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16 Initial Behavioral Health Response The Conundrums of a State Crisis Counseling Program

Julie L. Framingham

And.I.saw.Sisyphus.in.agonising.torment.trying.to.roll.a.huge.stone.to.the.top.of.a.hill..He. would.brace.himself,.and.push.it.towards.the.summit.with.both.hands,.but.just.as.he.was.about. to. heave. it. over. the. crest. its. weight. overcame. him,. and. then. down. again. to. the. plain. came. bounding. that. pitiless. boulder.. He. would. wrestle. again,. and. lever. it. back,. while. the. sweat. poured.from.his.limbs,.and.the.dust.swirled.round.his.head.

Bk XI: 593–640 The Odyssey

16.1  INTRODUCTION

In. the. wake. of. disaster,. state. agencies. frequently. play. a. crucial. role. in. the. immediate. response. to. impacted. communities. by. determining. if. a. need. for. behavioral. health. services. exists,. and. by. designing,.implementing,.and.managing.behavioral.health.programs..State.behavioral.health.agen- cies. have. access. to. certain. federal. funding. resources. that. are. unavailable. to. other. organizations. involved.in.disaster.response..This.chapter.will.focus.on.one.particular.federal.funding.resource,. the.Federal.Emergency.Management.Agency’s.Crisis.Counseling.Program,.and.discuss.some.of.the. challenges.encountered.in.designing,.implementing,.and.administering.the.program..In.illustration,. the.experiences.of.state.behavioral.health.agency.staff.in.Florida.as.related.to.programs.developed. around.Hurricane.Charley.and.subsequent.disasters.that.followed.from.the.period.of.2004.to.2007.

CONTENTS

16.1. Introduction........................................................................................................................... 289 16.2. The.Crisis.Counseling.Program............................................................................................ 290 16.3. Assessing.the.Need.for.Crisis.Counseling.Program.Services............................................... 291 16.4. The.State.Mental.Health.Authority’s.Response.to.Hurricane.Charley................................. 292 16.5. Public.Misconceptions........................................................................................................... 293 16.6. Temporary.Disaster.Employment.......................................................................................... 295 16.7. Provider.Agency.Capacity..................................................................................................... 296 16.8. Unemployment.Compensation............................................................................................... 296 16.9. Conclusion............................................................................................................................. 297 Notes............................................................................................................................................... 298 References....................................................................................................................................... 299

C o p y r i g h t 2 0 1 2 . C R C P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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290 Behavioral Health Response to Disasters

will.be.examined.a.Therefore,.select.issues.such.as.state.agency.funding,.program.continuity,.grants. administration,.and.jurisdictional.concerns.encountered.by.program.staff.in.Florida.are.addressed,. as.well.as.some.of.the.solutions.applied..Some.of.the.challenges.described.are.not.unique.to.Florida,. however,.but.have.been.experienced.by.other.state.behavioral.health.agencies.as.well..Therefore,.it.is. hoped.that.this.chapter.will.not.only.offer.some.insight.on.the.Crisis.Counseling.Program’s.potential. obstacles,.but.encourage.other.state.behavioral.health.agencies.to.find.creative.means.to.resolve.the. potential.barriers.to.administering.future.programs.

16.2  THE CRISIS COUNSELING PROGRAM

The. Crisis. Counseling. Assistance. and. Training. Program. (CCP. or. the. Crisis. Counseling. Program).was.first.authorized.by.the.Disaster.Relief.Act.of.1974.(Pub..L..93-288),.later.amended. by.Section.416.of.the.Robert.T..Stafford.Disaster.Relief.and.Emergency.Assistance.Act.of.1988. (Stafford.Act;.Pub..L..100-707)..The.Stafford.Act.authorizes.the.president.of.the.United.States,. through. a. disaster. declaration,. to. provide. states. and. U.S.. territories. with. a. wide. array. of. pub- lic. and. individual. assistance. program. funds.. Pursuant. to. Title. 42,. Chapter. 68,. Subchapter. IV,. Section.5183:.

