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Section I Chapter 1- ESSENTIALS OF DISASTER culturally appropriate official warnings and messages that
PLANNING (pg. 3-19) were disseminated through the Spanish-language media that
members of the community typically used were poorly
Section I Chapter 2- LEADERSHIP AND translated (Aguirre, 1988). After failing to take shelter, 30
COORDINATION IN DISASTER HEALTHCARE people ultimately died and 120 sustained injuries (Tierney,
SYSTEMS: THE U.S NATIONAL PREPAREDNESS Lindell, & Perry, 2001).
SYSTEM (pg. 23-49)
■ The 1988 Armenian earthquake killed perhaps as many as
Section I Chapter 3- HOSPITAL AND EMERGENCY 25,000 people. About two-thirds of the total deaths were
DEPARTMENT PREPAREDNESS (pg. 51-65) children and adolescents who were in classrooms in
Section I Chapter 4- EMERGENCY HEALTH inadequately designed schools at the time of the quake (Miller,
SERVICES IN DISASTERS AND PUBLIC HEALTH Kraus, Tatevosyan, & Kamechenko, 1993).
EMERGENCIES (pg. 67-77) ■ In the 3 years following the 1995 Great Hanshin (Kobe)
Section I Chapter 5- EMERGENCY MEDICAL earthquake in Japan, the proportion of low-income elderly
CONSEQUENCE PLANNING FOR SPECIAL EVENTS, men and women living alone in temporary governmental
MASS GATHERINGS, AND MASS CASUALTY housing increased substantially. The elders who were most
INCIDENTS (pg. 81-92) socially isolated suffered from the highest rates of sickness
and depression and were at elevated risk for suicide and
Section I Chapter 6- LEGAL AND ETHICAL ISSUES IN increased rates of alcoholism and suicide (Kako & Ikeda,
DISASTER RESPONSE (pg. 97-111) 2009; Otani, 2010). In response, a nursing college volunteered
in the “kasetu” used for elderly survivors. There, they
Section II Chapter 7- IDENTIFYING AND
encountered isolated seniors with increased rates of alcohol
ACCOMODATING HIGH-RISK, HIGH
and suicide. Out of concern for increased deaths (called
VULNERABILITY POPULATIONS IN DISASTERS (pg.
“kodokushi” or death alone and unnoticed), they moved
115-131)
residents into “kasetu” on the grounds of the nursing college
Chapter Overview (Kako & Ikeda, 2009).

Some populations are more vulnerable and at higher risk from ■ Among the approximately 1,300 persons who perished in
disasters than other populations. This chapter will help you New Orleans in Hurricane Katrina in 2005, 67% were at least
identify high-risk, high-vulnerability populations and 65 years old. Prior to the storm, this group represented just
understand their potentially unique needs in a disaster context. 12% of the population (Sharkey, 2007). In Orleans parish, the
Employing an ecosystems approach across the life cycle of a mortality rate among Black adults was 1.7 to 4 times higher
disaster, you will explore potential strategies to reduce than among White adults (Brunkard, Namulanda, & Ratard,
vulnerability, provide necessary assistance or accommodation, 2008).
and build the capacity of individuals, families, caregivers,
■ Superstorm Sandy, which struck the East Coast in 2012,
agencies, and organizations, and the community. Case studies,
highlighted that Black and Latino populations
tips, and tools are included to help you apply what you learn.
disproportionately reside in the census tracts within three
miles of the storm surge zone. In addition to seeing a direct
DEFINING AND UNDERSTANDING VULNERABILITY
and disproportionate impact on people of color, public and
Disasters in the United States and around the globe have subsidized housing residents were also disproportionately
caused widespread loss of life, destruction of built and affected. In Connecticut and New Jersey, roughly half of the
natural environments, significant economic damage, and public housing and subsidized housing units within storm-
prolonged suffering and hardship among survivors. affected census tracts were “highly impacted” by storm surge
Photographs of flooded communities submerged under murky or other storm damage (Haas Institute, 2016). In this chapter,
waters, of historic structures turned to rubble in earthquakes, we use the term “high-risk, high-vulnerability populations” to
and of homes and businesses flattened during tornadoes can refer to the people with a higher probability of being exposed
leave the impression that disasters are “equal opportunity to disaster who also face barriers to anticipate, cope with,
events.” Decades of social science research, however, provide resist, or recover from the event (also see Fordham,
substantial evidence to the contrary. Consider the following: Lovekamp, Thomas, & Phillips, 2014; Mileti, 1999; Wisner,
Blaikie, Cannon, & Davis, 2004). What can the previous
■ In 1987, a tornado destroyed nearly half of Saragosa, TX. examples and the myriad other cases that are now part of the
Home to about 400 people, virtually all of the families in this ever-growing disaster research literature teach us about human
small west Texas town were of Mexican descent and the vulnerability to disasters?
majority spoke only Spanish. Yet, the residents received no
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health, behavioral health, and social well-being. Smith (1981)

identified four dimensions of health:

1. the absence of illness,

2. the ability to perform one’s role,
3. the capacity to adapt,
Section II Chapter 8- HUMAN
4. and the pursuit of eudemonistic well-being.
SERVICES IN DISASTERS AND
PUBLIC HEALTH EMERGENCIES: The greatest impact of any disaster is the impact on social
SOCIAL DISRUPTION, INDIVIDUAL well-being.
EMPOWERMENT, AND COMMUNITY
RESILIENCE (pg. 139-145) Whether a community has been leveled by war or by
earthquake, the resulting social disruption is remarkably the
Chapter Overview same: infrastructure is lost, economy is damaged, people are
displaced, and lives are changed.
This chapter describes the relationship of nursing and human
services in disasters. It also provides an overview of the A disaster, by definition, entails social disruption, which in
societal impact of disasters and frames the role of human turn adversely impacts the self-sufficiency and functioning
services in emergency preparedness, response, and recovery. of individuals and families and the stability and viability of
Using nursing theories as a framework, the chapter discusses communities. These negative impacts on individual,
the role of nursing in the promotion of individual and household, and community functioning lead to problems of
community well-being in the aftermath of disasters. unmet basic human needs.
Finally, the chapter provides an overview of disaster case
management, including the role of the federal government, the HUMAN SERVICES “UNDER CLEAR SKIES”
case management model, and the role of nursing within the
------ how human services operate in communities in a
model.
predisaster environment. “Human services” have been
“broadly defined ... [as] approaching the objective of
 It is an axiom of emergency management theory that,
meeting human needs through an interdisciplinary
although disasters can be caused by a variety of
knowledge base, focusing on prevention as well as
man-made or natural events, it is not the
remediation of problems, and maintaining a commitment to
magnitude of that event, but its impact on human
improving the overall quality of life of service populations”
populations that makes any event a disaster.
(National Organization for Human Services, 2009).
 A climactic process such as a hurricane or a seismic
event such as a tsunami is not a disaster if it has no  Abraham Maslow established a theory of the
impact upon people or their communities. hierarchy of human needs (Maslow, 1954, 1970).
 The magnitude of the disaster is not measured by  Based on this prioritization, Maslow grouped
hurricane category, seismic intensity, or bioterror and ordered human needs into categories
agent category, but by the constellation of actual according to their primacy.
harms sustained by individuals and communities.
 Disaster preparedness, response, recovery, and
mitigation are all dimensions of the effort to lessen
the extent and severity of such adverse impacts.

In considering disaster impacts, health is a fundamental

domain for assessment and intervention. However, much of
the extant literature on disaster health issues focuses on a
narrow construction of health—the treatment of injury and
illness. Although the recent growth of the disaster behavioral
health field has expanded this focus to include the treatment of
physiological and psychological injury and illness, there
remains a tendency to limit disaster health to a model of
healthcare system approaches to disease and trauma.

Such a perspective is at odds with a long tradition in nursing

that views health as an integral relationship of physiological
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For the purposes of this chapter, we define human services as Populations routinely served by human systems include
the ensemble of systems, both governmental and economically disadvantaged individuals, children and
nongovernmental, whereby assistance is provided to youth, older adults, refugees, and survivors of family or
individuals and families in order to address needs at any sexual violence
level in Maslow’s hierarchy that those individuals and
families cannot meet solely with their own resources HUMAN SECURITY

 is a fundamental concept for the analysis of human

services in disasters.
 Globally, human service needs are the same, but there
are great disparities in different nations’ human
service system’s infrastructure to meet those needs.
 In many developing countries, the primary human
service system is not local or national, but is the
international humanitarian aid system.

The United Nations, in concert with international

humanitarian aid agencies, responds to disasters
internationally.

In 2000, the United Nations, seeking a more effective

framework for the humanitarian aid system, developed the
Although human services (or the synonymous term, “social concept of human security, which focused on individuals
services”) is popularly associated with programs for low- rather than on the government or on the state.
income households, there are both means-tested (low-  This concept is based on the need for a new
income-triggered) and non–means-tested (for all income paradigm of security that is associated with two
levels) human service systems. sets of dynamics (United Nations, 2003).
Examples of means-tested human services include: First, human security is needed as a response to the
1. governmental and nonprofit efforts such as complexity and interrelatedness of the new security threats
Temporary Assistance for Needy Families (TANF), of the 21st century, including civil violence; chronic and
which provides direct cash assistance; or persistent poverty; environmental and health threats;
2. means-tested programs targeted to a specific need, involuntary population displacements; and illicit trafficking of
such as Supplemental Nutrition Assistance Program drugs, arms, and people. These threats have transnational
(SNAP, better known as Food Stamps); the dimensions and exceed traditional notions of security.
3. Women, Infants and Children (WIC) program, and Second, human security is required as a concerted,
community-run food banks, which help meet the
comprehensive approach that utilizes the wide range of
need for food; the
new opportunities for tackling these threats in an
4. Low Income Home Energy Assistance Program
integrated manner.
(LIHEAP), Section-8 subsidized housing, and
community homeless shelters, which help meet  Human security threats require a new consensus
sheltering (including heating and cooling) needs; that acknowledges the linkages and
and interdependencies between development,
5. Medicaid, which helps meet the need for healthcare human rights, and national security (United
services (Administration for Children and Families Nations, 2003).
[ACF], 2011; Centers for Medicare and Medicaid
Services, 2011; Food and Nutrition Service, 2011). Human security
6. Other human service programs help individuals
 safety from chronic threats, such as
address unmet needs that occur in the population at
discrimination, unemployment, or environmental
all income levels, such as child care systems, child
degradation, and protection from sudden crises,
welfare systems, aging services, systems to provide
including economic collapse, environmental
supports for individuals with access and
disasters, acts of violence, or epidemics.
functional needs, and domestic violence
 Human insecurity can result from human actions,
prevention and service programs.
natural events, or an interaction of human
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decisions and natural processes (United 3. Reorganization, the third stage, occurs at some point
Nations, 2003). during or after impact. In this stage, individuals
 Human security is focused on the vital core of aspire to work out solutions and to escape the
the individual, distinguishing “human crisis.
security” from “human development,” a term 4. Change, the fourth stage, occurs when the main threat
that is not linked with disasters (Burd-Sharps, has passed. It is at this stage that communities are
Lewis, & Martins, 2009). able to focus on rebuilding (Hill & Hansen, 1962).

Evidence supports the efficacy of a human security focus in Using Maslow’s hierarchy of needs (Maslow, 1954) as a
promoting recovery. theoretical foundation, we know that the individual has
baseline requirements to sustain life.
For example, lessons learned from the December 2004
Asian tsunamis identified that early social, psychological, and  Once such basic needs are satisfied, the
community interventions resulted in better individual, individual can seek a state of self-actualization.
family, and community outcomes.
The hierarchic theory is often represented as a pyramid, with
 The social interventions were identified as physiological needs at the base. The pyramid then ascends
services to promote survivor normalization through safety needs; the need for love, affection, and
and well-being. belonging; the need for esteem; and, at the apex, the need for
 These services included the provision of self-actualization. Maslow believed that, if the environment
information, temporary housing, family were right, people would develop straight and beautiful, thus
tracing, keeping families together, and early actualizing the potentials they inherited. Maslow also believed
reopening of schools. that the only reason people would not ascend to self-
actualization is because of the socially produced barriers to
It was found that psychological support more often was individual development (Boehm, 2010).
effective when based on local culture, local idioms of distress,
and locally acceptable ways of coping and dealing with grief In disaster situations, minority groups—defined by
(Chandra, Pandev, Ofrin, Salunke, & Bhugra, 2006). socioeconomic status, race, or ethnicity—usually suffer the
most. Lower-income individuals are more likely to live in
These findings were consistent with Silove and Steel (2006), older and less well-constructed housing, have less insurance
who stated the starting point for psychosocial recovery is to protection from loss, and have less access to relief resources
ensure that the general emergency management plan is (Owen, 2004). Davis, Wilson, Brock-Martin, Glover, and
oriented toward an approach that empowers the Svendsen (2010) identified that the medically underserved
community to recreate a cohesive and secure society. population continues to have a disproportionate impact to
Understanding the early traumatic stress reaction as a disasters.
normative survival response encourages an approach to According to the United Nations International Strategy for
identifying those who need immediate professional Disaster Reduction (UNISDR) (www.unisdr.org), in both
intervention, particularly in contexts where resources and developing and developed nations, poor people suffer a
skills are scarce (Silove & Steel, 2006). greater economic impact related to disasters when
WHAT IS SOCIAL WELL-BEING? compared to nonpoor individuals from the same countries.

