following.any.disaster.to.help.
them.preserve.their.sobriety.
18.5.2  surViVors experiencing disasTer-relaTed MenTal healTh syMpToMs
Mental.health.diagnoses.including.PTSD.are.infrequently.studied.in.relation.to.postdisaster.sub-
stance. use. disorders,. but. it. again. goes. without. saying. that. these. people. need. special. care. and.
patience. as. they. process. what. healthy. people. have. difficulty. handling. themselves.. Clients. who.
are.displaced.from.their.service.providers,.as.when.the.mental.health.centers.in.lower.Mississippi.
and.in.New.Orleans.were.completely.wiped.out.after.Katrina,.may.be.without.a.trusted.therapist,.
or.without.medication.(see.Section.18.4.1.1),.and.most.psychotropic.medications.are.not.in.a.push.
pack.that.will.come.from.the.Strategic.National.Stockpile.(SNS).c.Setting.up.redundant.provision.
of.these.services.will.go.a.long.way.toward.reducing.anxiety.for.both.the.client.and.the.provider,.
in.the.event.of.disaster.
18.5.3  firsT responders
Police.and.firefighters.and.other.responders.are.trained.in.many.areas.of.trauma.response,.but.there.
is.no.one.who.can.mentally.digest.dealing.with.body.parts.of.children,.for.example..Oklahoma.City.
firefighters.had.25.percent.current.alcohol-use.disorder.and.reported.using.alcohol.to.cope.(North.
et. al.. 2002a,. 174). after. doing. recovery. work. at. the. Murrah. Federal. Building. site.. Additionally,.
these.responders.come.from.what.is.termed.a.“closed.shop”—those.who.come.from.the.outside.are.
often.viewed.with.suspicion..Frank.and.Owens.(2002).found.that.police.officers.in.New.York.City.
who. would. talk. with. them. were. resentful. when. they. were. required. to. go. through. stress. debrief-
ings.at.their.precincts;.a.recent.court.case.had.revealed.that.an.officer.was.alcoholic,.and.no.one.
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326 Behavioral Health Response to Disasters
then.trusted.the.confidentiality.of.services.provided.to.them.(13)..It.is.important.to.work.with.the.
Employee.Assistance.Programs.that.are.usually.in.place.for.first.responders;.it.is.here.that.they.will.
often.turn.
Self-help.groups.for.first.responders.and.others.make.sense.when.near.a.site.as.enormous.as.that.
in.New.York.City..The.officers.and.NYFD.firefighters.who.were.in.recovery.found.that.the.self-help.
groups.set.up.at.Ground.Zero.were.lifesaving.for.them.(Frank.and.Owens.2002,.12)..Helping.to.find.
sites.so.that.these.groups.can.form.is.one.way.to.assist.first.responders.and.to.help.avoid.relapse.for.
those.in.recovery.
18.5.4  adolescenT youTh
Youth.who.are.displaced.or.whose.lives.change.drastically.due.to.disaster.are.finally.being.exam-
ined. from. a. substance. abuse. perspective,. as. youth. are. the. most. vulnerable. to. early. onset. of. use..
Rohrbach.and.colleagues.(2009).were.already.studying.a.group.of.Lake.Charles,.Louisiana,.youth.
just. before. Hurricane. Katrina. hit,. so. baseline. data. were. established.. While. Katrina. spared. Lake.
Charles,.Hurricane.Rita.arrived.28.days.later,.and.this.time.it.did.not.bypass.the.area,.but.devastated.
it..Youth.here.were.evacuated.(87.percent),.while.6.percent.of.these.students.were.themselves.hurt,.
7. percent. saw. others. hurt,. 2. percent. saw. someone. die,. and. 38. percent. lost. their. homes.. Surveys.
administered. at. 7. and. 19. months. post-Rita. showed. increased. use. of. marijuana. that. was. directly.
related.to.exposure.to.the.hurricane.as.well. as.an.increase.in.all.alcohol.and.other.drug. use.as.a.
result.of.negative.life.events.caused.by.the.hurricane.(222)..
Following.a. café. fire.in. Volendam,. the. Netherlands,. in. 2001,. a. survey.of. adolescent. survivors.
by.Reijneveld.and.colleagues.(2003).found.a.significant.increase.in.alcohol.consumption,.with.cor-
responding.increases.in.anxiety,.depression,.and.aggressive.behavior..Prior.to.these.studies,.we.are.
aware.of.only.one.other.study.that.has.specifically.examined.adolescent.alcohol.use,.especially.binge.
drinking,.in.relation.to.disaster..In.1998,.several.devastating.tornadoes.tore.through.Minnesota,.and.
researchers.found.that.adolescents.increased.drinking,.especially.those.who.were.older,.who.had.
previous.trauma.history,.and.who.already.had.started.drinking..PTSD.symptoms.correlated.with.
higher.levels.of.binge.drinking.in.this.sample.(Schroeder.and.Polusny.2004).
18.6  CASE STUDIES
The. following. disaster. responses. by. three. different. states. that. assisted. survivors. with. substance.
abuse. problems. both. support. the. lessons. learned. through. the. cited. empirical. studies. and. offer.
additional. lessons. for. future. reflection.. The. state. field. reports. discuss. substance. abuse. services.
both. within. and. outside. the. FEMA-funded. Crisis. Counseling. Assistance. and. Training. Program.
(CCP)..The.CCP.is.a.supplemental.disaster.behavioral.health.response.and.recovery.grant.for.eli-
gible.states,.territories,.and.tribes.and.is.administered.through.an.interagency.agreement.with.the.
Substance.Abuse.and.Mental.Health.Services.Administration,.Center.for.Mental.Health.Services..