The.President.is.authorized.to.provide.professional.counseling.services,.including.financial.assistance. to. State. or. local. agencies. or. private. mental. health. organizations. to. provide. such. services. or. training. of.disaster.workers,.to.victims.of.major.disasters.in.order.to.relieve.mental.health.problems.caused.or. aggravated.by.such.major.disaster.or.its.aftermath.

The.CCP.is.jointly.administered.by.the.Federal.Emergency.Management.Agency.(FEMA).and. the.U.S..Department.of.Health.and.Human.Services.(HHS),.Substance.Abuse.and.Mental.Health. Services. Administration. (SAMHSA),. Center. for. Mental. Health. Services. (CMHS),. through. an. interagency.agreement.(FEMA.Crisis Counseling.nd;.SAMHSA.nd)..CMHS.provides.training. and.program.oversight,.as.well.as.monitoring.for.Regular.Services.Programs,.for.State.Mental. Health.Authorities.(SMHA;.42.U.S.C..§.201)..In.Florida,.the.SMHA.is.the.Florida.Department. of. Children. and. Families. (DCF).. DCF. has. the. responsibility. to. administer. mental. health. and. substance.abuse.services.within.the.state.and.is.eligible.to.request.grant.funding.from.FEMA.for. disaster.crisis.counseling.services.

Given.the.chronic.under-funding.of.many.state.mental.health.and.substance.abuse.services,.the. CCP.is.an.essential.resource.for.SMHAs.to.assist.large.numbers.of.survivors.experiencing.psycho- logical.distress.postdisaster..Sanctioned.CCP.activities.include.outreach,.counseling,.public.educa- tion,.and.referrals.to.community.resources..Activities.are.intended.to.assist.survivors.to.understand. their.situations.and.the.physical,.cognitive,.and.behavioral.reactions.that.can.result,.including.anxi- ety,. fear,. anger,. grief,. hopelessness,. and. changes. in. sleep. patterns. or. appetite.. Crisis. counselors,. sometimes. called. outreach. workers,. attempt. to. alleviate. adverse. stress. reactions. in. survivors. by. providing.emotional.support..Using.active.listening,.they.help.validate.the.survivors’.reactions.and. assist. them. to. understand. that. they. are. reacting. normally. to. an. abnormal. event. (SAMHSA. CCP. Program.Guidance.nd)..Psychoeducation.is.a.key.component.of.the.CCP.and.has.been.demonstrated. to. be. effective. in. a. number. of. trauma. contexts.. Psychoeducation. can. assist. individuals,. families,. and.communities.by.normalizing.stress.reactions.and.ameliorating.distress,.and.encourage.support. seeking,. resilience,. and. community. cooperation. (Layne. et. al.. 2008;. Jacobs,. Vernberg,. and. Lee. 2008;.Marbley.2007;.Naturale.2007;.Fremont.2004;.AACAP.2007)..

Crisis. counselors. also. help. survivors. review. their. recovery. options. and. teach. coping. skills. and. relaxation. techniques,. among. other. nonclinical. interventions.. Crisis. counseling. activities. are. short. term. and. community. based. and. occur. at. survivors’. homes,. schools,. places. of. employment,. senior. centers,. and. community. centers,. among. other. sites. (SAMHSA. CCP. Program. Guidance. nd)..Research.suggests.that.community.outreach.may.be.especially.helpful.for.reaching.out.to.and.

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291Initial Behavioral Health Response

empowering.certain.vulnerable.groups.after.disaster..These.groups.include.ethnic.minorities,.older. adults,. individuals. with. mental. illness,. or. others. who. lack. social. support. systems. and. services,. especially. when. delivered. by. indigenous,. trained. workers. (Norris. and. Alegria. 2005;. Elmore. and. Brown.2007;.Person.and.Fuller.2007;.Hardiman.and.Jaffee.2008)..Further,.communications.with. diverse.populations.in.the.community.assist.outreach.workers.to.overcome.biases.and.become.more. culturally.aware.(Goodman.and.West-Olatunji.2009)..CMHS.expects.SMHAs.to.develop.CCPs.that. acknowledge.the.diversity.of.the.communities.served.by.targeting.ethnic.and.racial.minorities.and. hiring. indigenous. workers. who. reflect. the. community’s. demographic. makeup. whenever. possible. (SAMHSA.CCP.Program.Guidance.nd).

