SPECIAL FOCUS
The Integration of Mental and Behavioral Health
Into Disaster Preparedness, Response, and Recovery
Betty Pfefferbaum, MD, JD; Brian W. Flynn, EdD; David Schonfeld, MD; Lisa M. Brown, PhD;
Gerard A. Jacobs, PhD; Daniel Dodgen, PhD; Darrin Donato; Rachel E. Kaul, MSW;
Brook Stone, MFS; Ann E. Norwood, MD; Dori B. Reissman, MD, MPH; Jack Herrmann, MSEd;
Stevan E. Hobfoll, PhD; Russell T. Jones, PhD; Josef I. Ruzek, PhD; Robert J. Ursano, MD;
Robert J. Taylor, PhD; David Lindley, PhD
ABSTRACT
The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the
National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the
progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health
into disaster and emergency preparedness and response activities. One vital opportunity to improve integration
is the development of clear and directive national policy to firmly establish the role of mental and behavioral health
as part of a unified public health and medical response to disasters. Integration of mental and behavioral health
into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services,
addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.
(Disaster Med Public Health Preparedness. 2012;6:60-66)
Key Words: disaster mental and behavioral health, disaster preparedness, response, recovery, emergency
management, federal and state disaster plans
R
ecently, substantial efforts have been made toward enhancing the US public health and medical infrastructure to ensure it is appropriate and
expeditious to the full spectrum of disasters and public
health crises. Nevertheless, gaps persist in the nation’s
ability to respond effectively to the mental and behavioral health effects of these events. The mental and behavioral health consequences of disasters can manifest
as physical symptoms, exacerbate existing physical illnesses, undermine compliance with public health directives and warnings, contribute to difficulties in individual functioning and interpersonal relationships,
increase work and school absenteeism, and adversely
affect survivors’ quality of life. These problems can be
both debilitating and persistent, resulting in considerable individual, community, and societal costs. Timely
mental and behavioral health interventions can improve response efficiency, prevent secondary adversities due to inappropriate or inadequate response, help
affected populations recover and adjust to changed circumstances, improve adherence to future recommendations and directives, and increase confidence in government. Therefore, concerted attention to mental and
behavioral health concerns is integral to success in preparedness, response, and recovery for disasters and public health emergencies.
60
Recent federal efforts in disaster preparedness, response, and recovery recognize the importance of mental and behavioral health.1,2 Homeland Security Presidential Directive-21 (HSPD-21),3 which presented a
national strategy for public health and medical preparedness, included mental health as part of mass casualty care. Recognizing psychological support mechanisms as essential elements of “a prepared and responsive
health system,” the 2009 US Department of Health and
Human Services (HHS) National Health Security Strategy (NHSS)1(p11) promotes two goals: (1) building community resilience and (2) strengthening and sustaining health and emergency response systems. The Federal
Emergency Management Agency (FEMA) National Disaster Recovery Framework (NDRF)2 promotes emotional and behavioral health considerations as an essential component of recovery.
INTEGRATING MENTAL AND BEHAVIORAL HEALTH
INTO DISASTER PREPAREDNESS AND RESPONSE
The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Successful
integration requires mental and behavioral health efforts to be (1) incorporated in assessments and services; (2) addressed in education and training; and (3)
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founded on and advanced through research. Integration must
be supported in underlying policies and administration.
Integration has the potential to
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promote compliance with public health directives;
enhance individual and community resilience;
augment prevention through education;
facilitate rapid identification of individuals in need of immediate care;
improve accuracy in diagnosis and treatment by health care
providers;
reduce the development of longer-term mental health problems;
facilitate adjustment to loss and coping with adverse circumstances;
further cost-effective and seamless care;
identify and minimize potential barriers to treatment adherence and compliance;
encourage mobilization and allocation of resources for atrisk and special needs groups;
support culturally informed and culturally responsive policies and services;
foster confidence and trust in government;
empower individuals to care for themselves more effectively; and
foster cohesion in the affected community to promote community resilience and facilitate the community’s timely return to normal.
