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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

New York State
County Disaster Mental Health Planning and Response Guide
A Guide for County Directors of Mental Health and Community Services

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The County Mental Health Disaster Planning and Response Guide provides specific information and resources to assist the county Director of Community Services (DCS) in the development of a comprehensive county mental health disaster plan. The Guide follows the disaster management continuum and takes into consideration the important aspects of Planning and Preparedness, Mitigation, Response, Recovery, and Evaluation.

It is recommended the DCS review his/her plan routinely so new information in the field of disaster mental health may be integrated into the plan in a timely manner. Key contact information for vendors, volunteers, employees, and others should be reviewed every six months and the plan updated accordingly.

1.     General Overview
1.1           Planning/Preparedness

1.2           Mitigation

1.3           Response

1.4           Recovery

1.5           Evaluation

2.     Planning and Preparedness
2.1           Convene a Disaster Mental Health Advisory Committee

The involvement of and collaboration with a wide variety of public and private agencies and organizations is strongly encouraged. Planners may find it useful to sort the planning process into ‘topic’ specific task groups or subcommittees addressing such areas as legal issues, recruitment and training issues, operational and deployment protocols, ‘special incidents’ planning, etc. A vibrant and comprehensive mental health disaster plan is highly correlated with the collaboration and diversity of participants involved in its development. Effort should be made to invite participants from multidisciplinary backgrounds and experiences. Representatives from the following list of public and private agencies and organizations might be invited to serve on the overall advisory committee or its topic specific task groups:

2.1.1        County/City Stakeholders

2.1.2        Regional/State/Federal Stakeholders

2.1.3        Other Public/Private Agencies and Organizations

2.2           Review Your County Disaster Plan

The county’s mental health disaster plan is one component of each county’s overall community-wide disaster plan. To obtain a copy of the County Disaster Plan, contact the County Emergency Manager or Director of Emergency Preparedness. Each county plan should include a general overview of the authority of the County Department of Mental Health during the event of a disaster. In reviewing the county’s disaster plan, pay particular attention to the county’s:

2.3           Review Disaster Plans for Local Disaster Response Agencies

A county’s local chapter of the American Red Cross is responsible for meeting the short-term or immediate disaster related needs of a community during times of disaster. A community may also have other organizations that have disaster-related service missions. Identify such agencies and request and review copies of their respective disaster plans. Identify opportunities to collaborate and reduce redundancies in service provision, where appropriate.

2.4           Develop a Comprehensive Mental Health Disaster Plan

Preparing for, responding to, and recovering from disaster is predicated on a comprehensive disaster mental health plan. Development of this plan should include representatives from across professional disciplines as well as those from the public and private sectors. Once the plan is completed, it should be shared with and reviewed by a wide audience, especially those who have direct responsibility for carrying out specific tasks and roles identified in the plan. Listed below are key elements of a mental health disaster plan. Further information regarding these key elements may be found in the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Mental Health All-Hazards Guidance Document, 2003 [see References and Resources section, Appendix A page 15].

2.4.1        Mental Health Disaster Plan-Key Elements

2.5           Develop Disaster Mental Health Response Teams

A county disaster mental health response team provides a significant resource to the community. Following a disaster, the majority of those affected will experience a range of reactions that can be both stressful and impact personal functioning. Disaster mental health response teams provide important supportive mental health interventions that may mitigate both the acute and long-term psychological consequences of disaster. Consideration must be given to the key issues listed below in the development of a county disaster mental health response team:

2.6           Establish Memorandum of Understanding with Community Partners

A Memorandum of Understanding (MOU) should be developed between the County Department of Mental Health and any agency or vendor identified in the plan that provides disaster mental health services or human and/or material resources to carry out the activities of the plan. These MOUs should clearly articulate the roles and responsibilities of the partner agencies and the mechanisms and procedures for carrying out such duties. MOUs should be reviewed and cleared by the County’s legal and risk management department.