The. CCP. is. unique. in. that. it. focuses. on. both. individual. and. community. recovery. and. relies. on.
a. strengths-based,. outreach-oriented,. public. health. model. for. the. provision. of. crisis. counseling.
services.. The. CCP. funds. individual. crisis. counseling;. group. crisis. counseling;. basic. supportive.
contacts;. public. education;. community. networking;. assessment,. referral,. and. resource. linkage;.
development.and.distribution.of.educational.materials;.and.media.messaging.(SAMHSA.nd)..CCP.
services. are. typically. provided. by. paraprofessionals. who. are. supervised. by. master’s. level. team.
leaders.. Once. grant. funding. is. received,. the. State. Mental. Health. Authorityd. typically. contracts.
with.local.community.mental.health.centers.that.have.experience.with.crisis.counseling.and.the.
CCP.model..Since.the.CCP.is.the.“primary.mechanism.for.the.federal.government.to.authorize.the.
delivery.of.behavioral.health.services.to.disaster-affected.communities.and.individuals”.(Chapter.
3,. this. volume),. addressing. disaster-related. substance. abuse. through. the. CCP. should. be. a. key.
objective.for.state.agencies.
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327Disaster and Substance Abuse Services
18.6.1  ioWa disasTer response
The.following.disaster.substance.abuse.response.field.report.is.based.in.part.on.a.questionnaire.sent.
to.Karen.Hyatt,.Emergency.Mental.Health.Specialist.for.the.Iowa.Department.of.Human.Services,.
Division.of.Mental.Health.and.Disability.Services.and.a.follow-up.interview,.as.well.as.the.state’s.
final.CCP.program.report..The.report.describes.the.experiences.of.incorporating.disaster.substance.
abuse. services. into. a. CCP. that. was. implemented. in. response. to. widespread. flooding. in. 2008..
Although.the.CCP.can.address.both.disaster-related.mental.health.and.substance.abuse.issues,.it.has.
been.a.challenge.to.consistently.address.disaster-related.substance.abuse.within.CCPs..State.men-
tal.health.authorities.infrequently.contract.with.substance.abuse.providers.to.offer.CCP.services..
Further,.ambiguity.in.federal.legislation.concerning.crisis.counseling.and.inconsistent.integration.of.
state.public.mental.health.and.substance.abuse.prevention.and.treatment.systems.has.contributed.to.
a.misconception.that.the.CCP.cannot.address.substance.abuse..Just.as.disaster-related.mental.health.
issues.are.addressed.through.the.parameters.of.the.CCP,.disaster.substance.abuse.can.be.addressed.
through. the. provision. of. psychoeducation,. supportive. interventions,. substance. abuse. screenings,.
referrals.to.traditional.substance.abuse.treatment.when.indicated,.and.networking.with.community.
recovery.support.systems.
18.6.1.1  2008: Catastrophic Floods
During.the.summer.of.2008,.catastrophic.storms.caused.widespread.flooding.across.most.of.Iowa,.
resulting. in. significant. devastation. to. many. communities. and. a. subsequent. presidential. disaster.
declaration.(FEMA-DR-1763;.FEMA.2010)..Ultimately,.78.of.Iowa’s.99.counties.were.declared.for.
Individual. Assistance. leading. to. the. largest. Crisis. Counseling. Assistance. and. Training. Program.
(CCP).in.the.state’s.history..This.program.was.known.as.Project.Recovery.Iowa.and.came.to.provide.
both.disaster.mental.health.and.substance.abuse.services.to.31.counties.
In.the.past,.the.State.relied.on.a.single.health.provider.to.offer.statewide.crisis.counseling.ser-
vices,.which.sometimes.resulted.in.services.being.offered.by.a.provider.that.was.not.indigenous.to.
the.communities.being.served..Project.Recovery.Iowa,.however,.utilized.a.different.service.delivery.
strategy.based.on.disaster.behavioral.health.service.provision.by.six.local.mental.health.and.sub-
stance.abuse.providers,.in.addition.to.the.Iowa.Concern.Hotline..One.provider,.in.particular,.was.
known.for.traditionally.offering.a.wide.range.of.substance.abuse.prevention.and.treatment.services,.
including.services.for.adolescents.
The. establishment. of. community-based. partnerships. was. critical. to. the. success. of. Project.
Recovery. Iowa. and. helped. to. provide. additional. disaster. substance. abuse. outreach.. Providers.
networked.with.groups.such.as.public.libraries,.farm.associations,.and.faith-based.organizations..
One. provider,. in. particular,. established. community-based. partnerships. with. local. substance.
abuse.service.centers.well.known.in.several.communities.(Iowa.Department.of.Human.Services.
2009).. The. State. noted. the. success. of. this. new. model. in. its. final. program. report.. “The. Project.
Recovery.Iowa.model.that.was.developed.by.the.MHDS.staff.was.clearly.a.best.practice.for.the.
State.of.Iowa..For.the.first.time.in.Iowa’s.CCP.grant.history,.community.mental.health.and.sub-
stance.abuse.providers.were.contracted.with.to.provide.the.grant.services..Their.knowledge.and.
history. assisted. in. the. needs. assessment. necessary. for. outreach. work,. in. the. projection. of. the.
needs.of.people.who.had.experienced.the.disaster.events.and.in.the.recruitment.of.people.to.hire.
for.Project.Recovery.Iowa.who.were.indigenous.to.the.communities.served”.(Iowa.Department.
of. Human. Services. 2009,. 35).. The. strategy. to. utilize. a. variety. of. behavioral. health. providers.
supported.both.the.needs.of.local.communities,.as.well.as.fostered.the.delivery.of.CCP.disaster.
substance.abuse.services.
Disaster.substance.abuse.services.benefited.greatly.from.Project.Recovery.Iowa’s.use.of.staff.with.
professional.substance.abuse.treatment.backgrounds..All.of.the.CCP.team.leaders.at.one.provider.
had.professional.substance.abuse.treatment.backgrounds..These.team.leaders.provided.supportive.
substance. abuse. interventions. and. referrals. when. needed. and. provided. project-wide. trainings. on.
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328 Behavioral Health Response to Disasters
substance. abuse. issues.. “As. staff. identified. the. training. needs. of. their. Crisis. Counselors,. Team.