THE CHARGE TO THE DISASTER MENTAL HEALTH
SUBCOMMITTEE
The National Biodefense Science Board (NBSB) was created
under the authority of the Pandemic and All-Hazards Preparedness Act, signed into law on December 19, 2006.4 The NBSB
was chartered to provide expert advice and guidance to the secretary of HHS on scientific, technical, and other matters of special interest to HHS regarding current and future chemical, biological, nuclear, and radiological incidents, whether naturally
occurring, accidental, or deliberate. As needed, the NBSB also
provides advice and guidance to the secretary of HHS and/or
the Office of the Assistant Secretary for Preparedness and Response (ASPR) on other matters related to public health emergency preparedness and response.5
The Disaster Mental Health Subcommittee, directed by HSPD213 and established under the NBSB, was charged with submitting recommendations to the NBSB for protecting, preserving, and restoring individual and community mental health in
catastrophic health event settings, including pre-, intra-, and
postevent education, messaging, and interventions. On November 18, 2008, the subcommittee submitted its initial report, Disaster Mental Health Recommendations6 (recommendations report), to the NBSB. Eight recommendations addressed
three areas related to disaster mental and behavioral health preparedness and response: (1) intervention; (2) education and
training; and (3) communication and messaging. The document included an extensive bibliography that provides scientific, clinical, and policy support for the content in this article.
The complete recommendations report is available on the NBSB
Web site.6 The NBSB unanimously approved the report and
voted to send the recommendations to the ASPR.7
On September 22, 2009, the ASPR asked the NBSB to convene the subcommittee to assess HHS’s progress in integrating
mental and behavioral health into disaster and emergency preparedness and response activities. On September 22, 2010, the
subcommittee presented a report to the NBSB, Integration of
Mental and Behavioral Health in Federal Disaster Preparedness, Response, and Recovery: Assessment and Recommendations (available on the NBSB Web site).8 Noting that successful integration requires meaningful metrics and accountability, the
integration report focused on policy and the organizational and
structural elements necessary to translate policy into action. The
NBSB voted to adopt the report and send its five recommendations to the secretary of HHS.9 This report describes the importance and context of the integration of mental and behavioral health and provides details of the subcommittee’s assessment
of integration and its recommendations for integration.
Approach and Analysis
The subcommittee assessed progress toward the integration of
mental and behavioral health within HHS by holding teleconferences in which ex officio members (or their designees) were
first asked to identify gaps in integration efforts within their agencies, identify strategies to address these gaps, and provide a timeline for this process. Second, they were asked to identify changes
in interaction with other federal agencies that would improve
the agency’s progress toward integration. Finally, they were asked
to identify impediments to enhancing integration and ways to
reduce such obstacles. A complete list of agencies is included
in the integration report.8
Although the subcommittee was not charged with assessing integration at the state and local levels, a true status assessment
requires an understanding of issues at these levels. Therefore,
the subcommittee asked representatives from the Multi-state
Disaster Behavioral Health Consortium to (1) identify some
best-practice examples of successful integration as well as challenges and barriers at the state and local levels; (2) describe current linkages between federal and state agencies and activities
that support integration as well as challenges and barriers; and
(3) identify federal activities that could be initiated or adjusted to improve integration at the state and local levels.
The subcommittee reviewed the recommendations provided to
the NBSB in its 2008 report, considered the need for integration and a functional definition, and analyzed the information
provided by federal agency representatives.
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Mental and Behavioral Health in Disaster Preparedness
Reflecting on the Subcommittee’s 2008
Recommendations Report
In preparing its 2008 recommendations report,6 the subcommittee conducted a literature review and used expert consensus to
generate a set of recommendations for disaster mental and behavioral health. In brief, the 2008 recommendations were to
• integrate mental and behavioral health into all public health
and medical preparedness and response activities (eg,
develop a disaster mental health concept of operations
[CONOPS]);
• advance the research agenda for disaster mental and behavioral health;
• enhance assessment and surveillance of mental and behavioral health needs during emergencies;
• enhance disaster mental and behavioral health training for
professionals and paraprofessionals;
• promote the population’s psychological resilience;
• ensure that the needs of at-risk individuals and issues of cultural responsiveness are addressed in all NBSB efforts;
• develop a disaster mental and behavioral health communication strategy; and
• prepare an Internet-based communication toolkit with, for
example, coordinated access to messaging and educational
materials.
The subcommittee concluded that, while some progress had
been made toward implementing the 2008 recommendations, persistent gaps warranted attention. These gaps
existed, in part, because the scope of the recommendations
was broad and because advances in disaster mental and
behavioral health have been limited. Thus, the first recommendation in the integration report8 was to fully implement
the 2008 recommendations. The subcommittee noted that
some of the action steps in the recommendations report were
too specific to reflect evolving concerns, current conditions,
and changed structures; thus, other approaches may be more
appropriate for implementation in the present environment.