The idea that disasters create stress within  Women and children were found to be 14 times
individuals, families, and communities is not new. In 1962, more likely to die than men during disasters
Hill and Hansen, in Man and Society in Disaster, stated (Leoni & Radford, 2011).
“disasters create the possibility of changed individuals in  Most of the 3.3 billion deaths resulting from
changed families within a changed community” (p. 200). disasters in the last 40 years have occurred in
poor countries.
The results of these changes are stress and crisis.
Economically disadvantaged groups also suffer the greatest
In this context, coping mechanisms are often ineffective in long-term consequences of disasters, often rendering them
dealing with changing conditions brought on by the crisis. more vulnerable to future disasters.

Four stages of crisis have been identified: The actual scale, in local terms, of economic loss in poor
countries is much greater than a mere equivalency in currency
1. Warning- signs of approaching danger. of more prosperous nations; thus, for example, the damage
2. With impact, the second stage, anxiety heightens. from the Indian Ocean tsunami in 2004 cost about $10 billion,
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compared to $130 billion for Hurricane Katrina, although partial; the capability of communities to take care of
more people lost livelihood and homes in the tsunami (Leoni themselves is the horizon of actual disaster recovery.
& Radford, 2011).
Norris and Stevens (2007) found that community resilience
Human development literature gives us an insight into social emerges from four primary sets of adaptive capacities.
well-being. In 1959, Erikson conceptualized human
development as a process of solving developmental tasks.  These capacities are economic development,
information and communication, social capital,
 The goals for attaining and maintaining and community competence.
autonomy and independence relate to  They defined social capital as the aggregate of
socioeconomic status and social integration. resources linked to social networks.
 As a result, life experiences or disadvantages in  Community competence was identified as collective
socioeconomic status can result in reducing action with problem-solving and decision-making
health and social well-being (Davis et al., 2010). skills that arise from collective efficacy and
empowerment.
The concept of well-being refers to optimal psychological
functioning and experience. Well-being comprises two The promotion of empowerment, whether for the individual,
general approaches: hedonic and eudemonic (Ryan & Deci family, or community, is a foundational element in
2001). emergency management, although it is not a term
generally used.
 The hedonic approach focuses on happiness, and it
defines well-being in relationship to attaining The Federal Emergency Management Agency (FEMA)
pleasure and avoiding pain. mission is “to support our citizens and first responders to
 The eudemonic approach focuses on meaning and ensure that as a nation we work together to build, sustain,
self-realization, and it defines well-being as the and improve our capability to prepare for, protect against,
degree to which a person is fully functioning respond to, recover from, and mitigate all hazards.”
(Pinquart & Sorensen, 2000).
The focus on empowerment within FEMA lies in two of their
EMPOWERMENT largest programs—Individual Assistance and Public
Assistance.
 a concept central to the domain of human services,
particularly human services in disasters.  These programs provide funding to individuals,
communities, and states to recover from the
Fundamentally, all human service systems exist to augment impacts of disasters (FEMA, 2011).
the capabilities individuals already possess without  Volunteer organizations, such as the Red Cross,
fostering dependence or undermining the self- provide assistance to families focused on meeting
determination of the client receiving services (Chesler & basic human needs and social needs.
Hasenfeld, 1989).  Volunteer organizations and federal, state, and local
In the case of disaster human services, the empowerment governmental social service agencies provide a
takes place at the micro-level (individual/family) and the variety of resources to the population impacted by
mezzo-level (community). disasters.

Systems for human services in disasters are designed to HUMAN SERVICES IN DISASTER RESPONSE AND
promote stabilization and viability at the community level RECOVERY
as well as self-sufficiency and human security at the Human services play a critical role in disaster response and
individual and family levels. recovery. Two distinct processes define the ways that natural,
Access to resources to meet immediate needs and tools to technological, or intentional disasters transform the landscape
restore the level of independence and autonomy are necessary of human service needs in impacted populations.
to participate in long-term recovery. First, because disasters can disrupt the infrastructure by
Disaster human services are not something done to take care which communities meet community members’ human
of clients, but rather they are means made accessible to needs, those disruptions in systems upon which individuals
clients to take care of themselves. depend can put human service systems’ clients at
significant risk until the human service infrastructure can
The intervention of federal and state agencies and of voluntary be reconstituted. For example, if a working mother of two
organizations active in disaster is necessarily time-limited and preschoolers loses access to child care services when a tornado
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destroys much of her community’s child care capacity, she reconstitution of community-based social
will likely be unable to work to support her family, even if her networks.
job site is intact and has power, until the child care  At the level of esteem needs, human service systems
infrastructure is reconstituted. A civil engineer who lived can be integral to efforts at restoration of
entirely independent using a wheelchair and paratransit independent living for those with access and
services before the disaster may become unable to work, shop, functional needs, at promoting economic self-
or seek routine medical treatment if the disaster shuts down sufficiency, and at return to livelihood
accessible mass transportation. employment (rather than “whatever work is
available,” a return to one’s own vocation).
Second, disaster impacts create new human service needs  Last, at the highest level of self-actualization needs,
that did not exist before the disaster event. For example, the human services play a decisive role in restoration of
human service needs of an affluent family will be radically community pride, economic opportunity, and
changed, likely for a significant period of time, by an social justice in the long-term disaster-recovery
earthquake that levels the family home, the children’s school, process.
and both parents’ jobsites; in a matter of seconds, the family
has fundamentally lost its stability and self-sufficiency, and Significantly, while at every level of human need there is a
will now require significant human service interventions to role for human services, the higher the level of need, the
meet basic needs related to economic and physical security. more direct community involvement and empowerment is
Three key drivers of new disaster-caused human service needs required to meet that need in disaster recovery.
are the extent and duration of evacuations and mass
THEORIES SUPPORTING THE ROLE OF NURSES IN
movements, critical and social infrastructure damage, and
HUMAN SERVICES
work/wage disruptions. These three manifestations of the
social disruption wrought by disaster impacts give rise to  Theoretical frameworks (or models) of nursing
many new human service needs by depriving survivors of provide a unique perspective; they are similar in the
access to their ordinary means to meet their own needs at all view that nursing is focused on the health and well-
levels of Maslow’s hierarchy being of individuals and populations.
Within Maslow’s hierarchy, it is possible to recognize  Traditionally, the focus of nursing has been on the
specific disaster human service systems operating to person or population rather than disease.
address needs and promote empowerment at every level of The writings of Florence Nightingale are relevant in the
the hierarchic pyramid. discussion of nursing in disasters. In her book, Notes on
 At the bottom level of physiological needs is the Nursing: What It Is and What It Is Not, Nightingale stated,
emergency provision of shelter, food, potable “All the results of good nursing may be spoiled or utterly
water, and clothing—the primary objectives of the negative by on defect, petty management, or in other words,
Emergency Support Function-6 (ESF-6, Temporary by not knowing how to manage that what you do when you
Housing, Mass Care, Emergency Services, and are there, shall be done when you are not there”
Human Services) and the classical understanding of (Nightingale, 1898/2010, p. 35).
the term “human services” in the emergency  This statement is consistent with the focus of
management world. empowerment in community development.
 At the next level up, that of security needs, relevant
human services include domestic violence Certainly, her stated position related to harm, “Apprehension,
prevention/services, child protection, income uncertainty, waiting, expectation, fear of surprise, do a
maintenance/cash assistance benefits, and some patient more harm than any exertion” provides a linkage
employment (including nonlivelihood, improvised between lack of understanding and harm (Nightingale,
employment, e.g., the Vessels of Opportunity 1898/2010, p. 35). Nightingale’s writings demonstrate her
employment opportunities in oil cleanup available view that nursing has a role in social well-being and
to Gulf Coast States fishermen when the 2010 empowerment.
Deepwater Horizon Oil Spill shut down the
The multitude of nursing theories provides a variety of
fisheries).
 Rising still higher, at Maslow’s level of perspectives for the promotion of health of individuals,
families, communities, and populations along the health
love/belonging needs, human services with key
equities include community stabilization programs, continuum.
family reunification systems, and the The common focus of nursing theories is the understanding
that social well-being is an element of the health of
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individuals, families, communities, and populations. Thus, psychological recovery for individuals, families, and
it is consistent with nursing theory that nurses have a role in communities are dependent upon adequately addressing
human services in disasters. significant gaps in human service needs early in the
response and recovery effort.
The nursing model of transitions can be used as a framework
to operationalize the role nurses have in meeting the human  In other words, both psychological and economic
services needs in disasters. The concept of “transition” is recovery of the community are hastened and made
defined as a passage or movement from one state or more comprehensive by strategic human service
condition to another. response planning and operations.

Three types of transitions have been defined: Programmatic systems for human services are integral to
disaster recovery, although their effective utilization to
1. developmental, promote community recovery is impeded if there is not
2. situational, effective multisectoral integration of human services, public
3. and health-illness. health, and emergency management systems—organized
The model of transitions suggests that nurses should view around population-level survivor requirements, rather than
the pattern of responses and identify the vulnerabilities institutional, agency, or disciplinary boundaries (White, 2014).
and critical needs during transition. Nurses are well positioned to help implement community-
level multisectoral efforts across these systems.
Using the concept of transition, nursing interventions are
aimed at supporting individuals to create conditions conducive THE ROLE OF NURSES IN HUMAN SERVICE
to healthful outcomes (Schumacher & Meleis, 1994).
ROLE: understand that individuals impacted by disasters
Evidence-based practice in the field of disaster mental health will experience some level of psychosocial disruption, to
supports the model that addressing the concrete human screen for human service issues, and to provide
services needs of disaster survivors is a critical primary appropriate referral.
intervention to reduce the prevalence of long-term
 The nurse will likely be the healthcare professional
psychological illness or injury in impacted populations.
who will interact at some level with the greatest
Operationally the provision of disaster mental health services amount of the impacted population.
is integrated with systems to address human service needs  This opportunity for interaction places the nurse at
caused by the disaster for, as Myers and Wee (2005) explain, the forefront of healthcare for the impacted
“the aim will be to provide human services for problems that population of a disaster.
are accompanied by emotional strain” (p. 31).
Nurses providing care to disaster survivors in treatment
The stressors attendant concrete losses and unmet human settings such as hospitals, clinics, or skilled nursing facilities
needs, of the type that human services in disasters are (SNFs) can play a critical role in assessment and referral of
designed to address and mitigate, are critical risk factors in patients and families to human service systems that can
postdisaster psychological injury and illness. help to meet their needs.