2.7           Participate in County Disaster Drills and Exercises

Counties are often required to hold community wide drills or exercises on a yearly or biyearly basis as required by the State Emergency Management Office. Other county or community agencies may also be required to hold similar drills and exercises (i.e. County airport, nuclear power facilities, hospitals, etc.). The County Department of Mental Health should take the opportunity to participate in these drills and exercises with the goal of evaluating the operational aspects of their plan in addition to building relationships with community and county partners.

3.     Mitigation
3.1           Identify High Risk Areas and Populations

The County Department of Mental Health must work in collaboration with the County Office of Emergency Preparedness to identify potential high risk disaster areas or populations within the county or its contiguous borders. These areas should be mapped and routinely reviewed by disaster mental health team members. Individuals from these high risk areas and populations can face significant psychological stressors in the aftermath of disaster. Efforts should be made to reach out to high risk groups and areas and provide pre-disaster education which has been found to be successful in potentially mitigating acute and long-term psychological consequences of disaster. Disaster mental health research, though limited, suggests the following populations may be at heightened risk for developing significant stress reactions or psychiatric illness following disaster:

3.2           Develop Disaster-Related Informational and Educational Brochures

Providing information to individuals about disaster preparedness and the anticipated psychological consequences following disaster may be an important preventative approach to mitigating such reactions. Informational brochures addressing personal, family and work life disaster planning, common post-disaster stress reactions and community resources available to meet the disaster related-needs of those impacted by disaster are important areas to highlight prior to disaster. These materials should be available in multiple languages specific to the population-based needs of your County.

3.3           Develop Operational Protocols to Manage Spontaneous Volunteers

Disaster history and experience suggests that a significant number of individuals will spontaneously present as volunteers following large scale disasters. Establishing protocols to screen, train, and deploy these spontaneous volunteers is critical to the disaster mental health operation. Counties must also address risk and liability issues inherent in volunteer management.

4.     Response
4.1           Activate Response Protocols for Disaster Mental Health Team(s)

An effective response protocol is predicated on the clear and concise descriptions of the roles and responsibilities of those involved in the response. It is highly advised that the County’s disaster plan incorporate a process by which the County DCS is notified and advised of local disaster events. This communication allows for the timely assessment and provision of immediate mental health interventions that can potentially mitigate acute, intermediate and long-term stress reactions in the community. The mental health disaster plan should include response protocols for a limited-team versus a full-team deployment. Team members should be advised as to the nature of the event, where they will report for their briefing and work assignment, and other issues that potentially impact their safety and security.

To maintain resource and scene management mental health response teams should be deployed according to the circumstances of the incident, availability of service sites, and number of victims involved. Many times, the ‘sense of immediacy to respond’ and the response chaos inherent in disaster, results in mass deployment. Care should be taken to provide service across the disaster response and recovery timeline and only once the need is assessed, verified and logistical arrangements have been addressed. Staggering team member deployment will also prevent exhausting your resource pool prematurely.

Prior to service site deployment, team members should be provided with appropriate identification and oriented to what is known about the event at that point in time. Specific information regarding victim demographics, safety and security issues, the service delivery plan, and other pertinent details of the incident or response should be provided. Team members should also be advised and provided with the names of their administrative (work site) and technical (clinical) supervisors and clear expectations and protocols regarding the use of such supervisors. Expectations regarding telephone contact and periodic updates with county disaster mental health administrative leaders should also be addressed.

4.2           Coordination with Other Community Disaster Mental Health Teams

As mentioned earlier in the planning and preparedness section, efforts should be made to identify other disaster mental health teams or resources located in your county. Further effort should be made to coordinate response to avoid duplication of services, or more importantly, disruption or absence of such service. At times, disaster mental health teams from outside the community may self deploy or be requested to augment local county teams. In these situations, coordination and clarification of roles and responsibilities is also important to address and resolve.