Six cross-cutting principles were identified in the recommendations report6: (1) define disaster mental and behavioral
health “comprehensively to include the highly interconnected
psychological, emotional, cognitive, and social influences on
behavior and mental health” in the context of disaster preparedness, response, and recovery6(p4); (2) encourage “practical, flexible, empowering, compassionate, and respectful”
disaster mental and behavioral health interventions6(p4); (3)
advocate responsiveness to culture and diversity; (4) promote
attention to vulnerable, at-risk populations; (5) discourage
additional burdens on states/territories, federally recognized
tribes, and local entities without appropriate funding and
resources; and (6) advance collaboration and integration of
effort among “non-traditional” government, academic, and
private sector partners as well as federal, state/territory, tribal,
and local partners.6(p5)
62
The subcommittee considered integration of disaster mental and
behavioral health in its first recommendation in the 2008 recommendations report.6 Recommendation 1b focused squarely
on integration in proposing (1) the inclusion of language on
mental health, substance abuse, and behavioral health in all
appropriate legislation, regulations, and grants; and (2) the inclusion of disaster mental and behavioral health planning and
exercises in performance benchmarks of new or existing federally funded emergency management programs or grants. The
first recommendation also noted the importance of coordinating mental and behavioral health services through a unified
CONOPS across pre-, intra-, and postevent phases. A mental
and behavioral health CONOPS would identify roles and responsibilities, procedures, and processes to be used when incidents occur and would create a structure that could facilitate
integration.10 Work toward this recommendation has advanced significantly in the last two years with the publication
of a Disaster Behavioral Health CONOPS by HHS11 that will
inform, and be integrated with, the nation’s Emergency Support Function (ESF) #8–Public Health and Medical Services
Annex.12
Recommendation 2 called for a national research agenda supported by federal agencies that fund research initiatives, a position echoed in the subcommittee’s integration report. This
recommendation proposed convening a working group of the
subcommittee to review research portfolios from various agencies to identify gaps in knowledge; areas of recent progress; and
priorities in program evaluation, early interventions, treatment, and dissemination of training in interventions.6
Integration was also promoted in recommendation 3, which advocated for enhanced assessment of mental and behavioral health
during emergencies. The subcommittee envisioned using existing surveillance systems to (1) establish a baseline; (2) assess status at critical points in time; and (3) monitor mental
and behavioral health reactions, needs, and recovery.6
Recommendations 4, 5, and 6 focused on education and training, emphasizing the importance of promoting psychological
resilience through education in disaster mental health and/or
training in psychological first aid and through a national strategy for the integration, dissemination, and evaluation of this
intervention. The report used the term “psychological first aid”
to describe supportive activities delivered by nonmental health
professionals to family, friends, neighbors, coworkers, and students as well as more sophisticated psychological support delivered by primary care providers to their patients.6 (p12) The report recognized the limited research on the benefits of
psychological first aid and called for the creation of a national
strategy for integrating, disseminating, and evaluating psychological first aid.6 Given the need to first establish an evidence
base for the effectiveness of psychological first aid, the subcommittee decided against promoting it in the integration report.
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The subcommittee endorsed the inclusion of mechanisms for
ensuring that the needs of at-risk individuals and cultural responsiveness are addressed in all NBSB efforts.6 This endorsement was covered in the integration report as well.
Recommendation 7 promoted the integration of communication strategies through education and training and through policies to coordinate communication efforts across federal components. The recommendation envisioned trained mental health
experts serving as consultants in developing communication
strategies. With respect to the content of messages, the recommendation specified the importance of psychoeducation and
information about available services and promoted a policy that
would require that messages and activities be informed by existing evidence.6
The eighth, and final, recommendation was the creation of a
federal Web site that might allow interaction with the public
as well as provide a conduit for both public and professional
information. This recommendation should not be interpreted
as support for a single federal Web site, which might carry with
it potential challenges on both sides of the communication equation. Obtaining consensus on what information to post may
prove problematic and time consuming. In addition, the public may prefer multiple Web sites, given individual preferences
and confidence in various information sources. The subcommittee recognized the need to stay abreast of rapidly emerging
and changing communication technologies and social networks for use in reaching appropriate audiences.
ity, accountability, and communication. The subcommittee clarified that the focus on integration does not mean that effective
existing programs specifically dedicated to disaster mental and
behavioral health should be eliminated. Nor does integration
mean that disaster mental health activities should be consolidated into a single agency or department, which could result
in attention to these issues being minimized within other agencies and departments or marginalized throughout the federal
system.8
ANALYSIS: THE INTEGRATION REPORT
The subcommittee concluded that, although the federal government has made progress toward integration in certain areas,
far more needs to be done. The most pressing and significant
opportunity to improve integration is the development of clear
and directive national policy to firmly establish the role of disaster mental and behavioral health as part of a unified public
health and medical response to disasters. Integration must be
modeled and supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.