Norris et al. (2002) determined that human service needs  In hospital settings, problem identification has long
—“chronic problems in living”—were fundamental to risk been a key aspect of the nursing role through nurses’
of serious psychological impairment following disaster biopsychosocial assessments, their bedside care
impacts. From a public health standpoint, effective and prompt relationships with patients and families, and their role
human service response to a disaster has a primary in discharge-planning processes.
intervention role in limiting mortality and morbidity due to the
behavioral health sequelae of disaster events. Nurses who become aware of unmet human needs that have
been caused or exacerbated by disasters have the opportunity
Hawkins and Maurer (2010) determined that disaster and the responsibility to assist their patients through
survivors’ efforts to regain what they believed to be appropriate referrals for multidisciplinary action to address
security had both psychological and concrete dimensions, those needs. In most cases, this will mean a referral to the
and took place both as individuals coped with stressors hospital social worker, or, if that is not an option, to social
and as neighborhoods and communities reconstituted services in the broader community.
themselves.
It is important to differentiate between “assessment” and
In practice, behavioral health interventions at the population “screening” in the disaster context. In the social service
level, and the foundations of economic recovery and literature, the concept of screening versus assessment is clear.
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The screening is rapid identification of potential issues across 2. The second element is screening for human service
the landscape of human services. Nursing can use these same needs as the individuals transition between pre-
tools to understand what, if any, human service issues are and postdisaster realities.
present for the individuals, families, communities, or
populations of interest. Nurses working in disasters irrespective of the location must
screen individuals during care contacts for any human service
 Screening for risk factors and comprehensive issues. Problem identification should be the goal of screening,
assessment of needs are processes rooted in the with the solutions for identified problems being the
biopsychosocial– spiritual assessment model, in responsibility of the referral agency.
which it is understood that the biomedical,
cognitive–emotional, cultural, socioeconomic, and 3. The third element is referral to the appropriate
spiritual contexts in which a patient is situated each organization.
influence one another and shape the overall In disasters, the social service agencies are often
experience of health and illness, to which nursing or overwhelmed, either due to a sharp and rapid increase in the
other health disciplinary interventions respond numbers of individuals requiring services and/or due to the
(Sulmasy, 2002). impacts of the disaster to the physical infrastructure and to the
 In the context of the suddenly volatilized social employees of the agency. It is important for nursing to
context of disaster survivors—those for whom basic understand their community’s emergency management plan
features of the social and physical environment may related to human services.
have been radically altered by disaster impacts—it is
particularly important to bring to assessment of needs CASE MANAGEMENT IN DISASTERS
a systems theory lens that considers the micro-
The case management model:
(individual), meso- (community), and macro-
(national/global) level phenomena informing the  useful model within disaster management to meet
patient’s biopsychosocial situation. the human service needs of individuals and
Nursing assessment of disaster survivors’ needs cannot families.
presume the existence of social and environmental “givens,”  The case management model is in reality not one but
such as a stable place to live, continuous access to necessary an array of models that use an interdisciplinary
or critical infrastructure, or uninterrupted enjoyment of a 21st- approach and can be defined as a collaborative
century American standard of living. process to assess, plan, implement, coordinate,
monitor, and evaluate options and services to meet
Consideration of patients’ physiological and behavioral health needs.
health needs for nursing treatment will be most effective in
a broader context of systems theory-informed Case management- seeks to understand complex needs and
biopsychosocial–spiritual assessment. align services to optimize outcomes.

Admissions or episodes of care do not occur in isolation; the - began with the development of social casework in the
admission, treatment, and discharge of hospital patients take late 1800s.
place in a larger social and medical context. - In the 20th century, case management flourished as
public health, nursing, and social work disciplines
Disaster impacts can significantly alter the social environment emerged.
out of which patients come into an acute care setting, and back - The most important outcome of the use of case
into which they are discharged. management is the decreasing fragmentation and
duplication of care while enhancing quality and
Nursing discharge planning must factor in the human service cost-effective outcomes (Huber, 2002).
needs and gaps that can render a previously viable discharge
plan unsafe for patients. The U.S. Congress authorized federal efforts to provide
disaster case management (DCM) as part of the Post-
The role of nursing in human services during disasters consists Katrina Emergency Management Reform Act (PKEMRA)
of three elements: in 2006.
1. Understanding the potential human service issues  While DCM was new to the federal government as a
for people within the disaster impact area is the mechanism to address the human service impact of
first element. disasters, this concept has been employed within
the volunteer organization community for a
number of years.
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 The Disaster Case Management Program (DCMP) is survivors, and coordinating between diverse human
a federal, FEMA-funded program that provides services systems with a person-centered approach to
supplemental funding to states, territories, and resources.
tribes in presidentially declared disasters with
individual assistance authorized. Nurses can provide that vital link to putting people in touch
 The DCMP provides implementation alternatives with the DCM system, or whatever other mechanisms exist in
including Immediate Disaster Case Management, the community to link individuals and families impacted by
a time-limited deployment of federally managed disasters with human service programs, resources, and
services, including the alternative to use ACF’s services that can assist them in meeting their needs.
Immediate DCMP; and a state grant for longer- Understanding and identifying the human service needs of
term service delivery and capacity building (ACF, their patients and their families, wherever that interaction
2015). occurs, begins the process. Knowing the disaster services
 In disaster recovery, DCM may be provided by within his or her community or area where one is working will
federal, state, or local governmental agencies, as provide the nurse with the ability to provide appropriate
well as by Voluntary Organizations Active in referrals.
Disasters (VOADs) and other nonprofit
organizations. As in so many other aspects of nurses’ work, nurses are
 DCM has the capability to promote the best positioned to make a critical difference in the lives of
outcomes for individuals and families, recognizing disaster survivors through accurate problem identification
that, even if helpful resources exist, if people do in screening and subsequent in-depth assessment, and
not access the system, the benefits cannot be referral to a multidisciplinary and multisectoral service
attained. system that can address unmet human service needs.

As a modality of assistance to disaster survivors, DCM SUMMARY

addresses three interconnected challenges to recovery:
Disasters are events that adversely impact individuals,
1. infrastructural, families, and communities. Nurses, in any care setting, have a
2. organizational, unique opportunity to identify human service needs and
3. and behavioral consequences of disaster. provide appropriate referrals to human service organizations.
This role in promoting social well-being has been a part of the
These three sets of consequences combine to create
nurse’s role throughout history. The key to success for the
heightened challenges for disaster survivors to identify and
nurse to implement this role in disasters is to understand the
access resources for recovery.
relationship of social well-being to health, screen patients for
Because disasters affect the social fabric and institutional human service needs, and know where to appropriately refer
infrastructure of affected communities, including the steady- patients and families to receive the necessary human services.
state human services systems, the postdisaster environment
is one with significant infrastructural challenges for Section II Chapter 9- UNDERSTANDING
survivors to access services. For example, social service THE PSYCHOSOCIAL IMPACT OF
systems may be operating below predisaster functioning DISASTERS (pg. 151-161)
levels, and survivors may face challenges related to Chapter Overview
transportation or communication getting assistance. The
postdisaster social environment also poses organizational Involvement in a disaster is a life-altering event, whether one
challenges to efficient, coordinated delivery of human is a survivor, a bereaved family member, a neighbor, or a
services assistance to survivors, as the predisaster, steady- helper. Although we know that individuals closest to a disaster
state human services systems and the newly arrived disaster- will be most affected, information about the type and scope of
specific assistance systems (brought by FEMA and VOADs, the disaster can enhance estimates of the intensity and duration
for example) may not be well aligned or coordinated. Third, of the psychosocial resources that will be needed to assist
disaster survivors’ ability to access services and resources those who will be affected by it. Resistance to psychosocial
postdisaster is behaviorally challenged, as a common intervention, however, is such a common reaction among
consequence of disaster-related stress is reduced capacity disaster survivors that mental health services must be made
to navigate complex bureaucratic systems. readily available and easily accessible to those at greatest risk.
Social support, in addition to support from governmental
 DCM is designed to address these heightened agencies, is essential for survivors. Moreover, mobilization
challenges to accessing assistance by tailoring of these services to survivors and the bereaved at their location
trauma-informed, disaster-specific services to
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is paramount to launching a success intervention. All helpers to 75% in a literature review performed by Goldmann and
need to know that many types of emotions, thoughts, Galea (2014).
behaviors, and sensations are normal reactions to a disaster
and should not be “pathologized.” Outreach provided by well- The World Health Organization estimates that 1 in 6 people
trained mental health workers is especially crucial for the most (10%–15%) who experience a disaster will suffer a mild to
vulnerable populations, such as children, the elderly, the moderate mental disorder, and approximately 1 in 30
medically frail, military veterans, and those with serious (3%–4%) will be emotionally impacted to the degree that
mental illness. First responders and other helpers must take it interferes with their ability to function (van Ommeren,
special precautions to mitigate the psychological impact of Hanna, Weissbecker, & Ventevogel, 2015).
disaster, as secondary traumatization is an ever-present hazard  When physical injury and loss of life are minimal, the
of disaster response. The rituals of normal grief and mourning incidence of psychiatric sequelae may be reduced.
can help individuals and communities draw on the strengths of However, subsequent factors such as continuing
the group to promote healing and eventual resolution. aftershocks following an earthquake or poor
temporary housing conditions can contribute to
DISASTERS
short-term and long-term traumatic stress.
 are stressful, life-altering  An environmental disaster can lead to a sense of
experiences, and living through mistrust toward government and business, leading to
such an experience can cause a sense of helplessness and hopelessness.
serious psychological effects and  The mental health effects of any type of disaster,
social disruption. mass violence, or terror attack are well documented
 affect every aspect of the life of in the literature to be related to the intensity of
an individual, family, and community. exposure to the event.
 Depending on the nature and scope of the disaster, Documented potential indicators of mental health problems
the degree of disruption can range from mild anxiety following the event are: sustaining personal injury, death of a
and family dysfunction (e.g., marital discord or loved one due to the disaster, disaster-related displacement,
parent–child relational problems) to separation relocation, and loss of property and personal finances (Neria &
anxiety, posttraumatic stress disorder (PTSD), Shultz, 2012).
engagement in high-risk behaviors, addictive
behaviors, severe depression, and even suicidality. Goldmann and Galea (2014) identify predisaster risk
factors:
Goldmann and Galea (2014) cite that following a disaster,
PTSD may affect 30% to 40% of those who directly 1. prior mental health problems,
experienced the trauma, with children being especially 2. female gender,
vulnerable. 3. and younger age;

Depression is also a common postdisaster peridisaster risk factors:

response and was found to be correlated
with personal vulnerability and life 1. degree or severity of disaster exposure (number and
stressors such as low socioeconomic intensity of disaster-related events,
status (Goldmann & Galea, 2014). 2. the type of disaster,
3. duration of exposure,
Although less frequently studied, 4. death toll,
substance use is also common following 5. and proximity to where the disaster occurred);
a disaster. A study by Vlahov et al.
(2002) after the terrorist attack on the postdisaster risk factors:
World Trade Center demonstrated almost 1. postdisaster life stressors (job loss, property damage,
25% of New Yorkers reported increased marital stress, physical health conditions related to
alcohol use, 10% indicated an increase in the disaster, and displacement)
cigarette use, and 3% reported increased marijuana use. 2. and low level of social supports
Generalized anxiety disorder (GAD) is also common, as are BIOTERRORISM AND TOXIC EXPOSURES
panic disorders, phobias, suicidality, and somatic symptoms
such as headache, abdominal pain, shortness of breath, and  Bioterrorism has a
fatigue with prevalence of these symptoms varying from 3% different profile from that
of natural disasters or
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even sudden violent events, such as bombings and 3. Clarify that negative health behaviors, which may
explosions. increase during time of stress (i.e., smoking,
unhealthy eating, excessive drinking), constitute a
According to Ursano, Norwood, and Fullerton (2004), greater health hazard than the hazards likely to stem
“bioterrorism is an act of human malice intended to injure from bioterrorism
and kill civilians and is associated with higher rate of 4. Emphasize that the only necessary action against
psychiatric morbidity than are ‘Acts of God’” (p. 1). terrorism on the individual level is increased
 The effects are more uncertain and occur over a vigilance of suspicious actions, which should be
longer period of time. reported to authorities
5. Clearly communicate the meaning of different levels
Terrorist attacks result in extensive fear, loss of confidence in of warning systems when such warnings are issued
institutions, feelings of unpredictability about the future, and 6. When issuing a warning, specify the type of threat,
pervasive experience of loss of safety (Ursano et al., 2004). the type of place threatened, and indicate specific
actions to be taken
The October 2001 anthrax scare was probably designed to be
7. Make the public aware of steps being taken to
more of a psychological attack than a physical one. In an
prevent bioterrorism without inundating people with
editorial, Wessely, Hyams, and Bartholomew (2001) note that
unnecessary information 8. Provide the public with
biological and chemical weapons are notoriously ineffective
follow-up information after periods of heightened
methods of mass destruction but are much more effective as
alert
weapons of terror—by introducing fear, confusion, and
uncertainty into everyday life. COMMUNITY IMPACT AND RESOURCE
ASSESSMENT
Fear of biological warfare can lead to mass sociogenic
illnesses in which common, everyday symptoms are believed  By brainstorming potential disaster scenarios and the
to be signs of biological exposure. Common psychological scope of resources anticipated with each scenario, the
reactions to bioterrorism (Holloway, Norwood, Fullerton, intensity and duration of the mental health response
Engel, & Ursano, 2002) include: can also be anticipated.
 Horror, anger, or panic The U.S. Department of Health and Human Services (2004)
 Magical thinking about microbes and viruses has promulgated a population exposure model that planners
 Fear of invisible agents or fear of contagion can use to estimate the psychological impact of mass violence
 Attribution of arousal symptoms to infection and terrorism and, therefore, the resources that might be
 Anger at terrorists, the government, or both needed. The model’s underlying principle is that individuals
 Scapegoating, loss of faith in social institutions who are most personally, physically, and psychologically
 Paranoia, social isolation, or demoralization exposed to trauma and the disaster scene are likely to be
affected the most. According to Donner and Rodriguez
Following the anthrax exposures in the United States, many of
(2011), population growth, most particularly population
these psychological reactions were seen around the world. For
density and urbanization, has increased vulnerability to
example, in the Philippines, local clinics were deluged by
disasters. Research comparing the psychological effects of
more than 1,000 people suffering from flu-like symptoms
human-caused versus natural disaster has yielded equivocal
because of rumors that those symptoms were due to
results.
bioterrorism. In response to these incidents, the American
Psychological Association [www.apa.org] is now strongly  No one type of disaster is “worse” than another,
recommending that people limit their exposure to the news although the number of associated deaths and serious
media, as overexposure may heighten one’s anxiety. injuries can be expected to have the most significant
and longest lasting impact on physical and emotional
Foa et al. (2005) state that reactions can be made worse by
well-being.
sensationalizing in the media and poor transfer of specific
recommendations by public officials. They recommend the
following interventions to minimize the potential
psychological and social consequences of suspected or actual
biological exposures:

