During the past 20 years, the number of devastating natural and manmade disasters in the United States has increased substantially. In 1990, a total of 43 presidential disaster declarations were issued, as compared to 112 in 2012. 1 These disasters have taken an economic and psychological toll on the affected communities, even though the fatalities from these events have decreased.Reference Rubonis and Bickman 2 - Reference Ursano, Fullerton and Terhakopian 4 One factor in this reduction could be the advancements that have been made in early warning systems and disaster recovery efforts. The decline in the loss of human lives is encouraging, but communities still struggle to assist disaster survivors who are exposed to the often devastating emotional effects caused by these life-altering events.
In spite of the field's ability to measure economic damages, society is challenged by attempts to calculate the impact that disasters have on psychological health. Trauma theory provides a helpful framework to analyze disaster reactions and assess the need for appropriate interventions and resources for disaster response. Berzoff and coworkersReference Berzoff, Flanagan and Hertz 5 and FigleyReference Figley 6 , Reference Figley 7 have defined trauma as “an emotional state of discomfort and stress resulting from memories of an extraordinary catastrophic experience that shatters the survivor's sense of invulnerability to harm, rendering him acutely vulnerable to stressors.” While many people are able to cope with the aftermath of trauma, others experience a range of negative behavioral health reactions and physical problems. We examined disaster behavioral health from a trauma theory perspective, assessed the needs of high-risk, special populations during disasters, and identified the disaster behavioral health resources developed by the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA).
Trauma Theory and Disaster Behavioral Health
Trauma theory provides a framework to analyze reactions that may occur and that can assist with the development of future interventions to address the behavioral health implications that emerge after a disaster takes place. Trauma theory asserts that psychological, physiological, and social consequences occur when a person experiences a traumatic event. Response to trauma is innate to preserve psychological and physiological well-being. Consequently, this natural response can become harmful if exacerbated. Many people display resilience after a traumatic event. For others, adverse emotional responses after a disaster can result in posttraumatic stress disorder, depression, anxiety disorders, and increased use of substances; these adverse emotional responses can complicate the efforts of survivors trying to understand and deal with the disaster experience.Reference Rubonis and Bickman 2 - Reference Ursano, Fullerton and Terhakopian 4 Such individuals may find themselves re-experiencing the trauma, feeling helpless, confused, fearful, or sad. Prolonged adverse emotional reactions that interfere with family, social, and work responsibilities can have a severe impact on the survivors of a disaster and their families.
The impact of a disaster can reach far beyond the individual survivor and may exacerbate previously experienced trauma. The population exposure modelReference Ursano, Fullerton and Terhakopian 4 , Reference Tucker, Pfefferbaum, Nixon and Foy 8 describes the effects that a disaster can have beyond the disaster survivor, reaching to bereaved extended family and friends, disaster responders, and people from the larger community. According to SAMHSA, 9 “Secondary trauma can occur among behavioral health service providers across all behavioral health settings and among all professionals who provide services to those who have experienced trauma (eg, healthcare providers, peer counselors, first responders, clergy, and intake workers).” Vicarious trauma or secondary trauma may occur in people who observe the aftermath of a traumatic event or hear about it on the news.
In addition, research in this area indicates that the more preexisting stress and trauma that a person has been exposed to, the greater the potential of a stronger and perhaps more harmful emotional impact.Reference Rubonis and Bickman 2 - Reference Ursano, Fullerton and Terhakopian 4 As a result, some disaster survivors with increased vulnerability are at higher risk.
While many of the individual and community reactions to a disaster are normal, it is important to provide supportive services to survivors to ensure that they are able to cope and progress through the stages of the recovery process. Unfortunately, after a disaster, local resources including health care and mental health agencies are often overwhelmed.
Disaster Behavior And Special Populations
The adverse impact of disaster-related trauma varies based on the type of event. The severity of the impact also depends on the characteristics of the survivors. Some populations are more at risk for adverse and prolonged stress reactions after a disaster. These special populations include children, older adults, people with physical disabilities, the homeless, and people with mental illness or substance abuse issues. Others who may also require special measures when responding to their behavioral health needs related to disaster include first responders such as firefighters, paramedics, and police officers. Response to special populations requires advance planning and specialized interventions that meet each population's distinctive needs. According to Ursano etal,Reference Ursano, Fullerton and Terhakopian 4 “[p]olicy planning for disaster and future research is critical to an effective public health response and addressing barriers to health care in vulnerable and often forgotten groups when disaster strikes.” It is imperative that research and future interventions address the needs of vulnerable populations before and after disasters.
