Introduction

James Halpern, Amy Nitza, and Karla Vermeulen

Disasters don’t just rob people of homes, property, and sometimes lives; they create extreme stress and trauma. Emergency managers and first responders place the psychological needs of disaster survivors second to saving lives and providing temporary shelter, food, and water. However, addressing psychological needs following disaster is now more appreciated and planned for than at any time in the past. It’s also better understood that restoring basic necessities does not just satisfy physical and practical needs, but psychological ones as well. There are fewer stigmas around requesting mental health support post-disaster. This is fortunate because in the United States and around the world, disasters are becoming more frequent and more intense. The U.S. has the most extreme weather in the world with tornado, hurricane, and wildfire seasons, along with the most gun violence, mass shootings, and mass killings in the developed world. Countries with less frequent natural disasters and less gun violence can nonetheless face daunting challenges when disaster strikes due to poverty, lack of response capacity, poor building construction, lack of medical supplies, and so on. These difficulties can extend survivors’ suffering and delay their recovery, placing them at higher risk of developing extreme mental health reactions in response to the disaster.

A growing body of research has guided the practice of disaster mental health. We know that disasters that are big and bad and long will have significant mental health consequences in the short and long terms. They will cause both transient distress in the majority of survivors and longterm psychopathology in a minority of survivors (North & Pfefferbaum, 2013). Following disaster there will likely be an increase in grief and traumatic grief, alcohol and substance misuse, depression, anxiety, post-traumatic stress, and family conflict (Bonanno, Brewin, Kaniasty & La Greca, 2010). We also understand the risk and resilience factors that make some people more vulnerable to developing symptoms. For example, knowing that children are particularly at risk for lasting reactions allows planners and responders to better target assistance to them, their parents, and schools. We can also identify other vulnerable and at-risk populations,

such as the frail elderly, people living in poverty, those who have been injured, and those with disabilities (Halpern & Vermeulen. 2017). But our understanding of what clinical tools to use with different individuals and populations is still in the early stages: Precisely because disasters, the people they impact, and survivors’ needs and reactions are all so diverse, it’s difficult to conduct standardized research that allows us to develop evidence-based interventions we can recommend for everyone. Additionally, disaster mental health (DMH) responders need to be flexible and adapt to each situation and each survivor they encounter, and historically there have been few opportunities to learn from each other’s experiences through traditional academic publications.

The case study method used for this book is intended to provide detailed, rich qualitative information and insight to improve practice and to further research. Case studies are often used in exploratory research. They can help us generate new ideas that might be tested by other methods and can illustrate how theories and practice are applied in real life situations. For example, research has guided us in working with parents after a disaster. We know that we can support children by encouraging parents to maintain routines, like helping children to have regular bed and wake up times. But the research does not tell us how it feels to enter a community or family assistance center where there has been a school shooting or explosion and children are injured or dead. The research does not inform us about the challenges faced when trying to help clients who have been the victims of political violence or who are suffering from a virus that could kill anyone - including exposed DMH helpers. So, we have worked with practitioners involved in the DMH response to 17 domestic and international disasters to capture their lived experiences throughout the event, in hopes that readers will be able to incorporate the lessons learned into their own future responses.

This book is intended for students of mental health and school counseling, psychology, and social work - and for working practitioners who want to learn directly from their disaster response peers. By providing the reader with more in-depth case studies than are found in any comparable text, it could stand alone or be a companion to Disaster Mental Health Interventions: Core Principles and Practices (Halpern & Vermeulen, 2017), which describes the impact of disasters and how to support survivors.

This collection of case studies, written by seasoned clinicians, demonstrates how disaster mental health interventions can be tailored to meet the needs of clients impacted by different disasters, under very different circumstances. Each case offers lessons learned and guidance for practitioners who want to assist clients at what is arguably the most difficult time in their lives. In recounting their experiences at disasters, contributing authors give us a rare and compelling view into the challenges of doing this work. They not only describe the impact on disaster survivors, but also tell us how their involvement affected them personally. We hope their insights will help you work more effectively with survivors.

Before we look at the individual cases, we will review some of the basic disaster mental health practices that are likely to be a part of every response.

A Brief Overview of the Practice of Disaster Mental Health

There’s a saying in this field that “if you’ve seen one disaster, you’ve seen one disaster,” and the same point applies to disaster survivors. Every event is unique, as is everyone who has experienced that event.