1. Provide information on the believed likelihood of

such an attack and of possible impact
2. Communicate what the individual risk is
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of a local disaster? Do they have a clinical specialty

or language proficiency? Who authorizes them and
Community victims killed what training do they have/need?
A and seriously
bereaved family members,
injured;  What resources can the local American Red Cross
chapter provide to responders and/or victims? Do
loved ones, close friends.
providers have existing memoranda of understanding
B Community victims exposed
to the incident and disaster with the Red Cross?
scene but not injured.  Is there a team of mental health workers specifically
Bereaved extended family trained in critical incident stress management
members and friends; available to debrief rescuers and hospital personnel?
residents in disaster zone How will they be activated? If there is not an
whose homes were identified team, who will be available to provide
destroyed; first responders, stress management for rescue/medical personnel?
rescue and recovery  Are there other nonpsychological services that local
C workers;
examiner’s office staff;
medical mental health providers can offer? For example, are
there programs or agencies that could provide space
service providers and food for staff or victims?
immediately involved with
bereaved families; obtaining One reason that medical professionals might be reluctant to
information for body include mental health professionals on the team, and a
identification and death reason that victims do not seek psychiatric consultation, is the
notification. concern that emergency mental health intervention implies
Mental health and crime that emotional distress is equated with mental illness.
victim assistance providers,

D clergy,
emergency
chaplains,
healthcare
The World Health Organization (2017) identifies that the
stigma of mental illness is still very viable and contributes
providers, governmental to limiting access to services following a humanitarian
officials, members of the crisis.
media.
Groups that identify with  This is a barrier that needs to be overcome, however,

E the target-victim group,

businesses with financial
as the immediate mental health response to a disaster
should be educationally oriented, not treatment
impacts, community-at- oriented.
large.
In the immediate aftermath, before clinically significant
psychiatric symptoms emerge, the recommended approach
Knowing what the public and private mental health resources includes: (a) provide a sense of safety, (b) calm anxiety, (c)
are ahead of time is key to effective crisis management. promote a sense of self- and community-efficacy, (d)
Questions that should be addressed during predisaster encourage connectedness through social supports and
planning include: bonding with others, and (e) instill hope (Hobfoll et al.,
 What are the types of disasters that are most likely to 2007).
occur in my community? Is this region most van Ommeren et al. (2015) point out that it is essential to
vulnerable to natural, technological, toxic, or man- develop a sustainable community mental health system as
made disasters? part of the recovery process.
 Is there a county and state mental health disaster
plan? If so, what does it entail, and how might it Several recommendations for the preparedness phase for
support local efforts? the mental health and psychosocial support include:
 What kind of expertise is needed? Will the
anticipated disaster affect a certain age group; racial,  Embed mental health and psychosocial supports into
ethnic, or religious subpopulation; or individuals national health policies, strategies, and emergency
having a specific disability, such as hearing preparedness plans
impairment, mental illness, dementia, or mental  Identify existing formal and nonformal resources and
retardation? practices in mental health and psychosocial supports
 Who are the qualified mental health professionals in  Orient staff involved as first responders, healthcare
the community who can be called upon in the event providers, and recovery personnel in “psychological
first aid”
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 Train and supervise healthcare staff in the COGNITIVE Confusion

management of mental health during emergencies Indecisiveness
according to the World Health Organization’s Worry
Clinical management of mental, neurological and Shortened attention span
substance use conditions in humanitarian Trouble concentrating
emergencies: mhGAP Humanitarian Intervention
Guide (mhGAP-HIG) (apps.who.int/iris/bitst PHYSICAL Tension, edginess
ream/10665/162960/1/9789241548922_eng.pdf) Fatigue, insomnia
 Assemble emergency stocks of essential psychotropic Body aches, pain, nausea
Startling easily
medications, with suggestions of: amitriptyline (or
Racing heartbeat
fluoxetine), phenobarbital (or carbamazepine),
Change in appetite
biperiden, haloperidol, and diazepam Change in sex drive
 Develop emergency preparedness plans for people
with severe and chronic mental illness who reside in
the community Resiliency in the face of Disaster
NORMAL REACTIONS TO ABNORMAL EVENTS Resilience is often the most commonly observed outcome
trajectory after exposure to a potential traumatic event
 Normal reactions to stress and bereavement can and (Bonanno, Rennicke, & Dekel, 2005).
do vary— sometimes even among members of the
same family. Characteristics associated with resilience include family
 Factors that affect expressions of stress and stability, social support, and capacity to tolerate stress and
bereavement include age, gender, ethnicity, uncertainty.
religious background, personality traits, coping
skills, and previous experience with loss, especially After Hurricane Maria in 2017, feeling abandoned by the
traumatic loss. federal and local governments, the people of Puerto Rico
improvised ways to remain alive without power or running
Stress symptoms can occur due to secondary exposure, water (Dickerson, 2017). This innovated spirit should be
meaning that those experiencing distress need not have been supported and celebrated by professionals. By promoting
present at the site of the disaster but may have witnessed it resilience and coping after disaster, mental health
secondhand either via media coverage or through retelling professionals can draw upon the individual’s strengths or
of the event by a person who was present. As these reactions create the supports needed to ward off lasting symptoms
can be quite startling and overwhelming to those who have not or functional difficulties, and avoid interventions that may
experienced them before, it is helpful for survivors to hear that actually interfere with one’s own inherent resiliency and
their experiences are entirely normal, given the tremendous therefore impede recovery.
stress to which they have been exposed
SPECIAL NEEDS OF POPULATION
EMOTIONAL Shock, feeling numb
Fear Certain populations affected by disasters
Grief, sadness may be more vulnerable and therefore
Anger require special consideration both in
Guilt, shame disaster planning and response. In
Feelings of helplessness particular, women, older people, children
INTERPERSONAL Distrust and young people, people with disabilities, and people
Conflict marginalized by ethnicity are more vulnerable (Sim & Cui,
Withdrawal 2015).
Work or school problems
Irritability  Formal vulnerability is “the characteristics of a
Loss of intimacy person or group and their situation that influences
Feeling rejected or their capacity to anticipate, cope with, resist and
abandoned recover from the impact of a natural hazard,” in
comparison with “differential vulnerability,” which
takes into account the fact that different populations
face different levels of risk and vulnerability (Donner
& Rodriguez, 2011, p. 1).
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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 Those suffering in silence may be easily overlooked,  Children often appear to cope well initially, and
and outreach to these vulnerable groups is critical adverse reactions may not be apparent for weeks to
following a disaster or humanitarian emergency months later.
 Children who have trauma histories or unstable
Children and Youth
family lives are particularly vulnerable to
While most children are resilient, reactivation of psychiatric symptomatology. Thus,
many children do experience those having preexisting emotional and family
some significant degree of problems will likely need greater support and
distress. Poverty and parents with counseling in the aftermath of a disaster.
mental health challenges put  Clearly, children of all ages find comfort and
children at higher risk for long- stabilization in the routines of daily life.
term impairments (McLaughlin et al., 2009).  Family interactions, going to school, playing with
friends—these activities provide structure to the
 Risk factors for children experiencing stress after an child’s world.
incident include loss of routine and loss/change in
caregivers (Elangovan & Kasi, 2014). Older Adults
 In instances of terrorism, studies found that children
Older adults are
suffer more severe reactions if they are female or
particularly vulnerable to
know someone who was killed, as well as when
loss.
children are exposed to higher levels of television
coverage, and have parents who suffer a higher Factors such as age and
level of distress (U.S. Department of Veteran disability affect
Affairs, National Center for PTSD, 2016). vulnerability to a disaster.
 Children who witness or experience war atrocities Both of these vulnerability traits are apparent in the elderly
may experience stress in the form of risk to their population. They are often lacking in social supports, may
physical safety as well as separation from their be financially disadvantaged, and are traditionally
family members. reluctant to accept offers of help.
 As refugees, the children can be deprived of food
and water, witness violence and harsh living  Older adults are also more likely to have preexisting
conditions, experience a disruption in their medical conditions that may be exacerbated,
schooling, as well as experience stress in response either directly because of the emotional and
to relocation in terms of adaptation and psychological stress, or because of disruptions to
acculturation while oftentimes experiencing social their care, such as loss of medications or needed
exclusion and discrimination (Measham et al., medical equipment, changes in primary care
2014). providers, lack of continuity of care, or lack of
 A child’s response to disaster can be influenced by consistency in self-care routines due to relocation.
many factors, including the characteristics of the  Over 70% of the fatalities from Hurricane Katrina
disaster and exposure to it, individual characteristics, occurred in individuals over age 65 (Donner &
family factors, and the social environment. Rodriguez, 2011).
 Of the demographic variables studied, including  Older women are at particularly high risk for PTSD
gender and age, results are inconsistent. in that they live longer than men, are more likely to
 Ethnic minority youth may be at greater risk for be widowed, have limited social supports, and are
maladaptive stress reactions; however, the extent to disproportionately more likely to be victims of crimes
which this may also be due to socioeconomic status, such as muggings and robberies (Lantz & Buchalter,
exposure to other traumatic events, and other family 2003).
factors is unclear.  In any event where there is personal loss and
 Exposure to other trauma has also been found to disruption in routine, there is an increase in
contribute to disaster-related posttraumatic stress anxiety symptoms.
(Pfefferbaum & North, 2008).  With financial loss and disrupted daily routines, there
 For adolescents, perceived social support has been is an observed increase in PTSD symptoms, while
associated with postdisaster adjustment. The depression is associated with evacuation and
personality and temperament of the child are also relocation in the elderly (Bei et al., 2013).
associated with risk for psychiatric symptoms.  Loss of irreplaceable possessions—photographs,
mementos, and heirlooms—often have even greater
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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meaning and value for older adults and are psychiatric and psychosocial care must be provided
irreplaceable. throughout the crisis (van Ommerer et al., 2015, p. 500).
 Disasters may serve as a reminder of the fragility and
Cultural and Ethnic Subgroups
ultimate finality of life.
 Older adults may also be more likely to withhold Sensitivity to the cultural and
information or refuse help due to fears of losing ethnic needs of survivors and the
their independence. bereaved is key not only in understanding
 Institutionalization remains a real concern among reactions to stress and grief but also in
senior citizens who suffer the trauma of a disaster. implementing effective interventions.
 The frail elderly are especially vulnerable to
relocation stress and may experience Mental health outreach teams need to
exacerbations of chronic health problems. include bilingual, multicultural staff and translators who are
 Disorientation can occur when the frail elderly are able to interact effectively with survivors and the bereaved.
moved to unfamiliar surroundings, especially  Whenever possible, it is preferable to have bilingual
without substantial support from caregivers. staff or trained translators rather than relying
Visiting psychiatric nurses following a disaster are important solely on family members because of privacy
as they provide additional screening, support, and follow-up concerns and the importance of maintaining
to the relocated elderly without the elderly having to travel to appropriate family roles and boundaries.
access the resources.  The availability of written materials in other
languages can also increase access to information
The Seriously Mentally Ill for those who do not speak English as their
primary language, and can serve as a reminder of
According to Austin and Godleski information only partially understood at a time of
(1999), the most psychologically great stress.
vulnerable people are those with a  Many online resources have materials written in
prior history of psychiatric languages other than English, and predisaster
disturbances. planning should include identifying known ethnic
Although previous psychiatric history groups in the community in order to have those
does not significantly raise the risk of PTSD, exacerbations of materials accessible as needed.
preexisting chronic mental disorders, such as bipolar and Understanding the local norms, history, and politics can be
depressive disorders, are often increased in the aftermath of important in providing culturally appropriate services.
a disaster.
Five principles for incorporating culturally sensitive
Those with a chronic mental illness are particularly emergency care during a disaster include:
susceptible to the effects of severe stress, as they may be
marginally stable and may lack adequate social support to 1. understanding that culture is the predominant force in
buffer the effects of the terror, bereavement, or dislocation. people’s lives,
2. that dominant culture serves people in various ways,
Utilizing existing community resources that already have 3. people have both personal identities and group
established relationships with this population can be identities,
particularly effective. For example, assertive community 4. diversity within cultures can be vast and significant,
treatment (ACT) teams played a vital role in maintaining 5. and that each individual and each group has unique
connections with those who were most vulnerable to the cultural values and needs (Bergeron, 2015).
effects of stress following Hurricane Hugo.
It is often the case in large-scale transportation disasters, such
 In the 3 months following the hurricane, not one ACT as those involving airplanes, that there are individuals of
recipient required a psychiatric hospitalization different cultures.
(Lachance, Santos, & Burns, 1994).
 Understanding and addressing the cultural needs of
However, it is vitally important to provide regular visits to survivors and the bereaved can be complicated by a
those institutions that are providing care to those with lack of cultural competence on the part of the
severe mental illness following a conflict as neglect and responders, as well as separation from usual supports
abuse of people in institutions is common in emergencies. and familiar environments on the part of survivors
Safety, basic physical needs (water, food, shelter, sanitation, and the bereaved.
and medical care), human rights surveillance, and basic
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Common Reactions in Children and Adolescents in not uncommon.