The analysis of the status of integration was organized around
two themes: (1) policy and (2) the organizational and structural elements needed to transform policy into effective action. The subcommittee noted that success will require meaningful metrics and accountability so that policy achieves the
desired goals.
Policy
THE NEED FOR MENTAL AND BEHAVIORAL HEALTH
INTEGRATION AND A FUNCTIONAL DEFINITION
The subcommittee considered the need for integration and for
a functional definition of integration. Attention to the integration of mental and behavioral health is necessary because
mental health has not been addressed systematically or consistently in disaster preparedness, response, and recovery. Attempts at integration have commonly relied on interested individuals and organizational structures that are subject to change.
Moreover, where it exists, integration has not been comprehensive or universally effective. The subcommittee noted that
without integration (1) mental and behavioral health efforts
may be duplicated and contradictory; (2) lessons from one disaster are not preserved for use in future disasters; and (3) responders in the field must search for and devise appropriate responses independently, do not know what resources are available
and effective, and lack training to use these resources.8 Essential to successful integration is balancing the inefficiency of unnecessary duplication with the advantages of redundancy.
A Functional Definition
Integration of disaster mental and behavioral health into preparedness, response, and recovery means that many different
programs should contribute their valuable and sometimes unique
expertise and services and that they should function as part of
a coherent, organized structure with clear lines of responsibil-
In the area of policy, the subcommittee addressed (1) the federal role; (2) concerns at the state level; (3) communication;
and (4) research. The subcommittee discussed the role of policy
as it relates to program development, implementation, and sustainability. Much meaningful progress has been made in understanding the centrality of mental and behavioral health factors in disaster and emergency preparedness, response, and
recovery; however, much remains to be done. The subcommittee concluded that many of these advancements have been made
in the absence of foundational policy and have been largely due
to key individuals working in an environment of shifting agency
influence, landmark disasters, and the vicissitude of budgets.
The subcommittee concluded that the federal government needs
to establish a foundation to policies that will support systematic implementation of an evidence-based, integrated, and sustainable approach to disaster mental and behavioral health.
Federal Role
The subcommittee recognized the need for clearer policy regarding the federal government’s role with respect to the most
significant long-term as well as immediate emotional consequences of disasters. Without a process to publicly debate the
issue and reach a consensus regarding the federal role, stakeholders both within and outside the federal government might
perceive operational practice as arbitrary. The subcommittee
recognized that policy discussion on this topic is inextricably
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Mental and Behavioral Health in Disaster Preparedness
linked to the broader debate regarding the role(s) of government in general.
Issues at the State Level
While a focus on concerns at the state level was not part of its
charge, the subcommittee chose to examine issues the states
face in their interactions with the federal government. Issues
identified for the subcommittee by state stakeholders included
the need for simpler mechanisms for funding disaster mental
and behavioral health efforts, greater consistency in federal–
state coordination around disaster-related concerns, and education for federal agencies concerning state and local capabilities in disaster mental and behavioral health. In general, the
subcommittee concluded that the absence of clear, integrated,
and implemented policies creates difficulty for the states in integrating their efforts with federal efforts as well as developing
their own disaster mental and behavioral health capacity.
Communication
The subcommittee recognized the prominent role of communication, including dissemination of information, directives, and
other messages, in disaster and emergency management. When
the mental and behavioral health response is fragmented among
entities, messages to the public may be inconsistent and may
generate confusion and anger that can thwart compliance. The
creation of consistent and useful messages will require integration of mental and behavioral health issues in the education
and training of responders and should be supported by a coherent policy.
Research
Preparedness, response, and recovery require a much stronger
evidence base than currently exists. Program evaluation studies that examine the effectiveness of existing crisis counseling
approaches are especially important. In its recommendations
report,6 the subcommittee recommended convening a working group to review the research portfolios of federal research
funding agencies to identify gaps in knowledge, progress, and
priorities. Recognizing the importance of this recommendation, HHS has begun intradepartmental discussions with
key agencies and is exploring avenues for initiating this kind
of review.
The subcommittee had also called for a national research agenda
supported by federal agencies that fund research in the area.6
Reflecting on the wide-ranging interest and the limited mechanisms and policies to support a comprehensive research agenda
across many federal departments and agencies, the subcommittee recommended that a forum be established to encourage the
development, shared ownership, and coordination of the research agenda with prioritized goals and adequate dedicated funding. Research efforts provide a good example of important collaboration and integration. These efforts are far more likely to
be successful if they are grounded not just in the good will of
individuals involved but in a clear and sustained policy based
on sound evidence.