4.3           Assess the Mental Health Needs of the Impacted Population

Information concerning the psychological impact the disaster has had on a community and the potential long-term effects should be gathered as expeditiously as possible. In collaboration with emergency response officials, selected team members may be deployed to gather information from community representatives regarding the impact the disaster has had on ‘at-risk’ populations previously identified.

4.4           Initiate Early Phase Supportive Interventions

In the initial aftermath of a disaster individuals will be primarily focused on addressing their immediate disaster-related needs such as receiving first aid for injuries suffered in the disaster, locating lost or missing family members, obtaining food, water, and clothing and seeking shelter. While not all disaster victims will require extensive mental health intervention, some individuals, based upon the circumstances of the disaster as well as their own individual characteristics (see page 10), may require more focused mental health support. Early phase supportive interventions usually involve providing basic comfort care while assessing the individuals for stress reactions that might signal future psychological complications. Pre-disaster training for response team members should include orientation and skill development in approved disaster mental health interventions as those indicated below. Interventions that exceed the provision of basic supportive care may in fact be harmful.

Early Phase Supportive Interventions

4.5           Identify High Risk Populations and Implement Appropriate Early Phase Interventions

While the majority of individuals impacted by disaster are likely to experience some stress reactions, many of these reactions are usually transitory and typically resolve within a short period of time. There are, however, some disaster survivors who will go on to develop more significant psychiatric complications. Previous disaster research has suggested certain disaster characteristics or those of certain individuals could place someone more at risk for developing severe stress reactions (see page 10). Efforts should be made to identify high risk populations and provide them with supportive interventions that could mitigate long-term psychological consequences. Reach out to individuals who may represent such risk groups and work collaboratively to address these issues.

4.6            Distribute Public Mental Health Educational Materials

Research suggests that mental health resiliency following disaster may be enhanced through the provision of educational materials that describe the common stress reactions and the methods and services available to respond to such reactions. Efforts should be made to release this information as soon as possible after disaster strikes. These educational materials may need to be translated into languages other than English depending upon the needs of your County and be released repeatedly over a period of time following disaster.

4.7           Collaborate with County Government in Risk Communication

In the event of a disaster, local county government must provide periodic information and updates regarding the county’s disaster response and recovery plan. The content of such information should be reviewed by disaster mental health risk communications experts in an effort to mitigate any adverse psychological reactions by the community. The County DCS or other disaster mental health expert should be consulted when preparing these disaster bulletins or updates. Mental health consultants in these roles should be provided with the appropriate Risk Communications training prior to disaster.

4.8           Implement Supportive Interventions for Disaster Mental Health Teams

Meeting the mental health needs of a community following disaster can be considerably stressful to those mental health professionals providing such aid. It is highly suggested that protocols and resources be developed and offered to meet the mental health needs of disaster mental health teams and others administering care to disaster survivors. Resources and ideas for providing mental health support to mental health professionals can be found in the Reference and Resources section, Appendix A of this guide.

5.     Recovery
5.1           Evaluate the Intermediate and Long-Term Mental Health Needs of the Community

Disaster mental health research suggests that while most of a disaster-impacted community will experience a range of stress reactions, these reactions are usually mild and transitory. It has also been found that a minority of individuals may develop more moderate to severe psychological reactions that over time, if untreated, may develop into such psychiatric disorders as Acute Stress Disorder, Major Depression, Post-Traumatic Stress Disorder, or Generalized Anxiety Disorder. Pre-disaster substance abuse and dependence disorders were also found to be exacerbated by disaster. With this in mind it is highly recommended that counties use systematic screening approaches to prioritize the delivery of more intensive mental health services. Outreach efforts must be implemented in the impacted community in a timely fashion so that a better understanding of the long-term mental health needs can be evaluated.

5.2           Identify Community Resources to Provide Mental Health and Substance Abuse Services

As indicated earlier in the Planning and Preparedness section, a county mental health disaster plan should include a listing of local mental health and substance abuse treatment facilities and individual providers willing to treat disaster survivors. Providers should possess the requisite education and training experience to evaluate and assess the range of intermediate and long-term psychological symptoms and psychiatric and substance abuse disorders in survivors resulting from disaster. Depending on the size and scope of the disaster, financial assistance to provide intermediate and long-term mental health treatment may be available. County mental health officials should utilize their regional and state office of mental health representatives to explore such options.