Leaders.developed.and.provided.additional.in-services..For.example,.instruction.was.provided.on.
how. to. conduct. an. educational. presentation,. facilitate. support. groups,. and. assess. for. substance.
abuse.and.mental.health.risk.factors”.(Iowa.Department.of.Human.Services.2009,.68).e.In.addition,.
some.of.the.outreach.workers.also.had.paraprofessional.substance.abuse.experience.
Project.Recovery.Iowa’s.crisis.counselors.offered.impacted.communities.a.wide.assortment.of.
educational.presentations.and.support.groups,.often.targeting.specific.at-risk.populations.for.addi-
tional.support.during.the.recovery.process..For.instance,.they.used.a.variety.of.activities.to.engage.
students.in.age-appropriate.discussions.of.feelings.associated.with.the.flooding.and.the.impact.on.
their.current.lives..In.the.following.example,.issues.of.substance.abuse.in.the.family.were.addressed,.
which.led.to.a.discussion.of.the.student’s.hopes.for.the.family..“Students.made.family.crests..One.
student.drew.a.beer.bottle,.and.explained.that.after.the.flood.his.dad.was.stressed.out.and.began.
drinking.heavily..The.student.explained.that.this.caused.a.lot.of.arguing.and.fighting.in.the.home.
and. how. he. hopes. for. peace. because. his.dad.is.going. to. AA.meetings.. This.opened. a.discussion.
about.alcoholism,.and.other.students.related.and.shared.their.experiences.with.this.student”.(Iowa.
Department.of.Human.Services.2009,.290).
Of. the. many. CCP. services. provided. by. Project. Recovery. Iowa,. the. consistent. administration.
of. substance. abuse. screenings. across. providers. was. a. strength. of. the. program.. Project. Recovery.
Iowa. crisis. counselors. and. team. leaders. implemented. alcohol. abuse. screenings. for. adults,. along.
with. the. adult. mental. health. screenings,. and. adolescents.. However,. challenges. accompanied. the.
introduction.of.the.CAGE.Questionnaire.for.adults.(Ewing.1984).and.the.CRAFFT.for.adolescents.
(Knight.et.al..1999)..“Initially,.the.crisis.counseling.staff.was.hesitant.to.use.the.screening.tools;.
however,.with.further.training.on.how.to.make.an.appropriate.referral,.staff.started.to.use.the.tools..
The.overall.feedback.from.staff.was.that.the.screening.tools.gave.them.a.comfort.level.in.asking.
questions.they.were.not.otherwise.comfortable.asking..Once.the.screening.tools.were.in.place,.there.
was.a.positive.increase.in.referrals.to.substance.abuse.treatment.services..The.data.[do].not.show,.
however,.whether.the.increase.in.referrals.was.because.more.people.screened.high.on.the.questions.
or.whether.staff.became.more.comfortable.referring.to.substance.abuse.treatment.services.based.
on.the.new.training.and.the.screening.tool”.(Iowa.Department.of.Human.Services.2009,.43)..It.is.
notable.that.staff.across.all.Project.Recovery.Iowa.providers.was.trained.in.the.use.of.these.tools..
In.addition,.all.Iowa.Concern.Hotline.counselors.received.training.in.listening.for.potential.clues.of.
substance.abuse.and.how.to.appropriately.respond.when.disaster.survivors.presented.with.substance.
abuse.issues.
The.Iowa.Concern.Hotline.was.instrumental.in.the.state’s.substance.abuse.response.to.the.floods..
In. illustration,. “Iowa. Concern. received. a. call. from. a. man. with. a. history. of. substance. abuse.. He.
stated.that.he.has.been.working.on.his.house.but.it.has.become.an.emotional.burden..He.is.having.
trouble.sleeping.and.concentrating,.and.has.had.memory.loss,.admitting.to.‘falling.off.the.wagon.’.
He.found.a.PRI.brochure.in.his.door.and.called.Iowa.Concern.for.help..He.said.he.was.relieved.to.
find.the.brochure;.it.was.the.answer.he.had.been.looking.for”.(Iowa.Department.of.Human.Services.
2009,.292).
Another.programmatic.element.that.facilitated.the.provision.of.disaster.substance.abuse.services.
was. the. importance. given. to. ongoing. needs. assessment.. Early. in. the. program,. Project. Recovery.
Iowa.used.a.“pyramid.diagram”.to.target.services.in.which.about.80.percent.of.a.community.ben-
efited. from. services. that. were. preventive. and. psychoeducational. in. nature,. about. 15. percent. of. a.
community.benefited.from.services.targeted.to.at-risk.populations,.and.about.5.percent.of.commu-
nity.members.required.more.intensive.services.based.on.significant.behavioral.health.adjustment.
needs.(Iowa.Department.of.Human.Services.2009)..Community.and.at-risk.population.needs.were.
continually.assessed.throughout.the.life.of.the.program,. leading.to.observed.variances.over.time.
as.well.as.differences.from.one.community.to.another..Such.ongoing.needs.assessment.activities.
helped. to. ensure. that. individuals. with. substance. abuse. issues. continued. to. be. among. those. who.
merited.special.consideration.throughout.the.program.
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329Disaster and Substance Abuse Services
Project.Recovery.Iowa’s.experience.illustrates.several.important.ways.disaster.substance.abuse.
services.can.be.effectively.incorporated.into.a.large-scale.disaster.behavioral.health.response.and.
recovery.program..First,.disaster.substance.abuse.services.fit.nicely.within.the.service.parameters.
of.the.CCP.and.should.be.viewed.as.a.critical.partner.of.mental.health.services..Second,.valid.and.
reliable.substance.abuse.screening.tools.for.both.adults.and.youth.should.be.completed.whenever.
mental. health. screening. tools. are. used. and. at. other. times. as. indicated.. Third,. crisis. counselors.
should. receive. appropriate. substance. abuse. training. at. the. beginning. of. a. CCP. to. assist. them. to.
identify.individuals.with.substance.abuse.problems..And,.finally,.state.disaster.mental.health.and.
disaster. substance. abuse. coordinators. should. be. encouraged. to. collaborate. during. the. writing. of.
the.CCP.application.in.order.to.maximize.effective.behavioral.health.outreach.efforts,.as.well.as.
develop.a.program.responsive.to.both.disaster.mental.health.and.substance.abuse.needs.