Disaster Behavioral Health Resources From Samhsa
Many tools for planning and response already exist: SAMHSA provides a wide range of resources for disaster behavioral health response, preparedness, and recovery. SAMHSA is dedicated to providing preventive measures and interventions that build resilience in communities predisaster and mitigate the effects postdisaster. The following sections provide an overview of SAMHSA's Disaster App, Disaster Behavioral Health Information Series (DBHIS), Disaster Response Template Kit, Disaster Kit, Disaster Distress Helpline, and National Child Traumatic Stress Network (NCTSN) online resources and web-based learning site. These brief descriptions are summarized from the SAMHSA Center for Mental Health Services Emergency Mental Health and Traumatic Stress Services branch resource guide. 9 The Table briefly describes the SAMHSA disaster behavioral health tools, their target populations, and how to access each resource.
SAMHSA Disaster Behavioral Health Resource Chart
Abbreviations: CCP, crisis counseling program; DBH, disaster behavioral health; DBHIS, DBH information series; FEMA, Federal Emergency Management Agency; SAMHSA, Substance Abuse and Mental Health Services Administration.
SAMHSA Disaster App
One of SAMHSA's most innovative resources is its disaster app. In a disaster, it is essential that behavioral health responders have the resources they need—when and where they need them. SAMHSA's mobile app makes it easy to provide quality support to survivors. Users are able to navigate predeployment preparation, on-the-ground assistance, and postdeployment resources at the touch of a button. Users are also able to share resources such as tips for helping survivors cope and the location of local behavioral health services. The disaster app also provides information about self-care support for responders at all stages of deployment and helps disaster responders focus on what really matters—the people in need. SAMHSA's disaster app ensures that responders will:
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• Be ready — by allowing them access to resources for any type of traumatic event, including tip sheets; guides for responders, teachers, parents, and caregivers; and a directory of behavioral health service providers in the affected area.
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• Be prepared — by allowing them to rely on and have access to previously downloaded resources on their telephone in case of limited Internet connectivity in the field.
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• Be confident — by allowing them to review key preparedness materials so they are confident they are providing the best support possible.
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• Share resources easily — by allowing them to send information to colleagues and survivors via text messaging, e-mail, or transfer to a computer for printing.
SAMHSA Disaster Behavioral Health Information Series
The DBHIS is an online resource that contains resource collections and tool kits pertinent to disaster behavioral health. This resource guide targets specific populations, specific types of disasters, and other topics related to all-hazards disaster behavioral health preparedness and response. All resources for which links are provided are in the public domain or have been authorized for noncommercial use.
Disaster Response Template Tool Kit
The disaster response template tool kit is an online resource that features public educational materials that disaster behavioral health response programs can use to create resources for reaching people affected by a disaster. Items included are print, website, audio, video, and multimedia materials that disaster behavioral health response programs can use to provide outreach, psychoeducation, and recovery information for disaster survivors. These materials can be tailored to fit the needs of each individual program and can be ordered through the online SAMHSA store.
SAMHSA Disaster Kit
The SAMHSA disaster kit contains SAMHSA's disaster behavioral health publications for professionals and the general public. Materials may be used to support immediate disaster behavioral health response efforts. The disaster kit coordinates with the Federal Emergency Management Agency's (FEMA) crisis counseling assistance and training program (CCP) and the CCP application tool kit, which contains guidance for CCP grant applicants.
Disaster Distress Helpline
The disaster distress helpline is, to our knowledge, the nation's first permanent hotline dedicated to providing disaster crisis counseling. The disaster distress toll-free helpline provides immediate counseling to anyone who needs help in dealing with disaster. This free, confidential, and multilingual crisis support service is available via telephone (800-985-5990) and text messaging (text TalkWithUs to 66746) to residents who are experiencing psychological distress as a result of natural or human-caused disasters. Callers are connected to trained and caring professionals from crisis-counseling centers in the network. The helpline staff, which is available 24 hours a day, 7 days a week, provides confidential counseling, referrals, and other needed support services. The helpline complements the Department of Health and Human Services, FEMA, and other disaster response agencies, and is available immediately anywhere within the United States.