Response to Tragedy and Ways to Help School-aged children are Provide extra physical
Common Reactions by Ways for Adults to Help more mature, both comfort and reassurance;
Age cognitively and emotionally, however, gentle, firm limits
Infants and toddlers will Provide physical comfort but remain highly should be set for acting out
react to trauma in response and maintain routines as vulnerable to events behavior if it occurs.
to the distress of their much as is possible. involving loss and stress.
caregivers and degree of > May present with more Provide reassurance that
separation or disruption in Maintain safety at all times classical symptoms of they are not responsible
relationship and routines. —safeguard against taking PTSD, as well as depressive for the disaster.
> They may demonstrate out one’s frustration on a and anxiety disorders.
separation anxiety, colicky or fussy infant by > However, reactions to Tell children that their
become fussy, develop using other familiar stress at this age may also feelings are normal and that
feeding or sleeping caregivers, if necessary include sleep and appetite others feel the same way.
problems, and become disturbances, academic
easily startled problems, and occasionally Use of puppets, dolls, and
Preschool children are Avoid unnecessary behavioral difficulties such other “props” facilitates
extremely dependent on separations from parents. as oppositional or the expression of anxiety-
routine and will react  It is okay for aggressive conduct. producing emotions
strongly to any disruption in parents to allow > Behaviors more typical of among young children.
their daily routine. children of this age a younger child may also be
> They may exhibit mild to to sleep in their seen, such as clinginess or By assisting children to
extreme helplessness, parents’ room on a whining, while others may identify sources of stress
passivity, and a lack of temporary basis. react by withdrawing and loss, and correct
responsiveness to people from friends and familiar distortions in thinking, a
and things in their Give plenty of verbal activities. more accurate and realistic
environment. reassurance and physical perception of the event can
> A heightened level of comfort. be developed by the child.
arousal, confusion, and
generalized fear may be Monitor media exposure to Provide structure by
present. disaster trauma. encouraging undemanding
> Other symptoms of home chores, physical
distress include a lack of Be honest and give exercise, and activities.
verbalization, sleep developmentally appropriate Adolescents tend to respond In addition to the extra
disturbance, nightmares explanations about the to a disaster much as adults attention and consideration
and night terrors, fear of traumatic event. do. However, this may also afforded to younger
separation and clinging to be accompanied by the children, teens should be
caregivers, irritability, Provide answers to awareness of a life unlived, encouraged to resume
excessive crying, and questions using language a sense of a foreshortened regular social and
neediness. they can understand. future, and the fragility of recreational activities, and
> Somatic complaints may life (Shaw, 2000). to participate in
include stomachaches,
Reassure children that they > May also exhibit a community recovery work
headaches, and
did nothing that caused the decline in academic should they so desire.
nondescript pains.
event to happen. performance, rebellion at
> At this developmental home or school, or Parents should avoid
stage, children may have a delinquency, as well as insisting that they discuss
tendency to assume that Encourage expression
through play activities. somatic complaints and their feelings with them
the disaster is related to social withdrawal. but should encourage
something they did or did > Adolescents may feel a them to discuss their
not do. strong need to make a disaster experiences with
> This age group is also contribution to the peers or significant adults
more likely to relive the recovery effort and find in their lives.
traumatic experience in play meaningful ways to “make
or behavioral a difference.”
reenactments.
> Resumption of bed-
wetting, thumb-sucking, Disaster Relief Personnel
and clinging to parents is
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 The list of those vulnerable to the psychosocial Limited attention span

impact of a disaster does not end with the survivors Loss of objectivity
and the bereaved. Often victims can include Unable to stop thinking about disaster
emergency personnel: police officers, firefighters, Blaming
military personnel, Red Cross mass care and PHYSICAL
shelter workers, cleanup and sanitation crews, the Increased heart/respiratory rate/blood pressure
press corps, body handlers, funeral directors, staff Upset stomach, nausea, diarrhea
Change in appetite, change in weight
at receiving hospitals, and crisis counselors.
Sweating or chills
Tremor (hands/lips)
 Some studies of PTSD among firefighters and other Muscle twitching
first responders have found the frequency of PTSD “Muffled” hearing
to be 10% to 20%, and that those at greatest risk Tunnel vision
were those whose occupations were least likely to Feeling uncoordinated
have disaster training (Sakuma et al., 2015). Proneness to accidents
Headaches
Clearly, stress-induced symptoms are a hazard of disaster Muscle soreness, lower back pain
work and can lead to absenteeism and burnout, as well as “Lump” in the throat
difficulties in family, work, and social life, and physical Exaggerated startle reaction
and psychiatric disorders. Fatigue Menstrual cycle changes
Change in sexual desire
Common Stress Reactions by Disaster Workers Decreased resistance to infection
PSYCHOLOGICAL Flare-up of allergies and arthritis
Denial Hair loss
Anxiety and fear
Worry about the safety of self or others
Anger Those medical personnel receiving disaster victims and
Irritability families at local hospitals can also be affected by the intense
Restlessness emotions of those seeking help. Often, nurses and other
Sadness, moodiness, grief, depression medical personnel report for emergency duty after having
Distressing dreams worked their regular shift. These workers not only treat
Guilt or “survivor guilt” injured survivors but also provide needed services to the
Feeling overwhelmed, hopeless families of the injured.
Feeling isolated, lost, or abandoned
Apathy Secondary traumatization is a hazard that comes with
BEHAVIORAL exposure to the horrific stories of the bereaved and
Change in activity level injured. Hospital personnel are also subject to the stress of
Decreased efficiency and effectiveness increased workload due to increased admissions and
Difficulty communicating discharges related to triage to make room for the trauma
Outbursts of anger, frequent arguments, irritability victims, and the need to communicate timely information
not only to families but also the request for interviews
Inability to rest or “let down” from members of the media. In addition, the number of
Change in eating habits individuals requiring treatment does not end with impact—
Change in sleeping patterns
many people will sustain serious injuries in the process of
Change in patterns of intimacy, sexuality
disaster cleanup
Change in job performance
Periods of crying  Nurses and other medical professionals may be afraid
Increased use of alcohol, tobacco, and drugs
to show their emotions during the disaster and
Social withdrawal/silence
therefore will often experience profound emotional
Vigilance about safety of environment
Avoidance of activities/places that trigger memories reactions afterward.
COGNITIVE  There may be a sense of emotional “letdown”
Memory problems followed by an “emotional rollercoaster,” in which
Disorientation emotions may vacillate between the euphoria of
Confusion saving a life to the sadness or anger of losing lives.
Slowness of thinking and comprehension  In addition, ongoing support for the mental health
Difficulty calculating, prioritizing, making decisions counselors at the disaster site is crucial. A study by
Poor concentration Lesaca (1996) found that at 4 and 8 weeks after a
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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1994 airline disaster, trauma counselors experienced 5. Focusing on your strengths and abilities helps you
significantly more symptoms of PTSD and heal.
depression than a comparison group. Fortunately, the 6. Accepting help from community programs and
only significantly increased symptom after 12 weeks resources is healthy.
was avoidance behaviors, specifically of situations 7. Everyone has different needs and different ways of
that aroused memories of the crash. coping.
 The impact of the traumatic scenes and the intense 8. It is common to want to strike back at people who
emotions of the survivors led to increased physical have caused great pain. (Department of Homeland
illness, psychological distress, and absenteeism. Security, 2016, “Understand Disaster Events”)
 Experience in Oklahoma indicates that a mental
For children, schools provide a key opportunity for outreach as
health consultant, separate from those providing
teachers and principals are in contact with students throughout
direct services, ought to be brought in to provide
the day, and they are in an excellent position to disseminate
support to staff, so as not to discourage open
information, allow expression of feelings, screen children for
sharing of personal feelings and reactions.
unusual difficulties, and make referrals when indicated.
The use of early career therapists, with little personal or
Both over- and underexposure to the disaster are potential
professional experience in dealing with bereavement, was
pitfalls that schools can avoid with consultation from
viewed as a mistake by the authors.
professionals.
 They recommend that therapists be mature, culturally
The first step, however, is to have established a preexisting,
sensitive, and trained in specific techniques, such as
warm, open consulting relationship between mental health
psychological first aid.
professionals and the schools.
Similarly, a recent study of counselors responding to the 9/11
Minimally, mental health professionals can work with
terror attack found that higher levels of secondary traumatic
principals and teachers to see that schools have the latest
stress was associated with a heavier prior trauma caseload,
information about reactions of children to disaster and
less professional experience, younger age, longer lengths of
supplement school counselors on-site when large numbers of
assignment, and more time spent with child clients,
children are anticipated to need crisis intervention.
firefighters, or clients who discussed morbid material
(Creamer & Liddle, 2005). This indicates that potential In addition, professionals can provide guidance about the age-
recruits need to be informed of the potential risk of specific strategies that might be used in discussing a
secondary traumatic stress; those at risk should have lower community-wide disaster.
risk assignments whenever possible, and ongoing monitoring
of counselor exposure to risk should occur at regular intervals The National Child Trauma Stress Network provides a Child
during the course of deployment. Trauma Tool Kit for Educators (2008) that contains many
helpful strategies for assisting children after exposure to a
COMMUNITY REACTIONS AND RESPONSES traumatic event. Screening of requests for resources and
assistance by a committee that includes a disaster mental
health professional can assist schools in identifying resources
consistent with their needs as well as accepted standard
practices.

Large-group preventive techniques for children have been

It is used for some time in California during the aftermath of
important to understand common responses and needs after a community-wide trauma (Eth, 1992).
disaster, regardless of the type of disaster. It is important to
recognize: This type of school-based intervention occurs as soon after the
event as possible, and follows three phases:
1. Everyone who sees or experiences a disaster is
affected by it in some way. 1. Preconsultation—identifying the need; preparing the
2. It is normal to feel anxious about your own safety and intervention with school authorities
that of your family and close friends. 2. Consultation in class—introduction, open discussion
3. Profound sadness, grief, and anger are normal (fantasy), focused discussion (fact), free drawing
reactions to an abnormal event. task, drawing or story exploration, reassurance and
4. Acknowledging your feelings helps you recover. redirection, recap, sharing of common themes, and
return to school activities
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3. Postconsultation—follow-up with school personnel feelings of dejection. Feeling sad is a common reaction to
and triage/referrals, as needed (See Case Study 9.2 disaster, but clinical depression is a much less frequent
for an example of a school mental health consultation occurrence, depending on the nature of the disaster.
in the wake of community-wide response to a victim
of murder.) Normal Manifestations of Grief
FEELINGS Sadness
Mourning, Milestones, and Anniversaries Anger
Guilt and self-reproach
 The normal process of mourning is often facilitated Anxiety
by the use of rituals, such as funerals, memorials, Loneliness
and events marking key time intervals, such as Fatigue
anniversaries. Helplessness
 It is important to include the community in the Shock (most often after sudden death)
services, as well as the immediate family members. Yearning (for the deceased person)
Emancipation
 Community-wide ceremonies can serve to mobilize
Relief
the supportive network of friends, neighbors, and Numbness
caring citizens and provide a sense of belonging, THOUGHTS Disbelief
remembrance, and letting go, as was recently Confusion
demonstrated after the 2017 Las Vegas shootings Preoccupation
where 58 victims were killed and over 400 wounded Sense of presence
by a shooter (Munks, 2017). Hallucinations
 Websites and social media groups link the bereaved PHYSICAL Hollowness in stomach
and can also provide special support during important SENSATIONS Tightness in chest
anniversaries or milestones. Tightness in throat
 Ceremonies or memorials in schools should be Oversensitivity to noise
developmentally appropriate and involve students in Sense of
the planning process. depersonalization/derealization
Breathlessness, shortness of breath
 Websites and pages to be created in the aftermath of a
Weakness in muscles
disaster serve as a place for people, both directly and
Lack of energy Dry mouth
indirectly impacted, to express their condolences and BEHAVIORS Sleep disturbance
offer support. Appetite disturbance
 Condolences and offer support. Many different terms Absentmindedness
have been used to describe grief and grieving. Social withdrawal
 Understanding the various nuances in meaning can be Avoiding reminders (of deceased)
helpful in properly identifying and labeling the Dreams of deceased
experiences and reactions of survivors and Searching, calling out
relatives of the deceased. Restless overactivity
Crying
Grief is the internal, emotional response to loss, affliction, Treasuring objects
or regret. It is a normal reaction and is experienced by Visiting places/carrying objects of
virtually all disaster survivors. remembrance