16.3  ASSESSING THE NEED FOR CRISIS COUNSELING PROGRAM SERVICES

Two.funding.mechanisms.are.available.to.SMHAs.through.the.CCP:.(1). the.Immediate.Services. Program,.which.provides.up.to.60.days.of.funding.for.disaster.crisis.counseling.services,.and.(2).the. Regular.Services.Program,.which.provides.for.an.additional.nine.months.of.funding.(FEMA Crisis Counseling.nd;.SAMHSA.nd)..The.date.of.the.presidential.disaster.declaration.is.the.start.date.for. both. the. Immediate. Services. Program. and. Regular. Services. Program. (SAMHSA. CCP. Program. Guidance.nd)..Between.2004.and.2007,.Florida’s.Immediate.Services.Program.grant.applications. were.approved.quickly,.whereas.Regular.Services.Program.grant.applications.averaged.between.8. and.22.weeks.for.review.and.approval.(Kimber.2007)..Requests.for.no-cost.extensions.(to.extend.the. program.end.date.without.additional.funding).or.additional-cost.extensions.of.Immediate.Services. Programs.were.therefore.necessary.to.avoid.services.disruption.

Given.the.copious.amount.of.information.that.needs.to.be.included.in.the.grant.applications,. this.generally.means.weeks.to.months.of.extended.workdays.for.SMHA.staff.assessing.the.needs. of.the.affected.communities,.gathering.the.data,.and.developing.the.plan.of.services.and.the.bud- get..CMHS.requires.SMHAs.to.complete.the.CMHS.Needs.Assessment.Formula.for.Estimating. Disaster. Mental. Health. Needs. (CMHS. Needs. Assessment;. included. in. the. grant. applications). when.calculating.the.numbers.of.survivors.who.might.benefit.from.crisis.counseling..The.CMHS. Needs.Assessment.follows.the.FEMA.damage.assessment.concept.and.includes.loss.categories. of.numbers.of.dead,.hospitalized,.or.otherwise.reported.injured;.homes.with.minor.and.major. damages,. or. totally. destroyed;. and. numbers. of. survivors. who. became. unemployed. as. a. result. of. the. disaster.. Each. CCP. grant. application. was. developed. in. close. consultation. with. FEMA. and.CMHS.project.officers.because.FEMA.damage.assessments.were.not.always.completed.for. each. county,. or. they. were. completed. under. very. difficult. conditions,. making. it. impossible. to. obtain.more.than.a.superficial.estimate.of.damages..FEMA.Individual.Assistance.applications. for.each.county.are.also.helpful.data.for.assessing.crisis.counseling.needs,.but.CMHS.discour- aged.use.of.these.data.if.using.the.FEMA.damage.assessment.methodology.due.to.the.potential. for.duplication.

Consequently,.DCF.program.staff.had.to.be.resourceful.to.find.ways.to.include.other.loss.cat- egories.or.data.sources.in.the.formula.that.would.be.acceptable.to.CMHS.and.FEMA.in.order.to. provide.more.realistic.numbers.of.individuals.likely.to.benefit.from.crisis.counseling..Negotiation. was.also.necessary.since.the.numbers.of.teams.and.team.members,.as.well.as.ratios.of.crisis.coun- selors.to.team.leaders,.were.prescribed.based.on.the.numbers.of.survivors.calculated.to.benefit.from. services.in.the.CMHS.Needs.Assessment..With.each.grant.application,.DCF.presented.the.unique. aspects.of.the.impacted.counties.and.the.service.districts.responding.to.the.disaster.by.highlighting. conditions.that.made.the.use.of.standardized.staffing.formulas.problematic..For.instance,.are.the. impacted.counties.mostly.urban.or.rural?.In.the.latter.case,.teams.may.have.to.travel.much.greater. distances.to.reach.survivors..Population.density.or.large.cultural.groups.could.also.be.reasonable. grounds.to.deviate.from.expected.staffing.formulas..While.the.state.may.include.special.populations. or.other.circumstances.in.other.sections.of.the.grant.application,.the.CMHS.Needs.Assessment is. given.significant.weight.during.the.application.review.