64
Organizational and Structural Elements
Unfortunately, organizational and structural issues can hinder
efforts to promote integration in a sustainable manner. The subcommittee recognized that achieving integration will be difficult and will likely require new personnel and resource structures, attention to state and local issues, and support from key
stakeholders. Obstacles arise from entrenched processes, budgeting, and planning as well as from an organizational culture
in which separate constituencies have developed both within
and outside government. The role and structure of the federal
government in disaster management are currently a matter of
great public debate. It is hoped that the outcome will result in
structures, processes, and an organizational culture that will foster the development and implementation of more integrated
and unified efforts.
Personnel and Resource Infrastructure
The subcommittee concluded that new personnel and resource structures will be needed to achieve integration, noting
that in addition to leadership, integration will necessitate expenditure of time and effort at all levels of relevant departments and agencies, policy-based expectations and direction,
and clear lines of authority and accountability. The subcommittee determined that a number of agencies have previously
collaborated, and are currently collaborating, to accomplish integration, particularly in response to a number of recent disasters. Ideally, with a clear and sustained policy, required personnel and appropriate resources will be available in response to
future events, and sustainable integration will be forwarded by
a clearer mandate, authority, and specific funding for collaborative efforts.
Issues at the State and Local Levels
The subcommittee acknowledged that success of federal programs will require attention to the organizational, structural,
and funding issues at the state and local levels. Federal partners must act in ways that recognize the diversity in state structures for disaster mental and behavioral health. For example,
in the National Response Framework’s ESF #8,12 mental health
is an element of the public health and medical response, but
many states administer mental health and public health programs separately. Furthermore, an indefensibly small proportion of federal preparedness, response, and recovery resources
that flow to the states are specifically directed to mental health
capabilities. Starting in 2002, modest grants were awarded by
the Substance Abuse and Mental Health Services Administration to 35 states to produce state disaster behavioral health
plans, but funding to sustain the initiative has not been available. All states have identified coordinators, but funding is lacking to create and maintain a dedicated staff and infrastructure.
Other Issues
Although it did not compile an exhaustive list of elements
needed to transform policy into effective action, the subcommittee identified the need for resources, a mental and behavioral health CONOPS, and training. The integration report iden-
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tified both personnel and material resources. With respect to
personnel needs and the use of subject matter expertise, the subcommittee raised two questions: (1) Where in the federal structure does the responsibility and authority reside to access content expertise? and (2) How is the expertise best cataloged,
maintained, and used? With respect to material needs, the subcommittee noted that integration requires comprehensive, available, and easily adaptable resources for both responder and
public use.
The subcommittee was reassured about progress toward including disaster mental and behavioral health components into plans,
but emphasized that putting these plans into action would require the development of an overall CONOPS. Creation of the
HHS CONOPS11 is an indication of successful integration.
Implementation remains an essential step toward progress.
In spite of a growing emphasis on training related to disaster
mental health, the subcommittee determined that a specific office or agency must be given responsibility for identifying appropriate content and audiences, creating inventories of existing educational materials and resources, proposing educational
objectives, and assuring quality. The subcommittee noted that,
to improve response, research is needed on the effectiveness of
various training approaches such as “train the trainer” and “justin-time training” models.
Strategic Recommendations
The NBSB adopted the five recommendations from the subcommittee’s integration report.9 The first recommendation was
that HHS adopt the eight recommendations presented in the
2008 recommendations report.6 The second recommendation
was that the secretary of HHS create a policy regarding disaster mental and behavioral health and a strategy to implement
that policy. The policy should be developed in consultation with
other federal departments and agencies; state, local, and tribal
agencies; nongovernmental organizations; civic and community groups; and subject matter experts.
The policy should (1) clearly articulate the nature and scope
of the federal government’s roles and responsibilities with respect to disaster mental and behavioral health; (2) identify and
delegate responsibility and authority to designated federal agencies and other entities to prepare for a full range of psychosocial consequences and provide for assessment and treatment of
those consequences; and (3) develop mechanisms to integrate
disaster mental and behavioral health capabilities and responsibilities across federal departments and agencies.
Because the charge of the subcommittee was to assess integration within HHS itself, and not more broadly within the federal government, the subcommittee noted that the best approach may be to pursue integration first within HHS, which
could then serve as a model for other agencies. It also noted
that policy gaps could be addressed in the pending reauthorization of the Pandemic and All-Hazards Preparedness Act by
including content that argues forcefully for the integration of
mental and behavioral health in preparedness, response, and
recovery efforts.