Mourning is the external expression of grief as seen in

traditional or creative rituals, especially for the dead. Working with the bereaved is a common need following
virtually every disaster because loss is such a predominant
 Disaster survivors may also mourn other losses, such theme.
as material possessions, homes, and jobs.
Grief counselors facilitate the normal process of mourning by
Bereavement is the state of having lost something, whether assisting individuals to express emotions, begin to detach
it be significant others, significant things, or a sense of self from the deceased, and eventually, to reinvest in life—
and well-being. It is generally ascribed to family members of including the possibility of another close relationship.
disaster victims.
The phases of the mourning process have much in common
Depression refers to a state of feeling sad or, more with the emotional phases of disaster recovery, and Worden
specifically, is an emotional disorder marked by sadness, (1982) has identified specific tasks that need to be
inactivity, difficulty in thinking and concentrating, and
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accomplished at each phase of mourning for successful emotional, cognitive, and behavioral capacity of the
resolution: individual. Involvement of mental health professionals, such
as psychiatric nurse practitioners and clinical nurse specialists,
Period of shock, or “numbness.” The task is to accept the should begin with the development of the community or
reality of the loss (as opposed to denying the reality of the agency disaster plan. Utilizing “psychological first aid”
loss). through assistance with problem solving, stress management,
Reality, or “yearning,” and “disorganization and despair.” and “normalization” of the emotional response can prepare the
The tasks are to accept the pain of grief (as opposed to not individual for the challenges yet to be faced, and in some
feeling the pain of the loss) and to adjust to an environment in instances, prevent frustration from escalating to maladaptive
which the deceased is missing (as opposed to not adapting to or dangerous behaviors. Also, when symptoms reach the
the loss). severity of a diagnosable psychiatric disorder, early
identification and treatment are essential if the individual’s
Recovery, or “reorganized behavior.” The task is to reinvest decline in social and occupational functioning is to be
in new relationships (as opposed to not loving). contained and quickly reversed. Longer-term psychological
recovery can take months to years, depending on the scope
One indicator of mourning coming to an end is when one is
and nature of the disaster. Cognitive behavioral therapies
able to think of the deceased person or loss without pain or
have been found to be an effective treatment of acute stress
the intense physical sensations. Another is when the survivor
reactions as well as posttraumatic stress. Psychological
can reinvest his or her emotions into life and the living. In
debriefing, when used as an educational tool, can assist first
some ways, however, mourning never ends; only as time goes
responders to share feelings and coping strategies,
on, it manifests itself less frequently and with less intensity.
although rigorous research into the effectiveness of
Old losses are mourned again with each new loss and life
debriefing is generally lacking. Evaluation through a post
transition.
disaster review process is the key to understanding the
effectiveness of mental health services for individuals and
SUMMARY
groups, as well as the strengths, weaknesses, and gaps in the
The psychosocial impact of a disaster and the resources that response of the mental health services as a system.
will be needed to respond to the disaster can be estimated
based on data from past experiences with a variety of natural  A mental health disaster plan is an essential part of
and man-made disasters. Normal reactions to abnormal events any community disaster plan.
include a range of distressing thoughts, emotions, sensations,  It is essential to ensure that rescuers do not deplete
and behaviors, which are different than the characteristics of a their psychological reserves, and that they get
mental illness. However, early outreach can set the stage for adequate sleep and food.
those at risk of a psychiatric disorder to accept help in the  The Red Cross system, certified mental health
future, should it be needed. Children display a variety of disaster counselors have the authority and the
reactions that are normal given the extreme nature of the obligation to recommend that volunteers showing
stressor and their level of emotional and cognitive maturity. signs of psychological distress take a break, and if
Mental health responders must be culturally competent and warranted, can take them off duty against their
attuned to the needs of special populations. In addition, they, wishes. In extreme cases, volunteers may be deemed
along with first responders, disaster workers, and healthcare unfit for work and sent home before their tour is up.
personnel, are particularly vulnerable to stress-induced
Summary of Disaster Mental Health Response Principles
symptoms and secondary trauma. Work groups, schools, and
entire communities not only react to a disaster but also serve 1. No one who experiences a disaster is untouched by it.
as a conduit for support and psychoeducational information. 2. Most people pull together and function during and
There is no timetable for grief, and expressions of mourning after a disaster, but their effectiveness is diminished.
and bereavement reflect the characteristics of the person, the 3. Mental health concerns exist in most aspects of
loss, and the disaster. preparedness, response, and recovery.
4. Disaster stress and grief reactions are “normal
Section II Chapter 10- MANAGEMENT OF THE
responses to an abnormal situation.”
PSYCHOSOCIAL EFFECTS OF DISASTERS (pg. 168-
5. Survivors respond to active, genuine interest and
177)
concern.
Chapter Overview 6. Disaster mental health assistance is often more
practical than psychological in nature (offering a
The management of psychosocial effects begins with a sound phone, distributing coffee, listening, encouraging,
plan to mitigate the adverse impact of the disaster on the reassuring, comforting).
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7. Disaster relief assistance may be confusing to disaster - may supervise the staff providing direct services to
survivors. They may experience frustration, anger, victims, and provide reports to the command
and feelings of helplessness related to federal, state, coordinator
and nonprofit agencies’ disaster assistance programs.
Psychiatric nurses and psychiatrists
They may reject disaster assistance of all types.
- well suited as members of the medical team, as they
MENTAL HEALTH RESPONSE TEAM
can also be alert to organic mental disorders caused
Designation of a mental health coordinator is a crucial first by conditions such as head injuries, toxic exposures,
step in the formulation of a team. preexisting illnesses, dehydration, or
hyper-/hypothermia.
Tasks: - Nurses have a tradition of practice in homes, in
 Manage and coordinate the mental health response schools, and other natural settings, they tend to be
from the command center readily accepted by members of the community.
 Decide what resources are needed, activate Agencies and staff that will be activated for counseling and
appropriate mental health agencies, and assign staff treatment upon referral from the on-site counselors also need
to locations such as neighborhood centers, Red Cross to begin preparations for the influx of individuals and the type
shelters (when requested), family assistance centers, of psychiatric symptomatology they are most likely to see,
schools, hospitals, and so on. based on the estimates of the command coordinator.
 Monitors field reports regarding the ongoing needs of
victims, workers, and counselors, and adapts the plan Paraprofessionals and volunteers
as events unfold.
- Play an extremely vital role in disaster response and
 May also serve as a consultant to agencies or recovery.
designate a member of the administrative team to - They may be indigenous workers known to the
provide this function. community affected by the disaster, and may share
 Based on experience in Oklahoma City, the ethnic or religious backgrounds.
consultant should be someone other than direct line
staff. The immediate responders deployed by the
coordinator may include mobile crisis teams, case
managers, professionals, and volunteers who have Psychiatric intensive case managers
been preapproved.
- Critical in maintaining a bridge with the community.
Most Red Cross chapters or regions have a Disaster Mental - Ensures aftermath, it is the case manager who
Health (DMH) team which is made up of: provides that consistent, familiar link for children
and families in the neighborhood needing referrals
1. independently licensed master’s level (or higher) for additional services.
mental health professionals including
psychiatrists, [Following demobilization, the mental health coordinator
2. psychologists, conducts a review of the mental health response both
3. licensed clinical social workers, separately and in conjunction with the entire disaster
4. marriage and family therapists, response team—medical, rescue, public safety,
5. professional clinical counselors, communications, and transportation.]
6. nurses with specialty certification,
Reviewing the adequacy of the predisaster plan in light of the
7. school psychologists; and
actual response:
8. school counselors.
 helps to strengthen future planning
Members of these teams respond at the local level
 brings a sense of closure to the participants.
supporting smaller responses like storm-related events
and can also be deployed to larger relief operations RECRUITMENT, SCREENING, AND TRAINING
outside their local area. Within the mission, the DMH
team supports not only those directly affected by One major task of the mental health coordinator in the
disaster, but other relief operation volunteers planning phase is:
(American Red Cross, 2013).
 recruit and prescreen potential volunteers and staff
Field coordinator for credentials, so that they can be a part of the team
from the very beginning of the event.
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Not everyone, however, is suited for disaster work.  Mental health professionals responding to a disaster
need to be familiar with general assessment and
 Those who cannot tolerate the uncertainty and chaos intervention strategies and be prepared
inherent in disaster work ought to consider being psychologically and physically for the arduousness of
available for counseling referrals in a hospital or the work.
clinic setting, rather than being part of the immediate  It is crucial that mental health professionals be aware
response team in the field. of their own strong emotional reactions to the
 Matching the skills and aptitude of individuals with disaster and the impact it would have on their work,
the phase of disaster response can avoid potential and that they also have access to support and
pitfalls. counseling.
 Last-minute changes in immediate responders may be  Perhaps most importantly, mental health workers
necessary if an individual is personally involved in need to be culturally competent to work with the
the disaster or is in acute distress for other population they are serving (i.e., know the
personal reasons; in such cases, the individual might language, spiritual beliefs, and rituals surrounding
need to excuse himself or herself. loss and bereavement), and need to be briefed about
 Easing the sense of guilt that those in the helping local referral resources.
professions feel when they are unable to respond is  When needed, the mental health professionals on the
an important stress reduction strategy. team can also provide consultation to volunteers and
 Over 90% of the American Red Cross responders paraprofessionals in instances where a greater
are volunteers (American Red Cross, 2017). knowledge of psychopathology is indicated in the
assessment or management of adverse responses.

The Red Cross Disaster Action Team (DAT) Academy DISASTER MENTAL HEALTH INTERVENTIONS

 free program that trains individuals to respond and Psychological First Aid
recover from a disaster.  Psychological first aid (PFA) is an evidence-informed
 Is charged with the initial response for most, if not approach to assist and support survivors in the
all, disaster events. immediate aftermath of a disaster.
Most governmental agencies deploying mental health  There has recently been a revived interest in PFA,
counselors rely on state-licensing criteria to assure minimum with the main goal being to relieve immediate
competency. distress and prevent or minimize the development
of pathological sequelae (Math, Nirmala,
Well-qualified mental health professionals, who have a variety Moirangthem, & Kumar, 2015, p. 3)
of skills in assessment and intervention, are suited for most  There are survivors who recover normally, so the
types of disaster work; however, the U.S. Department of goal of the immediate mental health response is to
Health and Human Services (HHS) recommends additional reduce distress, assist with current needs, and
training for all potential responders (medical, mental health, promote adaptive functioning.
human services, citizen volunteers, et al.) in several areas:  PFA provides a framework to prepare survivors and
the bereaved for the emotional challenges that lie
■ An understanding of disaster concepts and disaster recovery
ahead, and to identify those individuals and families
■ The needs of special populations (i.e., children, the elderly, needing additional follow-up and referral.
people with disabilities, ethnic populations)
Other steps that can be taken immediately to reduce
■ Disaster stress symptomatology: normal reactions and when/ potential psychological harm include:
where/how to refer
1. The prevention of re-traumatization—limit the
■ Helpful skills and styles of relating (listening, problem number of persons with whom victims must interact
solving, crisis intervention) in order to receive services, as well as reduce the
amount of red tape required.
■ Self-help and stress management skills for disaster survivors 2. Prevention of new victims—limit the number of
■ Recovery resources (HHS, 2015) people exposed to the sights, the sounds, and the
smells of a disaster site, whenever possible.
3. Prevention of “pathologizing” distress—avoid
labeling normal reactions as pathological to prevent
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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symptoms from being interpreted as a medical Thus, mobilizing the natural social support system of family,
condition or disorder that requires treatment. friends, the faith-based community, and coworkers can be one
4. Identification of individuals showing signs of acute of the most helpful interventions in the aftermath of a
distress—Those who may need immediate medical disaster.
intervention include individuals with obvious and
active physiological stress reactions (exceedingly Social isolation is one of the psychological threats inherent in
frantic, panicky, or extremely anger) or individuals most disasters as roads may be blocked, landline and cell
who are profoundly shut down (numb, dissociated, phone services interrupted, as well as access to the Internet
disconnected). limited.