5.3           Train Mental Health Professionals in Intermediate and Long-Term Mental Health Treatment Interventions

In the event of a large scale disaster, the County Department of Mental Health must project the long-term mental health implications on the community. Training opportunities in intermediate and long-term mental health interventions will be required. Below is a list of mental health treatment modalities commonly used for those individuals suffering significant post-disaster psychological consequences. These modalities have varying levels of scientific evidence supporting their efficacy.

Intermediate/Long-Term Treatment Approaches

Efforts should be made to train mental health professionals in these treatment approaches prior to or shortly after disaster strikes the community.

5.4           Implement Supportive Interventions for DMH Teams and Other Disaster Personnel

As mentioned previously, providing mental health support to disaster survivors, in and of itself can be stressful. Because mental health professionals are not immune to stress reactions in the context of their work, it is highly suggested that ongoing support services are offered to mental health response team members and other disaster relief workers, especially in the long-term recovery phase of disaster. Special care should be taken to administer only those supportive interventions that are recognized as efficacious by the disaster mental health field. (See Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence, on page 15 of Appendix A: Resources and References).

6.     Evaluation
6.1           Conduct Periodic Disaster Drills and Tabletop Exercises

Reviewing and evaluating the county’s mental health disaster plan can ensure an effective response that meets or exceeds the mental health needs of a community. A successful plan will include an evaluation component where specific protocols and processes are reviewed, tested, and evaluated for their efficacy and result. State and County emergency management practices often include periodic drills and exercises. It is highly suggested that components of the disaster mental health plan be included in these drills and exercises. Such drills might include a periodic call down of mental health team members to evaluate availability and response times; tabletop exercises which evaluate the Department’s ability to coordinate and deploy multiple internal and external agencies providing mental health resources; and special drills which might involve establishing a community family assistance center following a mass casualty incident or Point of Dispensing clinic typically used in responding to public health emergencies.

6.2           Convene an “After Action” Committee Following the Implementation of the Mental Health Disaster Plan

In the event that the Disaster Mental Health Plan is activated, arrangements should be made as soon as possible to review the results of the activation. Special attentions should be given to specific response and recovery activities associated with the plan. Opportunities to identify and revise specific planning, preparedness and mitigation efforts should also be addressed.

7.     Appendix A: References and Resources
7.1           Planning Tools and Technical Resources

CDC Public Health Emergency Response Guide for State, Local, and Tribal Public Health Directors, 2004

Department of Health and Human Services, Centers for Disease Control and Prevention

http://www.bt.cdc.gov/planning/pdf/cdcresponseguide.pdf Leaving OMH site

Community Guidelines for Developing a Spontaneous Volunteer Plan

Illinois Terrorism Task Force Committee on Volunteers and Donations

http://www.idph.state.il.us/pdf/volunteer_brochure.pdf Leaving OMH site (PDF)

Disaster Technical Assistance Center

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services

http://www.mentalhealth.samhsa.gov/dtac/ Leaving OMH site

Early Intervention for Trauma in Adults: A Framework for First Aid and Secondary Prevention

Litz, B.T. and Gray, M.J., In “Early Intervention for Trauma and Traumatic Loss.” Edited by Brett T. Litz. The Guilford Press, 2004.  Pp 87-111.