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292 Behavioral Health Response to Disasters

16.4   THE STATE MENTAL HEALTH AUTHORITY’S  RESPONSE TO HURRICANE CHARLEY

In.the.days.leading.up.to.the.landfall.of.Hurricane.Charley.in.August.2004,.personnel.in.the.Mental. Health.Program.Office.at.DCF.were.busy.preparing.for.the.storm’s.arrival..The.National.Hurricane. Center’s.tracking.and.prediction.graphic.models.suggested.that.the.hurricane.would.strike.Florida’s. Gulf.Coast.somewhere.between.the.Fort.Myers.and.the.Tampa.Bay.areas.with.initial.reports.pre- dicting.the.latter.being.the.most.likely.point.of.landfall.(NOAA.2006)..In.anticipation.of.Hurricane. Charley’s.arrival,.then.Governor.Jeb.Bush.executed.Executive.Order.#04-182.on.August.11.declar- ing.a.State.of.Emergency.(SLAF.nd).

On.Friday,.August.13,.2004,.Hurricane.Charley,.with.little.warning,.turned.suddenly.from. its.greatly.anticipated.landfall.near.Tampa.Bay.and.slammed.into.the.southwest.coast.of.Florida. at. Captiva. Island,. and. then. Port. Charlotte,. as. a. Category. 4. storm. with. winds. approaching. 150 mph.(NOAA.2006)..It.was.the.strongest.hurricane.to.hit.the.United.States.since.Hurricane. Andrew. in. 1992. (FDEP. nd).. It. was. also. the. first. time. Florida. had. been. struck. by. two. major. storms. in. less. than. 36. hours. (Tropical. Storm. Bonnie. struck. northwest. Florida. on. August. 12;. Avila. 2004;. FDEP. nd).. The. storm. then. continued. diagonally,. north. by. northeast,. across. the. state,.before.exiting.near.Daytona.Beach.as.a.Category.2.hurricane..Almost.1.5.million.people. evacuated. their. homes.. Tens. of. thousands. of. homes. and. businesses. were. damaged. or. totally. destroyed. and. more. than. 2. million. residents. were. left. without. electricity.. Damages. exceeded. $11. billion.. There. were. 24. hurricane-related. deaths. and. 792. injuries. (NOAA. nd).. Due. to. the. enormity.of.the.disaster,.Governor.Bush.requested.federal.assistance.from.the.president,.who. issued.a.Federal.Disaster.Declaration,.FEMA-1539,.the.same.day.(FEMA.Major Disaster.nd).. Of. Florida’s. 67. counties,. 26. were. declared. disaster. areas. eligible. for. Individual. Assistance. funding,.including.the.CCP.

It.had.been.several.years.since.the.state.of.Florida.had.experienced.a.major.disaster.or.had.the. need. to. provide. crisis. counseling. for. survivors. trying. to. cope. with. the. emotional. aftermath. of. a. storm..Nevertheless,.anticipating.there.would.be.a.need.for.such.a.response.to.Hurricane.Charley,. the. Disaster. Behavioral. Health. Coordinator. and. other. key. DCF. leaders. began. discussions. about. how.to.prepare.a.response.ahead.of.the.storm’s.arrival..They.formed.a.small.team.of.workers.con- sisting.of.several.permanent.and.temporary.staff b.to.develop.the.response.