As.a.disaster.behavioral.health.response.and.recovery.program.that.has.evolved.over.the.course.
of. its. 35-plus-year. history,. the. CCP. is. increasingly. addressing. disaster-related. substance. abuse.
issues.. State. public. mental. health. and. substance. abuse. prevention. and. treatment. systems,. which.
have.often.operated.independently.of.each.other,.have.continued.to.move.toward.a.unified.behav-
ioral.health.model.in.recent.years..As.a.result,.CCPs.will.most.likely.continue.to.engage.providers.
with.substance.abuse.expertise..The.Project.Recovery.Iowa.CCP.demonstrated.that.disaster-related.
substance.abuse.issues.can.be.addressed.through.the.inclusion.of.substance.abuse.providers,.as.well.
as.the.incorporation.of.substance.abuse.trainings,.screenings,.supportive.services,.partnerships,.and.
referrals.across.CCP.service.providers.
18.6.2  colorado disasTer response
The. following. disaster. substance. abuse. field. reports. are. based. on. a. questionnaire. sent. to. Katie.
Wells,. Disaster. Response. Coordinator. for. Substance. Abuse. with. the. Colorado. Department. of.
Human.Services,.Division.of.Behavioral.Health,.and.a.follow-up.interview..The.Colorado.reports.
highlight.how.substance.abuse.professionals.can.make.important.contributions.to.the.local.or.state.
jurisdiction’s.disaster.behavioral.health.response;.how.collaborative.education.and.cross-training.of.
mental.health.and.other.partner.organizations’.workers.can.raise.awareness.of.the.effects.of.disaster.
on.substance.use.and.abuse;.and.the.special.role.and.utilization.of.peers.in.recovery.and.12-step.
programs.in.disaster.response..The.importance.of.outreach.to.at-risk.populations,.the.building.of.
rapport.and.trust.with.survivors.with.substance.use.problems,.and.the.need.to.address.psychological.
triggers.that.can.threaten.recovery.and.sobriety.are.also.discussed.
18.6.2.1  2008: Severe Storms and Tornadoes
After.a.powerful.tornado.struck.north-central.Colorado.in.May.2008.(FEMA-1762-DR-CO;.FEMA.
2009),. efforts. were. made. to. link. the. Crisis. Counseling. Assistance. and. Training. Program. (CCP).
with. a. local. substance. abuse. prevention. coalition,. with. an. increased. focus. on. helping. youth. in.
school.settings..The.response.consisted.mostly.of.information.sharing.on.the.location.of.providers,.
crisis.intervention.for.individuals.who.were.struggling.with.relapse.and.trauma,.and.basic.support-
ive.services.for.those.in.varying.stages.of.recovery..For.individuals.requiring.substance.abuse.treat-
ment,. referrals. and. assessments. were. provided,. and. collaborative. partnerships. helped. to. provide.
transportation.to.treatment.providers..Many.survivors.were.very.reluctant.to.identify.their.need.for.
substance.abuse.services,.so.it.was.a.slow.process..Psychological.First.Aid.was.provided.by.mental.
health.staff,.and.substance.abuse.providers.were.consulted.when.a.substance.use.issue.was.discov-
ered.. Many. substance. abuse. professionals. helped. by. listening. and. providing. simple,. supportive.
interventions.
18.6.2.2  2005: Hurricane Katrina
Colorado.was.one.of.many.states.that.received.Hurricane.Katrina.evacuees,.under.a.program.entitled.
Colorado.Safe.Haven..Although.the.state.administered.a.CCP.for.the.Katrina.evacuees,.a.substantial.
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330 Behavioral Health Response to Disasters
portion.of.the.substance.abuse.services.provided.was.outside.the.CCP..Evacuees.began.arriving.in.
Colorado.on.September.4,.2005;.some.arrived.by.plane.and.were.assisted.by.the.Federal.Emergency.
Management.Agency,.and.others.came.on.their.own.using.different.modes.of.transportation..The.
state. provided. dormitory. housing,. medical. services,. services. for. pets,. crisis. counseling,. and. all.
other. necessities. for. the. evacuees. in. a. 550-room. dormitory. on. Lowry. Air. Force. Base.. Evacuees.
were.not.allowed.to.use.alcohol.or.other.drugs.while.at.the.base.
In.addition.to.certified.addiction.counselors.at.the.site.to.provide.support.and.guidance.for.those.
seeking.treatment.services.or.access.to.recovery.support.meetings,.the.participation.of.recovering.
individuals. from. 12-Step. programs. was. a. key. factor. in. the. substance. abuse. response. to. support.
Hurricane.Katrina.evacuees..Approximately.10–12.substance.abuse.responders.from.local.provider.
agencies.and.25–30.individuals.from.Alcoholics.Anonymous.and.Narcotics.Anonymous.provided.
outreach,. support,. screenings. and. assessment,. and. referrals. to. community. services. for. substance.
abuse.treatment..Outreach.included.literature.distribution;.brochures.were.left.at.the.site.for.families.
who. needed. referrals. for. medication-assisted. therapy,. detoxification,. or. ongoing. substance. abuse.
treatment.services..Educational.materials.were.also.distributed.to.local.schools.where.adolescent.
evacuees.attended.to.raise.awareness.of.substance.abuse.problems.and.community.resources..It.was.
expected.that.the.first.6–12.months.after.relocation.would.be.the.most.challenging.time.for.evacuees.
with.substance.abuse.problems..
