Mental Health Interventions Post-Disaster
One of the most pressing concerns for health officials following a natural disaster, such as widespread flooding or hurricane or earthquake damage, is the mental health of those individuals most directly affected by these catastrophic events. Disasters place unique psychological distress on survivors, evacuees and others who may have lost their homes and possessions and loved ones or have been displaced from their neighborhoods. The unfamiliarity of a new environment, such as a temporary emergency shelter, can create particular difficulty for people who were already relatively vulnerable before a disaster, including women, children, gay and transgender people, the elderly and people of color.
This essay examines the types of mental health interventions available after a disaster and outlines the principal challenges that attend such efforts. It also provides policy recommendations aimed at strengthening post-disaster mental health support programs.
“Psychopathology” is an umbrella term that refers to the study of a variety of potential psychological difficulties. Psychopathologies post-disaster can include Major Depressive Disorder, Post-traumatic Stress Disorder (PTSD), general anxiety, grief, phobias and other fears and Substance Use Disorder, including tobacco and undue alcohol use, which are characterized by unhealthy coping mechanisms that can affect physical health (Goldmann and Galea, 2014).
The development of psychological issues affects individuals differently, and some demographic populations are more likely to experience specific kinds of distress than the general population. For example, Goldmann and Galea have argued that, “middle-aged adults are generally at greatest risk of developing psychological issues, perhaps owing to having more chronic life stress and burdens and needing to support others” and that individuals who have partners and children are more likely to experience distress (2014, p. 174). The authors also point out, however, that single people are at greater risk for depression after a disaster, compared to married people. For its part, the U.S. Department of Veterans Affairs has formally suggested that middle-aged or older individuals are not necessairly at higher risk of developing psychopathologies because such persons have had more time to develop coping mechanisms than younger people (U.S. Department of Veterans Affairs, 2018). I posit that empirical reality may lie between these two perspectives; adults who have not experienced many disasters may be less able to cope and build resiliency than individuals who have done so, since the latter can anticipate their reactions and work consciously to address any issues that may arise. In this regard, age is not as much of a factor in developing capacity to confront disaster scenarios as lived experience.
According to the United Nations Office for Disaster Risk Reduction (UNISDR), from 2004 to 2015, 700,000 people have been killed and more than 1.7 billion people worldwide have been affected by disasters. Between 2004 and 2015, the United States alone saw 212 disasters, second only to China, which experienced 228. The U.S. events resulted in economic losses of $443 billion.
The nature of disasters vary; some are hyperlocal and concern people in a specific community, such as the case of the tornado that hit the city of Joplin, Missouri in 2011. Others affect a wider range of people owing to the size of the storm, such as Hurricane Katrina, for example, which affected large populations across several states. There are also human-created disasters, such as the September 11, 2001, and Boston Marathon terrorist attacks, for example. These may touch both more people than natural events, as the episodes in New York, the Washington, D.C. region and Boston¾ all highly populated areas¾exemplified. Beinecke, Raymond, et al. have estimated that in terrorist-related disasters, between 4 and 50 victims develop psychological issues for each death that occurs (2017). Goldmann and Galea have contended that it is also possible that psychological issues present differently based on the character of individual disasters, and that mass violence is more damaging than weather-related events as a result. Goldmann and Galea have contended that mass violence creates multiple traumatic experiences in close proximity to victims. Weather-related disasters may include high loss of life and other hallmarks of trauma as well, but they may also be larger-scale events that may then include more people who were not as affected by trauma (2014). Disasters, whether natural or human in their origins, may also create secondary mental health traumas, as many individuals who did not experience these occurrences directly nonetheless may have family members who did. Secondary trauma is also possible in the case of massive terrorist events, such as the ones that occurred on September 11, 2001, the news coverage of which dominated television and the internet around the world and captured the attention of millions.
Mental Health Interventions and Challenges
A variety of mental health interventions can be employed following disasters. At the federal level in the United States, mental health is covered under Emergency Support Function #8 (ESF #8)¾Public Health and Medical Services¾and coordinated by the Department of Health and Human Services (DHS). A central component of ESF #8 is behavioral health care, and DHS acts as a liaison with the staffs of many other federal entities, including the Department of Defense, to provide such assistance to disaster victims. Additionally, networks of mental health professionals including, hospital professionals and private practice practitioners, voluntarily coordinate with federal, state, and local authorities in various capacities to address mental health concerns that may arise in affected populations after a disaster. ESF #8 is one of the broadest ESFs because mental health has a large impact (Federal Emergency Management Agency, 2018). ESFs are meant to provide a framework to encourage different federal agencies to work together in response to disasters. Each ESF covers a specific area that has been deemed vital for the country’s infrastructure and protection of life and property. Mental health treatment is a requirement of any federally-declared disaster (Beinecke, Raymond, et al., 2017). The President is the sole authority that can declare a federal disaster, under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5121-5207), more commonly referred to as the Stafford Act. Under the Stafford Act, state governments may request federal assistance, typically when their (local and state) resources are overwhelmed. The President must then consider their requests, and approve or disapprove them.