The third recommendation was that the secretary of HHS identify and empower an office or agency within HHS to serve as
the leader for disaster mental and behavioral health integration. This office or agency should have authority to (1) oversee efforts across HHS, define goals, and measure progress; (2)
develop a high-level CONOPS for including mental and behavioral health across all phases of disaster management throughout the federal government; and (3) coordinate activities among
all sections of HHS to marshal existing expertise and obtain
additional expertise, integrate strategy, share data, and generate a credible and unified HHS response.
The fourth recommendation was that the secretary give senior
HHS leaders the task of developing a set of coordinated and
prioritized research goals related to disaster mental and behavioral health and the necessary support to accomplish those goals.
The fifth recommendation was that the secretary create and
maintain a structure that would allow subject matter experts
to regularly assess and report to the secretary on progress toward integration and on other mental and behavioral health
issues. This recommendation would entail institutionalizing the
subcommittee, or a comparable body or process, as an ongoing
resource to provide disaster mental and behavioral health technical expertise.
After making these recommendations, the NBSB dissolved the
subcommittee as a formal entity. Instead, mental and behavioral health expertise has been addressed by installing individuals with this expertise as members of the full NBSB. The
subcommittee members were asked to volunteer for activities
on an ad hoc basis.
CONCLUSIONS
Throughout the federal government, a limited number of officials have specific responsibility for championing the integration of disaster mental and behavioral health into federal
preparedness, response, and recovery planning and activities.
The subcommittee was impressed with examples of the need
for mental and behavioral health integration and progress toward it. Much of this work, however, is proceeding ad hoc, largely
as a result of commitment and effort by experts and motivated
individuals rather than as the consequence of formal policy. Recognizing the impressive work of these individuals, the subcommittee nonetheless emphasized that implementation of an integration policy will require (1) leadership commitment; (2)
policy-based direction and expectations; (3) clearer lines of authority and accountability; and (4) personnel and resource structures that currently do not exist.
In spite of these challenges, the subcommittee was pleased to
find evidence at the federal level illustrating awareness of the
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Mental and Behavioral Health in Disaster Preparedness
importance of mental and behavioral health including, for example, the NHSS.1 The subcommittee believes that accomplishing the NHSS goals will require systematic and sustained
integration of mental and behavioral health issues throughout
disaster and emergency preparedness, response, and recovery.
One critical obstacle to the integration of disaster mental and
behavioral health is that personnel in state, local, and tribal
authorities are typically not part of a larger and comprehensive effort for integration, and their power to initiate action is
limited.
The most pressing and significant opportunity to improve integration is the development of clear and directive national
policy to firmly establish the role of disaster mental and behavioral health as part of a unified public health and medical response to disasters. This will require clear lines of responsibility regarding where the authority to formulate and implement
such policy should reside. The two subcommittee reports provide an analysis of the status of integration with recommendations specific to the task8 in addition to a literature review and
recommendations for mental and behavioral health in general.6 The subcommittee recognized that while the secretary of
HHS can directly foster an integration policy and strategy only
within its agency, the ability of HHS to act as a guide and model
for other federal departments and agencies and for other levels
of government should not be underestimated.
Author Affiliations: Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City (Dr Pfefferbaum); Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences,
Bethesda, Maryland (Dr Flynn); Division of Developmental and Behavioral
Pediatrics, National Center for School Crisis and Bereavement, Cincinnati
Children’s Hospital Medical Center, Ohio (Dr Schonfeld); Department of
Aging and Mental Health, Louis de la Parte Florida Mental Health Institute,
University of South Florida, Tampa (Dr. Brown); Disaster Mental Health Institute, University of South Dakota, Vermillion (Dr Jacobs); Division for AtRisk Individuals, Behavioral Health, and Community Resilience, Office of the
Assistant Secretary for Preparedness and Response, Office of the Secretary, US
Department of Health and Human Services, Washington, DC (Dr Dodgen,
Mr Donato, and Ms Kaul); Commissioned Corps Affairs, Food and Drug Administration, US Department of Health and Human Services, Rockville, Maryland (Ms Stone); Center for Biosecurity, University of Pittsburgh Medical Center, Baltimore, Maryland (Dr Norwood); National Institute of Occupational
Safety and Health, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Reissman); National Association of County and City Health Officials, Washington, DC (Mr Herrmann); Department of Behavioral Sciences,
Rush University Medical Center, Chicago, Illinois (Dr Hobfoll); Department
of Psychology, Virginia Tech University, Blacksburg, Virginia (Dr Jones); National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California (Dr Ruzek); Department of Psychiatry, Uniformed Services University
of the Health Sciences, Bethesda, Maryland (Dr Ursano); and SAGE Analytica, LLC, Bethesda, Maryland (Drs Taylor and Lindley).