Substance. abuse. professionals. and. paraprofessionals. integrated. their. services. within. the. larger.
disaster.response.effort.and.worked.effectively.alongside.other.behavioral.health.response.partners.
such.as.the.American.Red.Cross.and.the.Colorado.Organization.for.Victim.Assistance..Substance.
abuse. workers. explained. the. services. that. recovering. individuals. would. need. and. their. own. roles.
and. responsibilities.. They. were. especially. helpful. with. the. referral. process. due. to. their. expertise.
and.knowledge.of.community.substance.abuse.treatment.and.detoxification.services..Having.peers-
in-recovery.onsite.was.invaluable,.as.they.provided.an.important.support.role.as.evacuees.made.the.
transition.to.their.new.location..They.provided.trucks.to.help.evacuees.move,.donated.items.evacuees.
needed.in.order.to.get.settled,.and.provided.transportation.to.12-Step.recovery.support.meetings.
18.6.2.3  2002: Wildfires
In.Colorado’s.2002.wildfire.disaster.(FEMA-1421-DR-CO;.FEMA.2004),.a.substance.abuse.treat-
ment. provider. participated. in. the. CCP. to. help. the. families. impacted. by. the. disaster.. One. of. the.
program’s.crisis.counselors.reported.conversations.with.different.survivors.with.substance.use.dis-
orders.after.the.fires..One.of.these.survivors.had.lost.everything.and.was.living.in.a.tent..Each.time.
the. crisis. counselor. spoke. to. him. he. was. intoxicated. and. refused. help.. Consequently,. behavioral.
health. workers. must. face. the. fact. that. survivors. with. substance. abuse. or. mental. health. issues. do.
not.always.seek.nor.will.they.accept.help..However,.outreach.workers.can.sometimes.motivate.such.
individuals.to.seek.help.by.providing.supportive.interventions,.which.contribute.to.relationships.of.
trust.in.which.confidentiality.and.safety.are.assured.
For.the.survivors.who.needed.medication-assisted.therapies,.the.substance.abuse-funded.provid-
ers,.known.as.the.Managed.Service.Organizations,.offered.the.assessments.and.services.required.
outside.the.CCP..There.was.significant.outreach,.including.door-to-door.canvassing,.to.older.adults.
and.non-English-speaking.populations.after.the.fires..Workers.provided.information.in.both.English.
and. Spanish. regarding. disaster. preparedness. and. stress. management,. including. how. to. deal. with.
painful. reminders. such. as. the. disaster’s. anniversary.. Such. trigger. events. can. test. the. resolve. of.
individuals.in.recovery.
The.Division.of.Behavioral.Health.discovered.that.both.large-and.small-scale.disaster.substance.
abuse.responses.include.the.importance.of.planning.ahead.of.time.and.knowledge.of.services.avail-
able.in.any.given.community..Whatever.can.be.done.to.elevate.the.need.for.an.awareness.of.the.role.
substance. abuse. can. have. on. survivors. would. be. helpful.. Due. to. lack. of. training. and. awareness,.
nonbehavioral.health.emergency.responders.do.not.often.consider.the.mental.health.and.substance.
abuse.issues.with.which.some.survivors.struggle..Therefore,.there.is.a.need.to.train.nonbehavioral.
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331Disaster and Substance Abuse Services
health workers. in. other. disaster. response. agencies. to. increase. their. knowledge. of. the. potential.
impact.of.disaster.on.people.in.recovery.or.in.active.addiction..Interagency.collaborations.and.train-
ings.should.occur.regularly.so.that.in.the.future,.no.matter.what.the.disaster,.a.community.response.
team.would.know.immediately.if.substance.abuse.services.have.been.interrupted.and.to.ensure.a.
substance.abuse.professional.is.always.available.and.involved.in.the.disaster.response..Distributing.
literature.to.help. responders. and.survivors.alike.recognize.when.an.individual’s.use.is.becoming.
problematic.is.an.important.aspect.of.outreach.education..Furthermore,.there.is.greater.recognition.
of.the.necessity.for.mental.health.services.postdisaster.than.substance.abuse.services..Training.on.
the. stigma. of. substance. abuse. is. important. to. help. mental. health. outreach. workers. to. talk. confi-
dently.about.the.subject.of.substance.use.and.abuse.with.disaster.survivors.
18.6.3  MassachuseTTs disasTer response
The. following. disaster. substance. abuse. response. field. report. is. based. on. a. questionnaire. sent. to.
Rodrigo.Monterrey,.All-Hazards.Coordinator.for.the.Massachusetts.Department.of.Public.Health,.
Bureau.of.Substance.Abuse.Services.(BSAS),.and.a.follow-up.interview..The.field.report.describes.
the.experiences.of.substance.abuse.workers.who.assisted.Hurricane.Katrina.evacuees.who.relocated.
to.Massachusetts.after.the.storm..Their.experiences.illustrate.the.importance.of.effective.substance.
abuse. screening. and. referral. of. survivors;. interagency. collaboration. and. cross-training;. medica-
tion.maintenance;.surge.capacity.and.worker.stress.issues..Furthermore,.the.provision.of.disaster.
behavioral.health.services.must.occur.within.the.context.of.the.local.or.state.jurisdiction’s.overall.
response. to. disaster.. Contrary. to. posing. a. barrier. to. substance. abuse. workers,. such. collaborative.
efforts.provide.opportunities.to.raise.awareness.of.survivor.substance.abuse.problems.
18.6.3.1  2008: Hurricane Katrina Evacuees and Response
On.August.29,.2005,.Hurricane.Katrina.impacted.the.southeast.Louisiana.coast.with.severe.flood-
ing,.damaged.levees,.and,.ultimately,.causing.flooding.and.loss.of.life.in.New.Orleans..Assisted.by.
the. Federal.Emergency. Management. Agency,. approximately. 200.evacuees. from. the. greater. New.