There are many benefits to on-site mental health counseling. First, it permits mental health providers to provide immediate and person-to-person attention and to assess more quickly whether afflicted individuals need a mental health facility. Secondly, person-to-person assistance allows assisting professionals to employ an evidence-based approach called Psychological First Aid (PFA). The National Center for PTSD has developed this approach and it is supported by a rigorous training program geared towards non-medical professionals to equip them to engage in immediate mental health counseling. It emphasizes a step-by-step process of helping those providing aid to internalize their surroundings and context to ensure they remain calm and emotionally prepared to offer assistance (U.S. Department of Veterans Affairs, 2006).
The benefits of Psychological First Aid are numerous. It can be applied in a variety of situations and can extend the reach of mental health intervention far beyond what certified medical professionals alone could achieve. This approach also can be taught to individuals working in all three sectors of the political economy without much need for adjustment Whether one is working with government, business or school employees or with nonprofit organization representatives, PFA’s training principles remain the same.
Technology has also aided mental health interventions. The Substance Abuse and Mental Health Services Administration (SAMHSA), part of the Department of Health and Human Services, operates a telephone and text Disaster Distress Helpline that is staffed by trained counselors and functions 24 hours a day, 7-days a week. In an interview with me, a SAMHSA project officer reported that the agency received 13,889 phone calls and 31,644 text messages from October 1, 2016 to September 30, 2017, primarily in response to Hurricane Harvey (Personal interview, October 4, 2018).
All states have their own help-lines specifically for use during disasters. These help counselors differentiate the needs of different populations and also to allocate aid resources more effectively. More generally, technology is beneficial as an addition to in-person mental health counseling because it provides more flexibility to caregivers who often cannot attend at once to all who are in need, especially in harder to access rural areas, or during sleeping hours. Helplines also enable people whose first language is not English to obtain assistance in their native language. Indeed, SAMHSA provides help-line services in several languages, including Spanish.
Underlying these formal intervention options is a community’s social network, which encompasses the informal ties among family members and friends. Honeycutt, Nasser, et al. have contended that strong interpersonal ties within communities help build resiliency, and when individuals have vigorous connections to a social network they have access to other support as well, such as physical and emotional assistance and resources (2008). Honeycutt, Nasser, et al. also concluded that those with reliable internet access were able to cope better with the aftermath of hurricanes if they also had a reliable social network, because they employed that capacity to access friends and family members for support (2008). Additionally, individuals enjoying those advantages reported that they allowed them to imagine conversations with their friends and family, and to feel less alone in their (now) unfamiliar environments. Honeycutt et al. also argued that the demographic characteristics of disaster survivors were also a factor in their capcity to respond to what had befallen them. They determined, for example, that among college students, transfer students and individuals of color were more likely to have weaker social networks (2008).
In a study related to how and from whom college students seek assistance when faced with issues such as needing a place to stay or emotional support, Small and Sukhu determined that those sought who assistance from those who were well-connected within their social networks¾whether close friends or relative strangers—adjusted better than those who did not possess such ties. This finding indicates that a strong social network can be based on deep friendships or more surface-level acquaintances, and that in times of mental or emotional crisis, both can serve as at least a temporary salve (in lieu of professional intervention, if needed) for a person in crisis. Nevertheless, it is important to acknowledge that in some cases, displacement causes distress for those who cannot access a strong social network and cannot find the social support they need to further their recovery.
Each of these intervention types (in-person care, technological and efforts to rely on social networks) has its own challenges. This is so because first responders may have multiple priorities. For example, those conducting search and rescue after a disaster may also need mental health counseling, but they are often not able to obtain it as easily or as quickly as necessary. In part this is so because their work to assist victims is a higher priority. While this is understandable, the delay in treatment and the possibility of seeing more damage and victims up close may create more trauma for those individuals in the long-term than they might otherwise have sustained had they been able to access care in a more timely fashion. On the other hand, first responders are often trained to recognize symptoms of distress and to seek treatment when they sense they are experiencing them (SAMHSA, 2018). Challenges associated with technology include cost. Shklovski, Burke, et al. surveyed musicians in New Orleans who were affected by Hurricane Katrina and found that before the hurricane, many of them did not own a laptop, but subsequently purchased one when it became clear such would be useful after the storm as a lifeline to their social networks (2010).
In general, the literature indicates that all individuals affected by a disaster are at risk of psychological distress, to varying degrees, and so interventions to assist confront a basic paradox¾they must be sufficiently comprehensive to help a large population (such as an individual state or the entire United States), but also sufficiently individualized to enable mental health professionals to address the needs of specific individuals requiring assistance. One model that seeks to address this challenge is the Pyramid of Interventions, depicted in Figure 1 below.