Mental Health All-Hazards Guidance Document, 2003

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services

http://mentalhealth.samhsa.gov/publications/allpubs/sma03-3829/default.asp Leaving OMH site

Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence

National Institute of Mental Health (2002)

http://www.nimh.nih.gov/health/publications/massviolence.pdf Leaving OMH site (PDF)

National Center for Post Traumatic Stress Disorder

http://www.ptsd.va.gov Leaving OMH site

National Institute of Mental Health

http://www.nimh.nih.gov Leaving OMH site

National Memorial Institute for the Prevention of Terrorism

http://www.mipt.org Leaving OMH site

New York State Education Department, Office of the Professions, Online Verification

http://www.op.nysed.gov/opsearches.htm Leaving OMH site

New York Office of Alcoholism and Substance Abuse Services

http://www.oasas.state.ny.us Leaving OMH site

State mental Health Authorities’ Response to Terrorism, 2004

National Association of State Mental Health Directors

http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Med%20Dir%20Terrorism%20Rpt%20-%20final.pdf Leaving OMH site

7.2           Risk Communication

Communicating in a Crisis: Risk Communication Guidelines for Public Officials

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), 2002

http://www.riskcommunication.samhsa.gov/index.htm Leaving OMH site

7.3           Disaster-Related Agencies and Programs

American Red Cross

http://www.redcross.org Leaving OMH site

Department of Homeland Security

http://www.dhs.gov Leaving OMH site

Federal Emergency Management Agency (FEMA)

http://www.fema.gov Leaving OMH site

National Voluntary Organizations Active in Disaster (VOAD)

http://www.nvoad.org Leaving OMH site

New York State Emergency Management Office (SEMO)

http://www.semo.state.ny.us Leaving OMH site

Project Liberty

New York State Office of Mental Health (OMH)

http://www.projectliberty.state.ny.us/

7.4           Special Populations

American Academy of Child & Adolescent Psychiatry

http://www.aacap.org/publications/factsfam/disaster.htm Leaving OMH site

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

http://www.mentalhealth.samhsa.gov/publications/allpubs/SMA03-3828/default.asp Leaving OMH site

Disaster Mental Health: Crisis Counseling Programs for the Rural Community (1999)

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

http://www.mentalhealth.org/publications/allpubs/sma99-3378/default.asp Leaving OMH site

Psychosocial Issues for Older Adults in Disasters (1999)

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

http://www.cdc.gov/aging/pdf/disaster_planning_goal.pdf Leaving OMH site (PDF)

Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster (1996)

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

http://www.mentalhealth.org/publications/allpubs/SMA96-3077/default.asp Leaving OMH site

Tips for Talking About Traumatic Events

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services.

http://www.mentalhealth.samhsa.gov/cmhs/TraumaticEvents/tips.asp Leaving OMH site

The National Child Traumatic Stress Network

http://www.nctsnet.org/ Leaving OMH site

7.5           Intervention Resources

Early Intervention for Trauma in Adults: A Framework for First Aid and Secondary Prevention

Litz, B.T. and Gray, M.J., In “Early Intervention for Trauma and Traumatic Loss.” Edited by Brett T. Litz. The Guilford Press, 2004.  Pp 87-111.

Grief Counseling Resource Guide

New York State Office of Mental Health

http://www.omh.ny.gov/omhweb/grief/

Mental Health Intervention for Disaster

National Center for Post-Traumatic Stress Disorders (NCPTSD)

http://ncptsd.va.gov/ncmain/index.jsp Leaving OMH site

7.6           Training Resources

Disaster Mental Health: A Critical Response

University of Rochester Center for Disaster Medicine and Emergency Preparedness

http://www.centerfordisastermedicine.org Leaving OMH site

Field Manual for Mental Health and Human Service Workers in Major Disasters

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (2000)

http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/Default.asp Leaving OMH site

Mental Health Response to Mass Violence and Terrorism: A Training Manual

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services

http://www.samhsa.gov Leaving OMH site

National Disaster Mental Health Training Program

National Center for Post Traumatic Stress Disorder (NCPTSD)

http://www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp Leaving OMH site

Triumph Over Tragedy: A Community Response to Managing Trauma in Times of Disaster and Terrorism

Edited by Evans, G.D., Wiens, B.A., The National Rural Behavioral Health Center, 2004.

http://www.joe.org/joe/2004april/tt8.php Leaving OMH site