Orleans.area.began.arriving.in.Massachusetts.by.plane.on.September.8,.2005..Another.100.evacu-
ees.arrived.by.other.means.of.transportation..Under.a.program.entitled.Operation.Helping.Hands,.
the.state.welcomed,.triaged,.and.temporarily.housed.the.evacuees.at.Otis.Air.National.Guard.Base.
on.Cape.Cod,.with.the.BSAS.playing.an.integral.role.in.the.effort..The.newcomers.were.referred.to.
as.“guests”.instead.of.the.more.impersonal.term.“evacuees.”
All.guests.arriving.at.Otis.Air.National.Guard.Base.were.given.a.brief.substance.abuse.screen-
ing..The.screening.documented.substance.use.history.with.a.focus.on.current.withdrawal.risks..It.
included.simple,.straightforward.questions.about.medications.guests.were.taking.or.typical.alcohol.
and.other.drug.intake,.in.order.to.prevent.survivors.from.experiencing.withdrawal.symptoms.while.
at.the.base..Drinking.or.illegal.drug.use.was.not.allowed.“on.campus.”.Guests.were.instructed.on.
the.rules.of.conduct,.compliance.with.which.was.a.prerequisite.for.remaining.in.theshelter.
BSAS. substance. abuse. outreach. workers. primarily. provided. interventions. consistent. with.
Psychological.First.Aid,.in.addition.to.ongoing.recovery.support.and.relapse.prevention.interven-
tions. for. evacuees. in. recovery.. However,. substance. abuse. education,. screenings,. and. referrals,. as.
well. as. transportation. to. and. from. formal. treatment,. were. also. part. of. their. roles.. Specific. tools.
were. developed. for. Department. of. Mental. Health. staff. to. conduct. substance. abuse. assessments.
effectively.. Based. on. the. substance. abuse. screenings,. three. guests. were. immediately. referred. to.
the. State’s. Acute. Treatment. Services. (ATS). or. a. detoxification. facility. following. arrival.. Others.
were. monitored. and. offered. support. throughout. their. stay. by. substance. abuse. outreach. workers.
who.were.trained.to.engage.clients.who.are.homeless.or.otherwise.unable.or.unwilling.to.access.
traditional.office-based.services..A.number.of.other.guests.were.subsequently.referred.to.substance.
abuse.treatment.during.the.course.of.their.stay..Additionally,.Alcoholics.Anonymous.was.invited.to.
establish.regular.meetings.on.campus..
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332 Behavioral Health Response to Disasters
Guests.on.medication-assisted.therapy.for.opioid.dependence.were.identified.through.the.initial.
medical.screening.given.to.all.guests.upon.their.arrival.at.the.base.and.referred.to.a.substance.abuse.
provider. for. an. assessment. to. ensure. treatment. continuity.. BSAS. arranged. for. a. licensed. opioid.
treatment. provider. to. be. on. the. base. during. the. first. 24. hours. of. guest. intake. to. take. referrals. if.
needed..Methadone.was.not.available.on.the.base,.but.several.times.a.day,.shuttle.buses.took.guests.
off.the.base.to.collect.their.medications.or.other.needs..There.was.also.a.medical.station.on.the.base.
where.guests.could.collect.their.prescription.medications.as.needed..After-action.reports.noted.staff.
concerns. about. medication. dosages. as. guests’. preexisting. diagnoses. and. medical. histories. were.
typically.inaccessible.after.the.disaster.
Although.the.Massachusetts.substance.abuse.prevention.and.treatment.infrastructure.did.not.suf-
fer.physical.damage.due.to.Hurricane.Katrina,.the.influx.of.guests.with.substance.abuse.treatment.
needs.tested.the.state’s.surge.capacity..To.mitigate.against.secondary.traumatic.stress,.the.outreach.
workers.were.offered.counseling..They.were.also.briefed.and.then.debriefed.at.the.beginning.and.
end.of.their.shifts.as.part.of.the.clinical.supervision.and.self-care.support.to.ensure.work.continuity.
and.worker.effectiveness.f
The.guests.came.from.a.very.different.culture,.in.many.cases.without.any.local.support.networks.
such.as.family,.friends,.neighbors,.spiritual.advisors,.or.work.colleagues..Consequently,.the.BSAS.
deployed.a.number.of.bilingual.substance.abuse.outreach.workers..Additional.interpreters.were.also.
available.on.campus.and.on.call,.if.needed..Older.adults.were.accommodated.on.the.ground.floors.
of.the.residences.and.provided.with.wheelchairs.and.canes,.as.well.as.other.assistive.devices..Many.
guests.brought.their.pets.and,.with.the.exception.of.certain.exotic.pets,.most.were.allowed.to.keep.
them. in. the. residences.. Families. with. children. were. kept. together. in. a. separate. building.. Sexual.
offender/criminal.background.checks.were.completed.to.ensure.guest.safety.
The.Massachusetts.BSAS.operated.within.the.state’s.Incident.Command.System.in.response.to.
receiving.evacuees..Most.of.the.nonbehavioral.health.disaster.agency.workers.had.little.knowledge.
of. substance. abuse. problems. and. services.. Many. of. them. saw. the. BSAS. as. the. “alcohol. or. drug.
police.”.Much.education.was.necessary.as.the.response.was.taking.place.with.nearly.every.entity.
involved.with.the.response.and.recovery.coordination.effort..These.collaborations,.however,.raised.
awareness.of.substance.abuse,.typical.signs.and.symptoms.of.use.or.abuse,.and.available.commu-
nity.resources,.which.contributed.to.greater.resilience.within.the.emergency.management.commu-
nity.for.future.disaster.response.
18.7  LESSONS LEARNED
There.are.a.number.of.important.takeaway.points.for.individuals.involved.in.disaster.substance.abuse.
planning. and. response.. Research. to. date. and. anecdotal. field. observations. support. that. the. issue. of.
substance.abuse.should.be.included.in.any.jurisdiction’s.overall.behavioral.health.response.to.disaster..