The part regarding survivors is essential to remember as there can be a tendency, in the chaos and often overwhelming demands you may encounter after a major event, to assume that everyone who went through a particular disaster is going to experience identical reactions, and therefore they’ll all benefit from the same interventions. Obviously but unfortunately (since it would make our jobs much easier!) this is not the case. Each person went into that event with different pre-existing resources, stressors, personality characteristics, and history of coping with adversity. This means they perceived the disaster differently while it was unfolding, even if they were literally in the same room when it happened. They also will have differences in their recovery resources, coping style, access to social support, and sense of self-efficacy that will influence how smoothly or bumpily they adjust to their disaster experience and losses. Therefore, DMH practice lesson number one is to remember to treat each survivor as an individual - as you doubtless would do during your usual mental health practice - and don't fall into that trap of generalizing expectations because of the collective nature of the traumatic experience.

And the same lesson applies to your own expectations going into a new response. As you gain experience in the field, you’ll probably start to feel more confident in your ability to help survivors and cope with whatever the next disaster throws at you. That’s natural and positive, but we encourage you to never assume that what worked last time will automatically suffice next time. We can’t emphasize enough that each disaster and survivor group is different, so you’ll need to work differently to help them. As you'll read in these case studies, some of the most experienced responders whose stories are included here are also the most humble, acknowledging that while they can certainly apply some lessons across events, they also have learned they need to go into a new response with an open mind and heart, ready to adapt to whatever they encounter.

With that need for flexibility established, there are some evidence-based, trauma-informed interventions that are recommended by the American Psychological Association and other professional groups as effective treatments for Post-traumatic Stress Disorder and other extreme reactions. It should be part of every DMH helper's on-site preparation to know what, if any, community resources are available for survivors who need referrals for these evidence-based longer-term treatments.

However, the primary focus of the disaster mental health response is not on addressing the minority of people who do develop these extreme reactions, but on the majority, if not the entire population, who experience “post-traumatic stress reactions.” These can resemble PTSD symptoms but are generally short-lived and less extreme - which is not to say that they don’t feel terrible for the people experiencing them at the time. These responses make sense given the traumatic event and subsequent losses these survivors are processing, and they can occur across multiple realms:

  • • Emotional.
  • • Behavioral.
  • • Physical.
  • • Cognitive.
  • • Spiritual.

The range of possible reactions within each of these realms is vast, and each individual survivor will experience their own unique combination of symptoms at any given time. While these varied reactions are common and reasonable in response to a particularly traumatic event, it’s important for you to be aware that they’re often shocking and overwhelming to those experiencing them. Survivors may fear that they’ll never feel better, or that they’re going crazy. Some people may feel weak for not being able cope better - or guilty about how well they are coping relative to those around them. It’s particularly challenging when members of a couple or family are responding differently and can't understand or support each other’s reactions.

As a result, an important DMH intervention is to provide psychoeducation about why survivors are feeling the way they’re feeling. We want to normalize their reactions - but without describing them as “normal” since that can feel invalidating to people in the throes of this intense response. Instead, we suggest this approach when working with a distressed client:

  • • Describe their feelings as reactions that make sense given what they’ve been through.
  • • Explain that most people who experience these strong feelings after a disaster start to feel better once some time has passed and the situation starts to stabilize.
  • • Explain what they can do to access more mental health support if they don’t start to feel better over time, and/or they would like to speak to a helper now.

That approach acknowledges and validates the person's current suffering while creating an expectation of recovery, and while providing resources to help in the event that additional assistance is indeed needed now or later.

Beyond that very basic, but often very helpful, provision of psychoeducation, most of the earliest DMH interventions are based on delivering Psychological First Aid (PFA), which you'll see mentioned in almost every one of these case studies. PFA focuses on providing immediate support for disaster survivors’ interrelated practical and emotional needs, and restoring a sense of safety. The goals are to remove any barriers to recovery and to kickstart survivors’ natural resilience. There are many different models of PFA, though all share the same core goals. All are short-term (you might have only one conversation with a survivor and never know how they fare in the future) and focus on returning the person to their pre-disaster functioning, not fixing every issue in their life.