Fortunately,. there. were. a. few. team. members. who. had. developed. CCP. grant. applications. for. prior. disasters.. DCF. was. also. contacted. by. federal. project. officers. with. offers. of. guidance. for. developing. the. grant. application.. The. Disaster. Behavioral. Health. Coordinatorc. had. been. making. preparations. throughout. the. preceding. year. by. obtaining. support. from. the. department’s. senior. management. should. the. need. arise. to. provide. a. behavioral. health. response. to. a. disaster.. He. also. cultivated.useful.contacts.at.other.state.agencies.and.nonprofit.organizations.that.could.offer.assis- tance.during.or.postdisaster,.including.the.Florida.Department.of.Health,.the.Department.of.Elder. Affairs,.the.State.Emergency.Operations.Center,.the.National.Organization.for.Victim.Assistance. (NOVA),.and.Florida.Interfaith.Networking.in.Disasters.(FIND)..FIND.played.a.prominent.role.in. the.Department’s.response.as.this.organization.was.able.to.put.the.DCF.in.contact.with.Lutheran. Disaster.Response.and.other.helpful.nongovernmental.organizations..Lutheran.Disaster.Response. offered.to.host.daily.conference.calls.for.Florida’s.state.agencies.and.voluntary.organizations.to.help. the.state.provide.an.adequate.level.of.coverage.for.behavioral.health.services.in.the.impacted.com- munities.while.avoiding.duplication..These.calls.helped.establish.lasting.collaborative.partnerships. by.fostering.candid.discussion.and.the.sharing.of.information.and.resources.among.the.participating. agencies.

Before.Hurricane.Charley,.DCF.endeavored.to.increase.its.capacity.to.respond.to.disasters.by. developing.and.training.a.volunteer.cadre..Long.experience.had.made.DCF’s.leadership.realize. that.each.time.a.disaster.was.over.and.the.impacted.communities.had.returned.to.“normal,”.the. staff.who.had.gained.experience.working.in.the.disaster.drifted.away.for.various.reasons..New.

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293Initial Behavioral Health Response

employment. opportunities,. relocation,. burnout,. or. disillusionment. after. prior. disaster. work,. or. lack.of.supervisory.support,.were.recurring.grounds.for.later.nonparticipation.and.contributed.to. a.chronic.loss.of.institutional.memory..The.agency.was.also.hamstrung.by.the.fact.that.disaster. behavioral. health. preparedness. funding. from. the. Centers. for. Disease. Control. and. Prevention. (CDC).and.the.Office.of.the.Assistant.Secretary.for.Preparedness.and.Response.(ASPR).is.ear- marked.for.ESF.8,.Public.Health.and.Medical,.agencies..Under.the.National.Response.Framework,d. ESF.8.agencies.are.tasked.to.provide.disaster.behavioral.health.services.e.In.Florida,.however,.the. ESF.8.agency.is.the.Department.of.Health,.whereas.DCF.is.designated.as.an.ESF.6,.Mass.Care,. agency..ESF.6.agencies.are.responsible.for.providing.disaster.crisis.counseling.(Sundararaman,. Lister,.and.Williams.2006).f

Without. preparedness. funding,. DCF. did. not. have. the. resources. to. maintain. sufficient. staff. year-round.to.prepare.for.future.disasters.and.sustain.its.knowledge.base..The.sustainment.prob- lem.was.not,.however,.limited.to.headquarters.staff..It.was.common.throughout.the.DCF.system,. including.its.contracted.community.agencies..Thus,.when.Hurricane.Charley.arrived,.DCF.found. itself.in.the.same.predicament.as.before..In.fact,.the.department.was.to.reexperience.this.same. dilemma.and.others.with.each.succeeding.hurricane.as.Hurricane.Charley.was.quickly.followed. by.Hurricanes.Jeanne,.Francis,.and.Ivan.in.2004,.and.Hurricanes.Dennis,.Wilma,.and.Katrinag. in.2005.

DCF.distributed.its.disaster.cadre.at.Disaster.Recovery.Centers,h.DCF.emergency.food.stamp. locations,i.comfort.stations,.or.other.designated.sites.established.within.the.impacted.areas..The. cadre.and.DCF’s.disaster.partners.provided.immediate.assistance.for.survivors.and.freed.SMHA. staff.to.develop.the.grant.applications.to.secure.sufficient.federal.funding.for.recovery.services.. Cadre. members. brought. educational. materials. and. set. up. information. tables. within. the. sites.. They.provided.emotional.support,.listened.to.the.survivors’.disaster.experiences,.provided.them. with. guidance. in. completing. FEMA. or. other. applications. for. assistance,. and. steered. them. to. helping.resources..One.colleague.described.her.first.experience.as.a.crisis.counselor.in.a.Disaster. Recovery.Center..She.stated.a.male.survivor.approached.her.while.she.was.standing.at.her.infor- mation.table:

She.asked,.“How.may.I.help.you.sir?”.The.man.immediately.exploded.into.a.tirade.concerning.his.frus- trations.with.the.disaster,.the.response.process,.and.the.bureaucratic.“red.tape”.that.impeded.obtaining. the.assistance.that.he.desperately.needed..The.crisis.counselor’s.eyes.opened.wide.and.she.froze.in.fear.. After.a.couple.of.minutes,.however,.she.plucked.up.her.nerve.and.repeated.her.question.