Individuals.in.recovery,.especially.early.recovery,.may.relapse.after.disaster.and.need.supportive.inter-
ventions.to.maintain.their.sobriety..Additionally,.survivors.who.are.borderline.addicts.or.individuals.
in.active.addiction.may.increase.their.consumption.of.substances.after.disaster,.sometimes.with.life-
threatening.results..Since.it.appears.that.loss.of.residence.and.lack.of.social.support.are.significantly.
related.to.substance.use.problems,.the.homeless.may.need.extra.support.to.prevent.substance.use.from.
spiraling.out.of.control..Likewise,.disaster.response.should.incorporate.measures.to.mitigate.against.
trigger.events.that.may.impede.the.best.efforts.of.individuals.in.recovery.to.preserve.their.sobriety.
Substance. abuse. professionals. and. paraprofessionals. should. be. included. in. both. the. jurisdic-
tional.disaster.behavioral.health.response.and.preparedness.efforts.because.they.are.trained.to.pro-
vide.initial.screenings.and.assessments.to.identify.addiction.issues.and.will.be.the.most.familiar.
with.available.resources.in.the.impacted.community..Their.actions.should.reflect.an.appreciation.
for.cultural.diversity.and.how.culture.can.impact.survivors’.response.to.disaster..Substance.abuse.
workers.should.also.be.proactive.in.reaching.out.to.and.collaborating.with.other.partner.organiza-
tions.active.in.the.response,.including.providing.education.and.training.to.mental.health.workers.
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333Disaster and Substance Abuse Services
and.nonbehavioral.health.partners.on.the.effects.of.stigma,.recognizing.signs.and.symptoms.of.sub-
stance.abuse,.and.building.rapport.and.trust.with.survivors.who.may.be.struggling.with.addiction.
Further,.the.demonstrated.ability.of.peers-in-recovery.to.regroup.quickly.after.disaster.and.their.
willingness.to.provide.support.to.survivors.facing.similar.issues.should.not.be.overlooked..Disaster.
planners. would. be. wise. to. engage. in. discussion. with. groups. such. as. Alcoholics. Anonymous. or.
Narcotics.Anonymous.and.to.augment.the.jurisdictional.disaster.response.and.develop.Memoranda.
of.Understanding.with.other.recovery.support.organizations.
Catastrophic.disasters.pose.special.concerns.because.they.can.destroy.or.indefinitely.delay.sub-
stance. abuse. infrastructure. and. services.. Even. when. disasters. do. not. destroy. or. delay. use. of. the.
substance.abuse.infrastructure,.providers.need.to.have.surge.capacity.and.sufficient.ability.to.con-
tinue.medication-assisted.therapies.to.avoid.dangerous.consequences.for.survivors..Therefore,.the.
emergency. planning. needs. of. opioid. treatment. providers. should. be. factored. into. local. and. state.
preparedness.activities..Further,.opioid.treatment.providers.need.to.have.protocols.for.guest-dosing.
in.place.prior.to.disaster.because.medical.records.may.be.unavailable.afterwards.
18.8  NATIONAL DEVELOPMENTS
Fortunately,.some.of.the.disaster.substance.abuse.lessons.learned.are.being.applied.on.the.national.
level.. Since. the. events. of. 9/11,. disaster. substance. abuse. responses. benefited. from. several. initia-
tives. and. developments.. State. and. territory. planning. for. the. substance. abuse. impact. of. disasters.
increased.and.is.becoming.more.integrated.with.mental.health,.emergency.management,.and.public.
health.planning..In.addition,.experience.with.the.impact.of.terrorism.and.large-scale.disasters.led.to.
efforts.to.ensure.that.patients.receiving.medication-assisted.therapy.can.get.medication.safely.and.
effectively.after.a.disaster..Finally,.there.is.a.substantial.increase.in.the.number.of.identified.state.
and.territory.disaster.substance.abuse.or.behavioral.health.coordinators.over.the.last.several.years.
18.8.1  disasTer suBsTance aBuse planning
Effective.response.to.the.substance.abuse.impact.of.disasters.depends,.in.large.part,.on.best.practice.
disaster. substance. abuse. preparedness. and. planning. efforts. at. the. state,. territory,. and. local. levels..
This.promotes.further.integration.of.disaster.substance.abuse.planning.with.overall.state.and.territory.
disaster.mental.health,.emergency.management,.and.public.health.plans..One.important.catalyst.for.
increased.and.coordinated.disaster.substance.abuse.planning.was.the.SAMHSA.Targeted.Capacity.
Expansion. Grants. to. Enhance. State. Capacity. for. Emergency. Mental. Health. and. Substance. Abuse.
Response,.also.known.as.the.State.Capacity.Expansion.(SCE).grants,.which.were.initiated.in.2003.and.
ended.in.2006.for.most.states.participating.in.the.initiative..These.grants.were.a.direct.outgrowth.of.the.
9/11.terrorist.attacks,.which.highlighted.the.need.for.coordinated.mental.health.and.substance.abuse.
responses.to.disasters.that.are.integrated.with.the.larger.emergency.management.and.public.health.
responses..Thirty-four.states.and.the.District.of.Columbia.received.the.grants,.a.primary.deliverable.
of.which.was.the.development.of.a.state.all-hazards.plan.that.required.“coordinated.mental.health.and.
substance.abuse.emergency.planning.and.capacity.development.activities”.(Donato.and.Mosser.nd,.2).
Prior.to.the.SCE.grants,.only.four.states.participating.in.the.SCE.grant.initiative.had.a.unified.
disaster.behavioral.health.plan.that.addressed.both.disaster.mental.health.and.substance.abuse.pre-
paredness,.with.an.additional.three.states.holding.a.disaster.substance.abuse.plan.that.also.addressed.
mental. health. concerns.. A. final. review. of. the. state. all-hazards. plans. submitted. under. the. grants.
indicated.improved.disaster.substance.abuse.planning.evidenced.by.26.states.with.a.unified.disaster.
behavioral.health.plan,.two.states.with.separate.disaster.mental.health.and.substance.abuse.plans,.
four. states. with. disaster. mental. health. plans. that. also. addressed. substance. abuse,. and. one. state.
with. a. disaster. substance. abuse. plan. that. also. addressed. mental. health. (Donato. and. Mosser. nd)..