Correspondence: Betty Pfefferbaum, MD, JD, Department of Psychiatry and
Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, PO Box 26901-WP 3470, Oklahoma City, OK 73126-0901
(e-mail: Betty-Pfefferbaum@ouhsc.edu).
Acknowledgments: Patricia Quinlisk, MD, MPH, former chair of the National Biodefense Science Board (NBSB), and CPT Leigh Sawyer, DVM, MPH,
66
US Public Health Service, former executive director of the NBSB, and the NBSB,
Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, provided guidance on issues discussed in
the manuscript and on appropriate terminology.
Received for publication August 26, 2011; accepted February 1, 2012
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.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ417
.109.pdf. Accessed January 31, 2012.
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/legal/boards/nbsb/Documents/amendcharter-nbsb-2010.pdf. Accessed January 31, 2012.
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Assistant Secretary for Preparedness and Response. Disaster Mental Health
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.gov/Preparedness/legal/boards/nbsb/Documents/nsbs-dmhreport-final
.pdf. Accessed January 31, 2012.
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Response Letter to The Honorable Michael O. Leavitt, Secretary of Health
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.phe.gov/Preparedness/legal/boards/nbsb/meetings/Documents
/dmhreport1010.pdf. Accessed January 31, 2012.
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Disaster Medicine and Public Health Preparedness
©2012 American Medical Association. All rights reserved.
VOL. 6/NO. 1
PSYCHOSOCIAL REACTIONS TO TRAUMATIC
EVENTS
- DISASTER MENTAL HEALTH
THE HELPERS
Bostonians Are Brave: Mr Rogers - "Helpers" PSA: https://www.youtube.com/watch?v=anKqsO9G6Dg
WHY IS DMH IMPORTANT?
Improve survivor’s short-term functioning
Reduce long-term negative behavioral health effects
Prevent and control disaster stress related injuries
and disorders
Promote individual and community resiliency and
recovery
Identify those at-risk for severe distress and
impairment
Accelerate recovery
- Adapted from the Florida Center for Public Health Preparedness at the University of South Florida
CHALLENGES
Identify and map out the range of possible
psychological responses
Define where, when and how to respond /
intervene
HISTORY
DISASTER MENTAL HEALTH
TRAUMA
1980 – first addition of PTSD to the Diagnostic and Statistical
Manual of Mental Disorders (DSM)
We continue to have skeptics regarding psychological trauma
Shift from the idea that mental illness came from internal
maladaption to the possibility that “external” events could
create such effects on the emotional and physical state of a
person
WAR
WAR: “controlled application of violence to achieve political goals” (Silver 2005)
likened to a “planned” disaster, one that unfolds over time
Civil War (U.S.) “neurasthenia” – a state of physical and mental exhaustion &
“nostalgia”, or homesickness
WWI the term “shell shock” (emerges in 1914)
WWII “Battle/ Combat fatigue”
Vietnam “posttraumatic stress syndrome”
Currently combat stress response; combat fatigue / 15-17% of soldiers (in Iraq) met
the diagnostic criteria for PTSD, generalized anxiety disorder, or depression
LEGITIMIZATION OF TRAUMA
Examination of the effects of war on a population (other than soldiers), e.g.
Holocaust Survivors
Psychological relationships between victims and victimizers (re: terrorism)
Impact of rape, domestic violence and incest
Why do you think it has been so difficult to legitimize
the effects of shocking and often unimaginable events
on people?
TRAUMATIC STRESS
“Traumatic stress disables people, causes disease, precipitates
mental disorders, leads to substance abuse, and destroys
relationships and families. Additionally, traumatic stress reactions
may lead to Posttraumatic Stress Disorder (PTSD)”.