FEMA Crisis Counseling Program
The FEMA CCP is a supplemental assistance program available to the United States, tribes, and territories. Section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1974 authorizes FEMA to fund mental health assistance and training activities in areas that have been presidentially declared a disaster. SAMHSA's Center for Mental Health Services, Emergency Mental Health and Traumatic Stress Services branch, works with FEMA through an interagency agreement to provide technical assistance, consultation, and training for state and local mental health personnel, grant administration, and program oversight.
The mission of the CCP is to assist individuals and communities in recovering from the effects of natural and human-caused disasters through the provision of community-based outreach and psychoeducational services. Three entities are eligible to apply for and receive CCP funding after a presidential disaster declaration: states, US territories, and federally recognized tribes. The CCP supports short-term interventions that involve the counseling goals of assisting disaster survivors in understanding their current situation and reactions, mitigating stress, assisting survivors in reviewing their disaster recovery options, promoting the use or development of coping strategies, providing emotional support, and encouraging linkages with other individuals and agencies who may help survivors in their recovery process.
Child, Adolescent, and Family Resources in the National Child Traumatic Stress Network
The SAMHSA-funded National Child Traumatic Stress Network has an online presence that provides information and resources to address the traumatic effects of natural and manmade disasters on children, adolescents, and families. The general website (www.nctsn.org) has 2 primary pages that focus on this area. On the first page is the heading Natural Disasters, which includes the psychological first-aid (PFA) field guide as a downloadable file and a link for the psychological first-aid online course. The PFA course is a free 6-hour interactive class in the Learning Center for Child and Adolescent Trauma that places the participant in the role of a provider in a postdisaster scene. Appropriate for those new to disaster response and for seasoned professionals, the PFA online resource features activities, video demonstrations, and tips from trauma experts and survivors. This project was funded by SAMHSA, the National Center for Posttraumatic Stress Disorder, and the National Association of County and City Health Officials. In addition, this website includes fact sheets that focus on response to various types of natural disasters including earthquakes, epidemics, fires, floods, hurricanes, and tsunamis.
The second relevant resource page is under the heading Terrorism. This page has several downloadable files that focus on catastrophic mass violence events and a link to view the recent NCTSN-sponsored speaker series on terrorism and disasters. All resources are free, although some require a no-cost registration for online learning courses.
Limitations
SAMHSA disaster resources are informed by evidence and are practice based. SAMHSA used research and best practices to design and implement programs and resources. At this time SAMHSA has not conducted randomized controlled trials to ensure that the resources are evidenced based. Nonetheless, many communities and individuals have used these resources and have reported finding them very useful and supportive as they prepare, respond, and recover from a disaster.
Implications For Disaster Behavioral Health
The need for resources to address the challenges faced by disaster-riven communities has been well established. SAMHSA has emerged as a leader in disaster behavioral health and continues to provide resources and assistance to communities affected by disaster. Dealing with the economic effects of disasters can be very challenging, but tending to the unseen psychological effects can be even more difficult. As stated by Bonanno etal,Reference Bonanno, Galea, Bucciarelli and Vlahov 10 “A growing body of evidence suggests that most adults exposed to potentially traumatic events are resilient.” Nonetheless, it is essential to provide support services and resources both to those who are resilient and those who may need extra help in coping with the aftermath of a disaster. Trauma theory provides a well-developed framework to analyze the potential reactions and implications of persons who have experienced a traumatic event such as a natural or manmade disaster. In addition, trauma theory lends itself to the development of trauma-informed interventions that are useful in working with populations that have experienced trauma.
The tools and resources developed to assist disaster-response professionals provide a firm foundation for best practices in providing supportive behavioral health care. At the same time, there is still much to be learned. The former Surgeon General Richard Carmona acknowledged, “Prevention can be practiced in the form of preparedness or await the alternative, another landmark report on what went wrong….Nothing less than a comprehensive approach can ensure the optimal outcome from the next public health crisis. The time to act is now.” SAMHSA agrees and will continue to provide innovative tools to assist disaster survivors and the nation. It is imperative that future research focuses on the needs of at-risk populations and interventions that address the mental health and substance abuse needs of populations affected by disaster. If the pace of disaster response continues to increase, such efforts will contribute in meaningful ways to the overall well-being of communities across the nation.
Acknowledgment
Anne Mathews-Younes, EdD, consulted on this project and provided subject matter expertise regarding behavioral health.