SAMHSA. is. continuing. to. promote. integrated. best-practice. disaster. substance. abuse. all-hazards.
planning.for.states.and.territories.that.is.compliant.with.the.National.Incident.Management.System.g
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334 Behavioral Health Response to Disasters
18.8.2  digiTal access To MedicaTion
One. important. program. that. resulted. from. lessons. learned. from. the. 9/11. terrorist. attacks. is. the.
SAMHSA. Center. for. Substance. Abuse. Treatment’s. (CSAT). Digital. Access. to. Medication,. or.
D-ATM.initiative..The.attacks.led.to.the.destruction.of.one.opioid.treatment.provider.(OTP).and.the.
closure.of.several.others.in.lower.Manhattan..The.disruption.in.medication-assisted.therapies.and.
the.subsequent.impact.on.roughly.1,000.patients.is.well.documented.in.the.Frank.and.Owens.(2002).
report.mentioned.earlier.in.this.chapter..As.a.result,.SAMHSA.CSAT.collaborated.with.stakehold-
ers,. including. the. Committee. of. Methadone. Program. Administrators. and. patient. representatives,.
to. plan. for. a. secure,. Web-based. database. that. would. allow. a. patient. to. be. effectively. and. safely.
guest-dosed.at.an.OTP.other.than.their.home.clinic.in.an.emergency..Later,.the.arrival.of.Hurricane.
Katrina.evacuees.at.guest.OTPs,.many.of.whom.came.with.no.identification,.reinforced.the.need.
for. both. effective. guest-dosing. protocols. and. the. development. of. the. D-ATM. project,. which. was.
initiated.in.the.fall.of.2005..D-ATM.utilizes.a.biometric.identifier.based.on.a.patient’s.finger.scan.
so.that.a.guest.OTP.can.verify.that.the.patient.is.in.treatment.at.another.D-ATM.participating.OTP.
and.can.receive.information.on.the.patient’s.medicinal.history..The.home.OTP.is.also.notified.of.the.
patient’s.request.for.guest.dosing,.the.dosage.provided,.and.the.frequency.of.guest.dosing..Patient.
participation.in.D-ATM.is.strictly.voluntary.and.the.system.is.designed.with.a.high.degree.of.secu-
rity.to.protect.the.patient’s.personal.information,.which.is.only.accessed.at.the.request.of.the.patient..
Currently,.D-ATM.is.in.phase.III.pilot.testing.with.plans.to.eventually.make.the.project.available.
to.OTPs.nationwide.h
18.8.3  disasTer suBsTance aBuse preparedness and response coordinaTion
Many.states.and.territories.have.increased.their.personnel.resources.devoted.to.the.coordination.of.
disaster.substance.abuse.preparedness.and.response..Known.as.disaster.substance.abuse.coordina-
tors,.virtually.no.states.or.territories.held.such.a.position.before.9/11..However,.by.2006,.at.least.six.
states.had.coordinators.serving.in.this.role,.and.as.of.this.writing,.17.state.or.territory.disaster.sub-
stance.abuse.coordinators.were.identified.by.the.SAMHSA.Disaster.Technical.Assistance.Center,.
with.an.additional.29.state.or.territory.disaster.behavioral.health.coordinators.holding.responsibili-
ties.for.both.mental.health.and.substance.abuse.disaster.preparedness.and.response.
18.9  CONCLUSION
This.chapter.used.several.methods.to.raise.awareness.of.disaster.substance.abuse.including.a.review.
of.recent.literature,.field.observations.from.several.state.responses.to.disaster,.and.discussion.of.sev-
eral.important.state.and.federal.initiatives.that.incorporated.some.of.the.lessons.learned.from.prior.
disasters..Although.the.practice.of.disaster.substance.abuse.is.a.relatively.new.field.of.study,.current.
research.suggests.that.use.of.substances.after.disaster.increases.and.survivors.in.recovery.may.be.at.
greater.risk.of.relapse..We.believe.the.information.presented.in.this.chapter.will.stimulate.the.appe-
tites.of.both.readers.and.behavioral.health.researchers..Much.more.research,.including.longitudinal.
studies.in.particular,.is.needed.to.understand.the.relationship.between.disasters.and.substance.use.
and.abuse..It.is.our.hope.that,.having.shed.light.on.disaster.substance.abuse,.others.will.continue.to.
refine.interventions.and.practices.that.will.improve.the.health.and.well-being.of.disaster.survivors.
with.substance.use.problems.
NOTES
. a.. Meals.Ready.to.Eat.(MREs).are.prepackaged,.individual.meals.bought.by.the.U.S..military.for.use.in.
combat.and.other.field.deployments.where.food.facilities.may.be.unavailable.
. b.. PL-104-321;. see. http://www.fema.gov/pdf/emergency/nrf/EMACoverviewForNRF.pdf. for. additional.
information.about.the.EMAC.
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335Disaster and Substance Abuse Services
. c.. See.the.Centers.for.Disease.Control.(CDC).Web.site.at.http://www.cdc.gov/phpr/stockpile.htm.for.infor-
mation.about.the.Strategic.National.Stockpile.(SNS).
. d.. State.Mental.Health.Authority.(SMHA),.42.U.S.C..§.201.
. e.. The.term.in-services.refers.to.intraorganizational.trainings.offered.by.CCP.staff.
. f.. The.debriefings.were.not.based.on.Critical.Incident.Stress.Debriefing,.however.(see.Mitchell.1983).
. g.. Information. concerning. the. National. Incident. Management. System. can. be. found. at. http://www.fema.
gov/emergency/nims/.
. h.. See. the. SAMHSA. D-ATM.Web. site. for. additional. information. on. this. important. project:. http://datm.
samhsa.gov.
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Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

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Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

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Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

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Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

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Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

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