(Lerner & Shelton, 2001)
EMPHASIS ON RESILIENCE
Natural human resilience equips most people to recover
from traumatic experiences with no outside
intervention
People possess the inner resources for growth and
healing (Humanistic psychology)
AMERICAN RED CROSS
The first voluntary disaster relief agency to……
Acknowledge the need for mental health support during times of disaster
Develop standards regarding who could deliver such services
Develop a standardized training curriculum for mental health volunteers
Consider the needs of Survivors and Disaster Workers
NOTABLE RESOURCES FOR DMH
International Society for Traumatic Stress Studies (www.istss.org)
American Psychological Association – Disaster Response Network
(http://apa.org/practice/programs/drn/index.aspx)
Disaster Psychiatry Outreach (http://disasterpsych.org/)
National Center for PTSD (Dept of Veterans Affairs: www.ptsd.va.gov)
National Child Traumatic Stress Network (http://www.nctsnet.org/)
ACADEMIC CENTERS
University of South Dakota, Disaster Mental Health Institute (DMHI) –
Gerard Jacobs
The State University of New York at New Paltz – Institute for Disaster
Mental Health (IDMH) – James Halpern
University of Washington – DART Center for Journalism and Trauma
National Centers for Disaster Preparedness e.g., Columbia University
Children & Disaster Bulletin
HOW DO WE KNOW HOW TO RESPOND TO DISASTERS?
Customer
Feedback
Program
Evaluation
Disaster
Research
Trauma
Research
Experience
Expert consensus
A GROWING DISCIPLINE….
NIMH (2002): “Mental Health and Mass Violence: Evidence-Based Early Psychological
Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on
Best Practices”
PSYCHOSOCIAL REACTIONS
TED Talk:
Karen Thompson Walker
What Fear Can Teach Us
https://www.ted.com/talks/karen_thompson_walker_what_fear_can_teach_us
EXPOSURE TO TRAUMA
Signs and symptoms of stress and exposure to trauma may include:
❖
Emotional reactions, such as shock, fear, irritability, anger, sadness, feeling numb;
❖ Behavioral changes, such as dietary changes; social withdrawal; increases in the use
of mood-altering substances
❖ Intrusive thoughts or memories, flashbacks or nightmares about traumatic events;
❖ Physical effects such as fatigue, insomnia, tension, headaches, stomach upsets;
❖ Relationship problems such as strain, conflict, withdrawal, distrust, loss of intimacy.
❖ Spiritual questioning, such as how could God let this happen? Is there a God?
SHAKING THE FOUNDATION OF ONE’S WORLD VIEW
https://www.youtube.com/watch?v=d3zc9ZGJPCQ
STAGES OF DISASTER REACTIONS
Helpful to think of reactions as connected to different stages
Pre-impact (notice vs. non-notice; planning
enables empowering action)
Impact (shock, denial, numbness, fear,
heightened arousal, fight/flight response,
hypervigilance, purposeful acts)
Post-impact (Heroic Phase,
Honeymoon phase, disillusionment
phase, reconstruction phase)
STAGES OF DISASTER RECOVERY
Survivors’ reactions to disaster correspond to the stage of recovery
Heroic amazing and noble efforts
Honeymoon focus, like-minded
effort and sentiment; shared sense of
purpose
Disillusionment anticlimactic phase;
withdrawal of resources & volunteers;
lessoned community activity
Reconstruction several years …or
the rest of one’s life; challenge to adapt
to the new way of life, the new normal
COMMON REACTIONS TO TRAUMA
Arousal
Avoidance
Re-experiencing
THIS IS A NORMAL RESPONSE to a CRISIS situation
Most disasters elicit a ‘classic’ PTSD response during and immediately following the event
COMMON REACTIONS TO TRAUMA (ALL AGES)
Anger
Anxiety
Appetite changes
Colds or flu-like symptoms
Concentration problems
Fear of crowds or strangers
Fear of darkness
Feelings of hopelessness
Guilt
Headaches
Mood swings
Nausea/stomach problems
Nightmares
Poor work performance
Confusion
Crying easily
Denial
Fatigue
Fear of being left alone
Hyperactivity
Hyperviligence/increased
watchfulness
Increased drug and alcohol use
Irritability
Isolation
Reluctance to leave home or
loved ones
Sadness
Sensitivity to loud noises
Sleep difficulties
What does this tell us….
This big list of common reactions?
COMMON REACTIONS TO TRAUMA (CHILDREN OF ALL AGES)
Anxiety and irritability
Clinging, fear of strangers
Fear of separation, being alone
Head, stomach, or other aches
Increased shyness or aggressiveness
Nervousness about the future
Regression to immature behavior
Reluctance to go to school
Sadness and crying
Withdrawal
Worry, nightmares
EXISTENTIAL REACTIONS
Meaning
Sense of Self
Trade the terms “Closure”, “Recovery”, and “Healing”
For
ADJUSTMENT
Identity
World view
Beliefs about human
beings
Beliefs about one’s
culture
Rando (1993)
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