Our PFA model (Halpern & Vermeulen, 2017) includes these elements:

  • • Being calm.
  • • Providing warmth.
  • • Showing genuineness.
  • • Attending to safety needs.
  • • Attending to physiological needs.
  • • Providing acknowledgment and recognition.
  • • Expressing empathy.
  • • Helping clients access social support.
  • • Helping clients avoid negative social support.
  • • Providing accurate and timely information.
  • • Providing psychoeducation and reinforcing positive coping.
  • • Empowering the survivors.
  • • Assisting survivors with traumatic grief.

We'll point out that when people with any kind of mental health background study PFA, their immediate response is often along the lines of, “well, of course those are things 1 would do with anyone in distress!” Indeed, the elements themselves are simple and seem like common sense. However, in the heat of a disaster response, common sense is often overwhelmed by the stress of trying to attend to dozens or even hundreds of survivors, so it’s essential not only to study PFA but to practice it through roleplays or other exercises so you’re able to implement each element as needed. You can and should take a PFA training with the American Red Cross or other organizations, or through various online programs, before you consider responding to a disaster.

Beyond PFA, DMH helpers often need to draw on other clinical skills to address the stress and uncertainty in the post-disaster community, including:

  • • Correcting distorted self-cognitions among survivors who are unfairly blaming themselves or others, or who have exaggerated perceptions of ongoing threats.
  • • Rumor control, as false information inevitably springs up to fill the vacuum of official news about the event.
  • • Mitigating conflict, as perceptions about unfair distribution of resources or the ongoing stress of living in a crowded shelter elicit anger and frustration.
  • • Assessment and screening to ensure that needs at the individual and community levels are recognized and. if possible, addressed.
  • • Referrals for long-term care for those who need a connection to a community-based mental health professional. Of course, this applies to cultures and communities where there is an existing mental health infrastructure and professionals who are available to provide treatment. Where this is not the case, introducing a sustainable approach to training paraprofessionals and building local capacity can be an important DMH role.

Remember that your role typically involves supporting colleagues and other responders as well as disaster survivors, so encouraging them to practice stress management and self-care is important, as is attending to your own needs in those areas in order to maintain your ability to help others.

We hope this very brief summary of the goals and practices of disaster mental health response makes it clear that the specialty requires an intense level of dedication and flexibility. More detailed descriptions of PFA and other early interventions in DMH can be found in Disaster Mental Health Interventions: Core Principles and Practices (Halpern & Vermeulen, 2017), and we encourage you to seek out as many training opportunities as possible through the Red Cross and other organizations to be sure you build up the range of skills you’ll need to support survivors. As the case studies you’re about to read demonstrate, the work is hard, but many practitioners describe their disaster mental health responses as among their most gratifying professional experiences.

A Guide to This Book

The book you’re about to read consists of 17 case studies divided into three sections. They include a number of high-profile disasters that most readers are likely to be familiar with, as well as several others that may not be as well known:

Natural Disasters in the United States

  • • 2014 Mudslides in Oso, WA, by J. Christie Rodgers
  • • 2005 Hurricane Katrina in Louisiana, by Gerald McCleery
  • • 2013 Wildfire in Yarnell, AZ, by Margaret McGee-Smith
  • • 2016 Floods in Mississippi, by William L. Martin
  • • 2011 Tornado in Joplin, MO, by Richard Bigelow
  • • 2012 Super Storm Sandy in New York City, by Diane Ryan

Human-Caused Disasters in the United States

  • • 1995 Bombing of the Oklahoma City Federal Building, John R. Tassey
  • • 2001 World Trade Center Attack in New York City, by Mary Tramontin
  • • 2012 Sandy Hook School Shooting in Newtown, CT, by Wayne F. Dailey
  • • 2012 Shooting and Fire in Webster, NY, by Steven N. Moskowitz
  • • 2014 Mass Murder in Isla Vista, CA, by Erika Felix
  • • 2016 Pulse Night Club Shooting in Orlando, FL, by Tara S. Hughes

International Disasters

  • • 1998 Las Casitas Mudslides in Nicaragua, by Joseph O. Prewitt Diaz
  • • 2010 Earthquake in Haiti, by Wismick Jean-Charles
  • • 2013 Asylum Seeker Camp Riots on Nauru, by Stephen Brooker
  • • 2013 Massacre at Rabaa Square in Egypt, by Basma Abdelaziz
  • • 2014 Ebola Outbreak in Guinea, by Reine Lebel

These cases have been chosen to reflect different types of events in different geographic locations, and include natural and human-caused disasters of varying scope, intensity, and duration. They resulted in different reactions, challenges, and interventions; they also occurred in communities with diverse populations and disparate access to resources that necessitated a range of cultural and contextual considerations which the authors describe. The experiences of the DMH responders in this collection of events contribute to lessons learned of a remarkable breadth and depth.