Psychological Triage
Crisis Intervention  One of the most important roles of the mental health
Substance Abuse and Mental Health Services professional in the immediate aftermath of a disaster
Administration [SAMHSA] (2015a, 2015b) recommends that is to identify which individuals are most at risk for
“crisis intervention services should be considered as a first psychiatric complications and to make referrals
line of emergency management for those potentially affected for further mental health evaluation and
by large-scale community disasters ... These interventions treatment when indicated.
are meant to ‘lend’ survivors the strengths needed to Factors increasing the risk of ASD and PTSD in someone
decrease their fear responses (thereby calming themselves) suffering a sufficient precipitating event include the following:
and access immediate care and support, allowing them to
move to the next stage of recovery” (p. 1).  Loss of a loved one in the event
 Significant injury from the event
 Crisis intervention is still the mainstay of disaster  Witnessing of horrendous images
counselors.  Dissociation at the time of the traumatic event
 Crisis intervention is a technique used to assist  Development of serious depressive symptoms within
persons whose coping abilities have been 1 week that last for 1 month or longer
overwhelmed by a stressful event.  Numbness, depersonalization, a sense of reliving the
 Most survivors at some point in the evolution of a trauma, and motor restlessness after the event
disaster experience a level of stress so overwhelming  Preexisting psychiatric problems
that their usual coping is inadequate to meet the need.  Previous trauma
Two key tools of the crisis/disaster worker are  Loss of home or community
active listening and problem solving.  Extended exposure to danger
 Toxic exposure
Active listening- allows the disaster worker to establish a
 Absence of social supports, or social supports who
sense of respect and trust and to better understand the
were also traumatized and thus are incapable of
survivor’s situation and needs.
adequate emotional availability (Lubit, 2016,
Because survivors are often so overwhelmed by their situation, “Etiology”)
it is difficult for many to know where to start. Thus,
Mental Health Referrals
counselors may advise survivors not to make any new or big
decisions while undergoing a crisis. While some are Referrals to a mental health professional ought to be made
immobilized by the stress, others may feel pressured to take when one or more of the following symptoms are present
some action. Helping individuals to prioritize their energies (DeWolfe, 2000):
can be very beneficial, as some might find themselves
spending inordinate amounts of time on things they cannot 1. Disorientation—dazed; memory loss; inability to
control, while not taking necessary action in matters where give date or time, state where he or she is, recall
they can make a difference to themselves and their families. events of the past 24 hours, or understand what is
happening
Social Support 2. Depression—pervasive feelings of hopelessness and
despair, unshakable feelings of worthlessness and
 Social support networks can provide important
inadequacy, withdrawal from others, inability to
affective and material aid that mitigates the adverse
engage in productive activity
effects of disaster trauma (van Ommeren, Hanna,
3. Anxiety—constantly on edge, restless, agitated,
Weissbecker, & Ventevogel, 2015).
unable to sleep, frequent frightening nightmares,
flashbacks and intrusive thoughts, obsessive fears of
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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another disaster, excessive ruminations about the  Directly experiencing the traumatic event(s)
disaster  Witnessing, in person, the event(s) happening to
4. Psychosis—hearing voices, seeing visions, delusional others
thinking, excessive preoccupation with idea or  Learning that the event(s) occurred to a close family
thought, pronounced pressure of speech (e.g., talking member or close friend (in cases of actual or
rapidly with little content continuity) threatened death of a family member or friend, the
5. Inability to care for self—not eating, bathing, or event[s] must have been violent or accidental)
changing clothes, inability to manage activities of  Experiencing repeated or extreme exposure to
daily life aversive details of the traumatic event(s) (e.g., first
6. Suicidal thoughts or plans—expressing indirect or responders collecting human remains or police
direct thoughts of harming self officers repeatedly exposed to details of child abuse)
7. Other behaviors of concern—problematic use of
alcohol or drugs, domestic violence, child abuse, or
elder abuse Even if a referral is not accepted at the 2nd criterion is the presence of at least 9 of 14 symptoms
time it is initially made, the trust that has been from any of five categories—intrusion, negative mood,
established early in the aftermath can be crucial to dissociation, avoidance, and arousal—beginning or
later follow-up. worsening after the traumatic event(s) occurred.
ACUTE STRESS DISORDER Intrusion symptoms include the following:
 Although a variety of psychiatric disorders may be  Recurrent, involuntary, and intrusive distressing
seen in the aftermath of a disaster, within the first memories of the traumatic event(s); children may
month of a traumatic event, ASD is the disorder engage in repetitive play during which themes or
most likely to be encountered by the disaster aspects of the traumatic event(s) are expressed
response team. Again, those in closest proximity to  Recurrent distressing dreams in which the content or
the event are at greatest risk. affect of the dream is related to the event(s); children
 Although lack of social supports, history of childhood may experience frightening dreams without
traumas, and poor coping skills may increase recognizable content
likelihood of the disorder, ASD can develop in a  Dissociative reactions (e.g., flashbacks) in which the
child or an adult having no predisposing individual feels or acts as if the traumatic event(s)
conditions, particularly if the stressor is extreme. were recurring
 Because the likelihood of developing PTSD is  Intense or prolonged psychological distress or
elevated for those having ASD, assessment of marked physiological reactions in response to internal
individuals for the presence of ASD is key to or external cues that symbolize or resemble an aspect
identifying those at high risk for future of the traumatic event(s)
complications.
Negative mood consists of the following:
 The prevalence of ASD following exposure to a
traumatic event varies greatly, depending on the  Persistent inability to experience positive emotions
severity and persistence of the trauma. (e.g., inability to experience happiness, satisfaction,
 Characteristic of the disorder is the development of or loving feelings) Dissociative symptoms include the
anxiety, dissociation, and other symptoms following:
occurring within 1 month after the trauma, lasting  Altered sense of the reality of one’s surroundings or
a minimum of 2 days. If symptoms persist longer oneself (e.g., seeing oneself from another’s
than 4 weeks posttrauma, a diagnosis of PTSD perspective, being in a daze, or feeling that time is
should be considered. slowing)
 The American Psychiatric Association’s  Inability to remember an important aspect of the
Diagnostic and Statistical Manual of Mental traumatic event(s), typically resulting from
Disorders, Fifth Edition (DSM-5), lists five specific dissociative amnesia and not from other factors (e.g.,
diagnostic criteria for ASD. head injury, alcohol, or drugs)

1st
Avoidance symptoms include the following:
criterion is exposure to actual or threatened death,
 Efforts to avoid distressing memories, thoughts, or
serious injury, or sexual violation in one (or more) of the feelings about or closely associated with the
following ways: traumatic event(s)
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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 Efforts to avoid external reminders (e.g., people,  At least one re-experiencing symptom
places, conversations, activities, objects, or  At least one avoidance symptom
situations) that arouse distressing memories,  At least two arousal and reactivity symptoms
thoughts, or feelings about or closely associated with  At least two cognition and mood symptoms
the traumatic event(s)
Re-experiencing symptoms include:
Arousal symptoms include the following:
 Flashbacks—reliving the trauma over and over,
 Sleep disturbance (e.g., difficulty falling or staying including physical symptoms like a racing heart or
asleep or restlessness during sleep) sweating
 Irritable behavior and angry outbursts (with little or  Bad dreams
no provocation), typically expressed as verbal or  Frightening thoughts
physical aggression toward people or objects
 Hypervigilance Re-experiencing symptoms may cause problems in a
 Problems with concentration person’s everyday routine. The symptoms can start from the
 Exaggerated startle response person’s own thoughts and feelings. Words, objects, or
situations that are reminders of the event can also trigger re-

3rd
experiencing symptoms.
criterion for ASD is that the duration of the
Avoidance symptoms include:
disturbance is 3 days to 1 month after trauma exposure.
 Staying away from places, events, or objects that are
 Although symptoms may begin immediately after a reminders of the traumatic experience
traumatic event, they must last at least 3 days for a  Avoiding thoughts or feelings related to the traumatic
diagnosis of ASD to be made. event

4 th Things that remind a person of the traumatic event can

criterion is that the disturbance causes clinically trigger avoidance symptoms. These symptoms may cause a
significant distress or impairment in social, occupational, person to change his or her personal routine. For example,
or other important areas of functioning. after a bad car accident, a person who usually drives may
avoid driving or riding in a car.

5th and final criterion is that the disturbance cannot be

Arousal and reactivity symptoms include:

attributed to the physiological effects of a substance (e.g., a  Being easily startled

medication or alcohol) or another medical condition (e.g.,  Feeling tense or “on edge”
mild traumatic brain injury) and cannot be better  Having difficulty sleeping
explained by a diagnosis of brief psychotic disorder.  Having angry outbursts

 ASD may progress to PTSD after 1 month, but it may Arousal symptoms are usually constant, instead of being
also be a transient condition that resolves within 1 triggered by things that remind one of the traumatic
month of exposure to traumatic event(s) and does not events. These symptoms can make the person feel stressed and
lead to PTSD. angry. They may make it hard to do daily tasks, such as
 In about 50% of people who eventually develop sleeping, eating, or concentrating.
PTSD, the initial presenting condition was ASD. Cognition and mood symptoms include:
Symptoms of ASD may worsen over the initial
month, often as a consequence of ongoing stressors  Trouble remembering key features of the traumatic
or additional traumatic events (American Psychiatric event
Association [APA], 2013).  Negative thoughts about oneself or the world
 Distorted feelings like guilt or blame
POST TRAUMATIC STRESS SYNDROME  Loss of interest in enjoyable activities
 a response to a recognizable, serious stressor that is Cognition and mood symptoms can begin or worsen after
characterized by specific behaviors. the traumatic event, but are not due to injury or substance
A diagnosis of PTSD requires that several criteria be met. To use. These symptoms can make the person feel alienated or
be diagnosed with PTSD, an adult must have all of the detached from friends or family members (National Institute
following for at least 1 month: of Mental Health, 2016).
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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 Symptoms usually begin early, within 3 months of strategies to help provide ongoing support to their
the traumatic incident, but sometimes they begin child(ren).
years afterward.
 Symptoms must last more than a month and be severe Older Adults
enough to interfere with relationships or work to be  Inquire how they have coped with past adversities
considered PTSD. and remind them of what has worked in the past.
 The course of the illness varies. Some people recover However, some older adults may not have grieved or
within 6 months, while others have symptoms that healed from previous stressors, making them more
last much longer. In some people, the condition vulnerable to the stress of the current situation.
becomes chronic.  Be aware of preexisting physical limitations and
PTSD IN CHILDREN assess the need to replace lost equipment (canes,
wheelchairs, hearing aids, glasses).
Children and teens can have extreme reactions to  In addition, older adults may also have preexisting
trauma, but their symptoms may not be the same as medical conditions and may need access to
adults. In very young children (less than 6 years of age), medication and/or supplies, such as oxygen.
these symptoms can include:  While developing a plan to address immediate needs,
older adults may be reluctant to take “handouts.” It
 Wetting the bed after having learned to use the can be helpful to acknowledge their contribution to
toilet family and community and frame any assistance as an
opportunity for the community to give back.
 Forgetting how to or being unable to talk
 It can be particularly distressful for older adults who
 Acting out the scary event during playtime may have loss of items of sentimental value that are
 Being unusually clingy with a parent or other irreplaceable, and this grief should be recognized and
adult acknowledged.