Figure 1. The Intervention Pyramid for Mental Health
Source: Inter-Agency Standing Committee on Mental Health and Pschosocial Support in Emergency Settings (2007).
The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC) (2007) developed the Pyramid of Interventions along with what its members consider to be minimum guidelines for post-disaster intervention. The first level obliges professionals to provide a basic level of care, which includes addressing disaster victims’ immediate physical and emotional needs. Such services can, for example, include providing potable water and shelter and helping family members find each other. Without strong basic services and security, it is difficult to develop the other areas of the pyramid.
Additionally, the IASC has emphasized the integration of several mental health intervention programs so that they can complement each other. A school district may, for example, implement its own intervention pyramid, focused on the long-term mental health needs of children. Fox, Carta, et al.’s suggested services pyramid, shown in Figure 2 below, was not initially designed to address disasters (2010). However, it emphasized the basic types of care that are important to a child’s long-term well-being, such as promoting nurturing and responsive caregiving relationships. This approach intersects nicely with the concept of strengthening basic services and security in the second tier of the IASC pyramid, community and family supports.
Figure 2. The Pyramid Model, a Structure for Intervention During Early Childhood
Source: Response to Intervention and the Pyramid Model (2010).
Mental health interventions are a fluid matter that can and must change with each disaster. There is no one-size-fits-all solution to how victims react to and experience distress, how it should be treated or by whom. Psychopathology equips researchers, government officials, medical professionals and citizens with knowledge of the types of psychological issues responders may encounter, but these are hardly the only ones possible. Showing empathy for victims who have been affected by an immense trauma and ensuring that their basic needs and safety are secured helps ensures and may lessen the traumatic effects of the disaster they have endured.
Substance Abuse and Mental Health Services Administration project officer, personal interview, October 4, 2018.
Beinecke, R., Raymond, A., Cisse, M., Renna, K., Khan, S., Fuller, A., and Crawford, K. 2017. “The mental health response to the Boston bombing: A three-year review.” International Journal of Mental Health, 46(2), 2017, pp. 89-124.
Federal Emergency Management Agency, 2018. Emergency Support Function #8. Federal Emergency Management Agency, https://emilms.fema.gov/is230c/fem0104160text.htm Accessed October 15, 2018.
Fox, L., Carta, J., Strain, P., Dunlap, G., Hemmeter, M.L., “Response to Intervention and the Pyramid Model.” Infants & Young Children, 23(1), 2010, pp. 3-13.
Goldmann, E. and Galea, S., “Mental Health Consequences of Disasters.” Annual Review of Public Health, (35), 2014, pp.169–83.
Honeycutt, J., Nasser, K., Banner, J., Mapp, C., and DuPont, B., “Individual Differences in Catharsis, Emotional Valence, Trauma Anxiety, and Social Networks Among Hurricane Katrina and Rita Victims.” Southern Communication Journal, 73(3), 2008, pp.229-242.
Inter-Agency Standing Committee, IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Inter-Agency Standing Committee, 2007. http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf Accessed October 19, 2018.
National Center for PTSD, Psychological First Aid Field Operations Guide, 2nd Edition. U.S. Department of Veterans Affairs, 2006, https://www.ptsd.va.gov/professional/treat/type/PFA/PFA_V2.pdf Accessed October 18, 2018.
National Center for PTSD,. The Impact of Disaster on Older Adults. U.S. Department of Veterans Affairs, 2018. https://www.ptsd.va.gov/professional/treat/type/disaster_older_adult.asp Accessed October 16, 2018.
National Center for PTSD, Disaster: Risk and Resilience Factors. U.S. Department of Veterans Affairs, 2018. https://www.ptsd.va.gov/professional/treat/type/disaster_risk_resilience.asp Accessed October 16, 2018.
Shklovski, I., Burke, M., Kieslerb, S., and Krautb, R., “Technology Adoption and Use in the Aftermath of Hurricane Katrina in New Orleans.” American Behavioral Scientist, 53(8), 2010, pp.1228-1246.
Small, M. and Sukhu, C. “Because they were there: Access, deliberation, and the mobilization of networks for support,” Social Networks, 47, 2010, pp. 73-84.
Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, The Dialogue, 14(1), 2016, https://www.samhsa.gov/sites/default/files/dtac/dialogue-vol14-is1_final_051718.pdf Accessed October 19, 2018.
United Nations Office for Disaster Risk Reduction, Disaster Statistics, 2018, https://www.unisdr.org/we/inform/disaster-statistics, Accessed October 15, 2018.
Joanne Tang is pursuing her Master of Public Administration and a Graduate Certificate in Homeland Security. During her time at Virginia Tech, she has developed an interest in combining urbanist issues such as affordable housing and environmental protection with emergency management. She intends to focus her studies on increasing community resilience. She currently works in strategic communication and policy within the homeland security community. Her other interests involve writing, hiking, and photography. She can be found on Twitter at @joanneliveshere.
October 25, 2018