At the same time, this list is a small and non-representative sample of the countless disasters that could have been included in each section. For every disaster that is described, there were numerous others that we wish could have been included. The selection of these specific events is not intended to elevate their significance over that of any others. Similarly, the authors whose experiences are shared here are in many cases one of a number of DMH responders who could have written about their roles in that disaster; in that way, each chapter reflects only one story of many. Each of the included authors is a mental health professional who was involved directly in the response in a DMH role. Many were responding to a disaster in their own community or region; others were deployed to the disaster site through an agency that was invited to respond, such as the American Red Cross or Médecins sans Frontières. The dynamics and challenges of responding to a disaster in one’s own community versus being deployed to the site are very different; toward that end, the authors describe the community context in which they were responding, as well as their own thoughts and considerations as they prepared to enter and engage with that community as a DMH responder.

Each case study follows the same outline:

Author background: Authors from different mental health professions present their varied backgrounds, their motivations for becoming involved in disaster response work, and their levels of experience. Some describe themselves as entering the scene well prepared and trained while others saw themselves as less experienced, trying to adapt their clinical training to the chaos they encountered.

Pre-disaster community: Authors describe the community and culture they entered and how it shaped their expectations and approach to helping. Communities varied enormously in terms of resources, familiarity with disaster, and mental health services available. The authors discuss working with different types of populations and cultures, how they joined and worked with police, firefighters, clergy, oppressed political groups, the very poor, parents of young children, LGBTQ populations, and so on.

The characteristics of the event: Client and community reactions are shaped by the size, expectedness, duration, and cause of the event. Each chapter provides a description of a different kind of turmoil that you, the reader, might encounter should you be asked to deploy to a similar event.

Thoughts pre-disaster: Authors discuss their thoughts and preparations before going out to a response - their immediate reactions when they first got the call to help. Readers should note authors’ apprehensions as well as their different self-care plans and levels of experience and confidence. Few report feeling fully prepared to respond, but all rose to the occasion using techniques that may be valuable for new helpers to adopt.

Response experience: Authors describe what they saw and heard - the impact of the event on survivors and the populations impacted, as well as the practical challenges they faced and the significant clinical actions and interventions they practiced. The reader might consider which interventions seemed most consistent with your own style. Do the case studies suggest you would benefit from additional training and practice?

Post-response adjustment: In this section authors describe the personal impact of the event and response, their reflections on the experience, and what they thought and did returning from assignment. Please note that engaging in disaster response should never be taken lightly. The authors all recognize the need for self-care in order to maintain wellness and competence to serve others.

Lessons learned: Authors summarize what they took away from their experience and what they view as useful to practitioners who may be involved in disaster response in general and/or responding to a similar type of disaster.

If you’re new to the field, the case studies presented in this book are intended to prepare you for the experience of assisting clients in a chaotic situation where there may be few facts and much uncertainty. When an author describes an event, think about how you would prepare to respond if it were you receiving that call. There might be smoke, debris, news reports of casualties. You might be traveling far from home to support a group of strangers, or you might be balancing professional and personal demands if the disaster strikes your own community. When you enter a disaster scene, shelter, or family assistance center, you’re entering “disaster world” - a world of confusion and trauma and need. We hope these case studies provide you with some exposure that will help you be more ready and more effective when it’s your time to respond. If there is one thing that is certain in this field, it’s that there will be no shortage of disasters in the future. By reading this book, you can absorb the wisdom of these 17 DMH practitioners and improve your capacity to help when needed.

We are grateful to each of the authors who shared their stories with us; we found their descriptions of the moments of human connection they achieved, as well as the moments of uncertainty that they faced, to be both informative and inspiring. We hope that you will learn as much from their experiences as we have.

References

Bonanno, G.A.. Brewin, C.R., Kaniasty, K., & La Greca, A.M. (2010). Weighing the costs of disaster: Consequences, risks and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11, 149.

Halpern, J., & Vermeulen, K. (2017). Disaster Mental Health Interventions: Core Principles and Practices. New York: Routledge.

North, C.S., & Pfefferbaum, B. (2013). Mental health response to community disasters: A systemic review. Journal of the American Medical Association, 310, 507 518.

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