Older children and teens are more likely to show Individuals With Mental Illness
symptoms similar to those seen in adults. They may also Shelters usually house many individuals, have minimal
develop disruptive, disrespectful, or destructive privacy, and can be loud and busy. For individuals with
behaviors. Older children and teens may feel guilty for preexisting mental illness this could potentially exacerbate
not preventing injury or deaths. They may also have symptoms and may require special provisions. A DMH worker
thoughts of revenge (National Institute of Mental can help to identify individuals with preexisting mental illness
and advocate on their behalf for accommodations such as a
Health, 2016).
quieter location with less stimulation. In addition, DMH
INTERVENTIONS WITH SPECIAL POPULATION workers can assist with linkage to their ongoing mental
health providers, and can also facilitate access to
Children and Youth medications, if necessary.
 modify one’s language to match the child’s Cultural, Ethnic, and Religious Subgroups
developmental level using direct and simple
language. When working with individuals from cultural, ethnic, and
 crouch down to their eye level. religious subgroups, it is important to be sensitive to roles of
 assist children with identifying their feelings by family members, such as who is considered the head of the
providing labels (i.e., mad, sad, worried, scared). family or decision maker. If using an interpreter or translator,
make sure to look at the person to whom you are talking
 It is important to encourage them to express their
instead of the individual translating. Also, be aware of the
concerns and ask questions.
role of community as there may be suspicion and distrust
 Adolescents are likely to be more responsive to adult-
of outsiders, and help may usually be accepted only from
like requests to address their feelings, concerns, and
within the community. If possible, attempt to work with
questions.
community support providers who have established
 It is normal for children and adolescents to regress
relationships with these subgroups.
either behaviorally or in their language or speech.
 It can be helpful to educate parents and caregivers Disaster Relief Personnel
about normal reactions and reinforce use of these
 Disaster relief personnel can also be susceptible to
the stress associated with the traumatic exposure of
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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the disaster itself as well as the disaster response Linkage with Collaborative To link survivors with
efforts. However, disaster workers will often deny Services needed services, and inform
that they are experiencing stress and do not want them about available
to appear “weak” or unable to “handle it.” services that may be
 DMH workers are in a good position, as members of needed in the future
the larger response team, to observe other workers
and monitor disaster-related reactions.
FATIGUE MANAGEMENT
 It is important to provide support through casual
interactions— get to know their role in the  The U.S. National Response Team (NRT)
disaster response, listen to their concerns, and developed a document to address worker fatigue
create opportunities to be approachable. When a during large-scale disaster operations such as the
worker does reach out for support, it is helpful to Oklahoma City bombing; the 9/11 World Trade
identify a space that offers some confidentiality. Center attacks; anthrax contamination; the Columbia
Providing PFA, including education about typical Space Shuttle Recovery; and Hurricanes Katrina,
stress reactions and importance of self-care, can be a Rita, and Wilma.
helpful intervention  The document is intended to serve as a hands-on
manual to assist organizations with the
Psychological First Aid (PFA) Core Actions development of programs and plans to address
Contact and Engagement To respond to contacts fatigue issues among disaster workers (NRT,
initiated by affected 2009).
persons, or initiate contacts  NRT recommends use of an incident-specific fatigue
in a nonintrusive, management plan that includes a list of:
compassionate, and helpful
manner. 1. Personnel
Safety and Comfort To respond to contacts 2. brief description of the event and site conditions
initiated by affected 3. identification of fatigue risk factors present (work
persons, or initiate contacts hours and rest periods, living conditions, nature of
in a nonintrusive, work)
compassionate, and helpful 4. management and administrative support, potential
manner. emotional stress
Stabilization (if needed) To calm and orient 5. controls to be implemented (worker education,
emotionally— advanced planning, work hours and rest periods,
overwhelmed/distraught transportation, living conditions, recuperation
survivors. provisions, and healthcare services)
Information Gathering: To identify immediate 6. and the evaluation schedule
Needs and Current Concerns needs and concerns, gather
additional information, and WHEN GRIEF AND STRESS GO AWRY
tailor PFA interventions. Mental health services will remain in place long after
Practical Assistance To offer practical help to the initial impact. After the rescuers and disaster workers have
survivors in addressing demobilized and returned to their homes and routines, grief
immediate needs and and trauma counselors face the task of promoting the healing
concerns
process and treating those who develop psychiatric
Connection with Social To help establish brief or
Supports symptoms that have not abated with time.
ongoing contacts with
primary support persons or  In Oklahoma City, counselors were still providing
other sources of support, services to survivors more than 5 years after the
including family members, bombing.
friends, and community  More than 30 years after the Attica uprising, family
help resources members and survivors were receiving psychological
Information on Coping To provide information services for persistent or previously undetected PTSD
(about stress reactions and and traumatic grief symptoms.
coping) to reduce distress
and promote adaptive The hallmark for diagnosing a psychiatric disorder is that the
functioning. symptoms are significantly distressing, or cause
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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impairment in social, occupational, or other daily-life 1. Chronic—prolonged, extensive; person not able to
functioning. get back to life
2. Delayed—the pain not experienced until sometime
This is more difficult to assess in a disaster, as normal daily- later; minor event triggers an intense grief reaction
life functioning is substantially disrupted because of the event. 3. Masked—a physical symptom (e.g., headache,
Practitioners often have to rely on the individual’s subjective gastrointestinal distress) or disturbance of conduct or
report or that of the family that the symptoms experienced behavior (e.g., delinquency, depression; APA, 2013)
are not consistent with family/cultural norms, and are
causing significant distress or impairment in daily Symptoms of complicated bereavement may include:
functioning.
 Guilt about things other than actions taken or not
Many types of psychiatric disorders can be seen in the taken by the survivor at the time of the death
aftermath of a disaster. One of the most common is PTSD;  Thoughts of death other than the survivor feeling he
others include adjustment disorders, substance use or she should have died with the deceased person
disorders, major depression, complicated bereavement,  Morbid preoccupation with worthlessness
and generalized anxiety disorders.  Marked psychomotor retardation
 Prolonged and marked functional impairment
Marital discord and domestic violence can be exacerbated in  Hallucinatory experiences other than thinking he or
an environment of extreme stress, and all clinicians should be she hears the voice of, or transiently sees the image
alert to the hallmarks of spousal, child, or elder abuse. of the deceased person
Among children, other psychiatric difficulties encountered Treatment with medications for depression or anxiety has
posttrauma include depression and separation anxiety. been found to be beneficial and can prevent subsequent
Adolescents may display disruptive behaviors consistent disability. Psychotherapies and medications used for the
with a conduct disorder (e.g., fighting, destruction of treatment of major depression and PTSD have also been found
property, stealing, running away) in the months or years to be useful in the treatment of the traumatically bereaved.
following traumatic stress, and thus, the connection to the EVIDENCE-BASED PRACTICES IN THE
traumatic event is often missed. While anniversaries can be a TREATMENT OF ASD AND PTSD
time to share emotions and focus on the future, they can also
be a time in which distressing symptoms are easily reactivated.  Cognitive behavioral intervention during the acute
aftermath of a disaster for ASD has been found to
TRAUMATIC GRIEF (COMPLICATED
yield positive results in preventing subsequent
BEREAVEMENT)
posttraumatic psychopathology.
 Grief can be determined to be traumatic when it  Treatment for PTSD typically begins with a detailed
follows a loss that is sudden, violent, or is evaluation and development of a treatment plan that
accompanied by extreme and intense emotional meets the unique developmental needs of the
distress. individual.
 In such cases, the grief can be unrelenting and Generally, PTSD-specific treatment is begun only when the
overwhelming. individual is safely removed from the trauma or crisis
 Those experiencing a loss through sudden or violent situation.
death are often left with a feeling of unreality about
the loss.  In persons who are currently experiencing violence
 Involvement with protracted medical or legal (acts of war), abuse (physical, sexual, or emotional),
investigations can delay the grieving process. or a disaster, immediate removal from the situation
 Feelings of guilt tend to occur when the death is is the first step in managing the crisis.
sudden, as does the need to blame someone for what  Persons who are severely depressed or suicidal,
happened. experiencing extreme panic or disorganized thinking,
 The sense of helplessness is often profound, as it or in need of drug or alcohol detoxification need to
represents an assault on one’s sense of power and have these crisis problems addressed as part of the
orderliness. initial treatment phase.
 Use of PFA is recommended by the National Center
The complications of grief usually present in one of three for PTSD by focusing on reducing ongoing adversity,
ways: promoting safety, attending to practical needs,
enhancing coping, stabilizing survivors, and
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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connecting survivors with additional resources to  Trauma-focused group therapy

help mitigate the consequences of the traumatic
events/disaster (USDVA, National Center for PTSD, Not Recommended (No Evidence)
2016a).  Psychological debriefings
Pharmacotherapy (medication) can reduce the anxiety,  Single-session techniques
depression, and insomnia often experienced with PTSD,
UTILIZING TECHNOLOGY AS AN ADJUNCT TO
and in some cases may help relieve the distress and
INTERVENTION AND TREATMENT
emotional numbness caused by trauma memories.
With the growing utilization of technology in daily life, there
 Antidepressants and other medications may be
is opportunity to incorporate these tools/applications (apps) to
prescribed along with psychotherapy. Other
support interventions and treatment. HelpGuide.org,
medications may be helpful for specific PTSD
www .helpguide.org/, offers tips and tools for managing both
symptoms. For example, although it is not currently
generalized stress and PTSD symptoms.
FDA approved, research has shown that Prazosin
may be helpful with sleep problems, particularly
nightmares, commonly experienced by people with
PTSD (National Institute of Mental Health, 2016).
1 One app that has been created is called “PTSD Coach.”
The app contains 17 tools that individuals can use to learn
Exposure therapy can help people face and control their about PTSD and how to manage symptoms. PTSD Coach
fears. It gradually exposes them to the trauma they was created by the USDVA’s National Center for PTSD in
experienced in a safe way. It uses imagining, writing, or partnership with the Department of Defense’s National Center
visiting the place where the event happened. The therapist for Telehealth and Technology (USDVA, National Center for
uses these tools to help people with PTSD cope with their PTSD, 2017).
feelings (National Institute of Mental Health, 2016).

Cognitive restructuring is a form of therapy that helps

people make sense of the bad memories. Sometimes people
2 “Breathe 2 Relax,” created by the National Center for
Telehealth and Technology, can be used as a stress
remember the event differently than how it happened. They
management tool to support deep diaphragmatic
may feel guilt or shame about something that is not their fault.
breathing, helping to reduce the fight or flight response.
The therapist helps people with PTSD look at what happened
in a realistic way (National Institute of Mental Health, 2016). Federal Emergency Management Agency has an app available
that contains safety tips and an interactive emergency kit
Previous studies (Matthews & Mossefin, 2006; Russell, 2008;
list. The American Red Cross also has an app available
Schubert & Lee, 2009) have summarized the evidence
through digital media stores (go to www.redcross.org/
supporting psychotherapy models in PTSD using the
prepare/mobile-apps for the list of providers).
American Psychiatric Association Practice Guideline for the
Treatment of Patients with ASD and PTSD as follows:  While these tools are not designed to replace
professional intervention, they are easily accessible
Recommended With Substantial Clinical Confidence
and can be used to support adaptive coping for those
(Level I)
experiencing traumatic stress symptoms (Disaster
 Cognitive behavioral therapy Ready.org, 2014).
 Psychoeducation CRITICAL INCIDENT STRESS MANAGEMENT
 Supportive techniques
 is a formalized, structured method whereby a group
Recommended With Moderate Clinical Confidence (Level of rescue and response workers reviews the stressful
II) experience of a disaster. (National Center for PTSD)
 Exposure techniques  was developed to assist first responders, such as fire
and police personnel; it was not meant for the
 Eye movement desensitization and reprocessing
survivors of a disaster or their relatives.
Imagery rehearsal
 was never intended as a substitute for therapy. It was
 Psychodynamic therapy
designed to be delivered in a group format and meant
 Stress inoculation
to be incorporated into a larger, multicomponent
May Be Recommended in Some Cases (Level III) crisis intervention system labeled Critical Incident
Stress Management (CISM).
 Present-centered group therapy
DISASTER NURSING AND EMERGENCY PREPAREDNESS
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CISM includes the following components: for PTSD and cognitive behavioral approaches along with
exposure therapy are most likely to be beneficial.
 Precrisis intervention
 Disaster or large-scale demobilization and
informational briefings (town meetings)
 Staff advisement, defusing, CISD
 One-on-one crisis counseling or support
 Family crisis intervention and organizational
consultation
 Follow-up and referral mechanisms for assessment
and treatment, if necessary (USDVA, National Center
for PTSD, 2016b)

THE DEBRIEFING CONTROVERSY

 In general, psychological debriefing has not been

found to reduce psychological distress or prevent
PTSD (Schwarz & Kowalski, 1992; Wilson,
Raphael, Meldrum, Bedosky, & Sigman, 2000).
 There are several studies that suggest that debriefing
may actually produce harm (Math et al., 2015).
Specifically, individual, single-session debriefing can
no longer be recommended according to a study by
Rose, Bisson, Churchill, and Wessely (2002).
 Follow-up assessment should be increasingly
viewed as important, and the use of screening and
treatment programs need to be developed and brought
to the most vulnerable groups where they live or
work. Rescuers should be debriefed as a group, in
which participation is voluntary and occurs only
when the group is no longer exposed to traumatic
conditions.

SUMMARY

The mental health response to a disaster must be a well-

coordinated effort that draws on a variety of professionals,
paraprofessionals, and volunteers who have been prescreened
and specially trained for this work. In the immediate
aftermath, the goal of mental health intervention is to facilitate
normal coping, to treat those with immediate needs, and to
begin to identify those at risk for psychiatric disorders in the
ensuing weeks, months, or years. Although mental health
interventions have not been shown to prevent psychiatric
disorders once exposure to a traumatic event has occurred,
research continues to search for strategies that can mitigate
harmful effects. Management of the psychosocial effects of
disaster will continue long after the initial impact. PFA is an
evidence-informed approach designed to reduce distress in the
immediate aftermath of a disaster and foster adaptive
functioning and coping. Major depression and PTSD can be
disabling consequences of exposure to disaster among those of
any age group and, thus, early diagnosis and treatment are
critical to the prevention of future disability. There is a
growing body of research identifying that effective treatment