“Sir,.how.can.I.help.you?”

Suddenly,.the.survivor.ceased.his.tirade,.took.a.deep.breath.and.looked.at.her.and.said,.“I.feel.much. better.now..Thank.you!”.He.then.walked.off.without.asking.for.any.other.assistance.or.information.j

The. point. illustrated. here. is. that. crisis. counselors. provide. a. great. deal. of. emotional. support. simply.by.listening.to.survivors’.stories..Survivors.may.not.need.much.more.than.having.someone. listen.to.them.and/or.some.informational.materials.to.help.them.understand.their.reactions.to.the. disaster.and.learn.more.adaptive.ways.to.cope.with.current.stressors.

16.5  PUBLIC MISCONCEPTIONS

In. fact,. the. term. crisis counseling. is. somewhat. misleading. since. all. CCP. services,. even. when. delivered.by.licensed.behavioral.health.specialists,.are.nonclinical.in.nature..However,.the.disaster. literature.suggests.that.the.majority.of.survivors.do.not.develop.long-term.posttraumatic.psychopa- thology.(Gray,.Litz,.and.Maguen.2004;.Davidson.and.McFarlane.2006),.especially.in.the.absence. of. extensive. property. damage,. injuries. and. loss. of. life,. or. human-caused. incidents. (Norris. et. al.. 2001)..Consequently,.no.clinical.services.are.authorized.under.the.CCP.(SAMHSA.CCP.Program.

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294 Behavioral Health Response to Disasters

Guidance.nd)..Crisis.counselors.are.expected.to.refer.individuals.in.need.of.clinical.mental.health.or. substance.abuse.treatment.to.preexisting.community.behavioral.health.agencies,.which.frequently. have. long. waiting. lists. for. Medicaid-funded. services.. An. unfortunate. consequence. of. failing. to. authorize.clinical.services.is.that,.of.those.individuals.who.do.go.on.to.develop.long-term.psycho- logical.or.substance.use.disorders,.the.uninsured.and.under-insured.suffer.the.most.(Sundararaman,. Lister,.and.Williams.2006).

The.fact.that.no.clinical.services.are.offered.in.the.CCP.appears.to.contradict.the.Stafford.Act’s. language,.which.states.that.“professional.counseling”.may.be.offered.to.survivors.experiencing. psychological.distress.postdisaster.(42.U.S.C..§.5183)..However,.it.has.been.left.up.to.CMHS.to. determine.what.constitutes.professional.counseling.(Drury,.Scheeringa,.and.Zeanah.2008)..The. FEMA. CCP. instead. relies. on. many. of. the. same. principles. used. in. the. Psychological. First. Aid. model. developed. by. the. National. Child. Traumatic. Stress. Network. (NCTSN). and. the. National. Center. for. Posttraumatic. Stress. Disorder. (NCPTSD),. which. many. organizations. have. endorsed. as. a. preferred. intervention. for. response. to. emergencies. or. disasters. (Chapter. 10,. this. volume).. Similar.to.the.CCP,.Psychological.First.Aid.is.used.in.diverse.community.settings.and.is.designed. to.provide.disaster.survivors.with.nonclinical.assistance..Core.components.of.Psychological.First. Aid. involve. engaging,. comforting,. and. stabilizing. survivors;. gathering. information. about. their. needs. or. concerns. and. offering. practical. help. to. satisfy. those. needs;. connecting. survivors. to. social.support.systems.and.community.resources;.and.providing.information.on.stress.reactions. and.coping.(Brymer.et.al..2006).

Misconceptions.about.what.the.CCP.has.to.offer.survivors.has.led.to.a.number.of.misunderstand- ings. with. the. media. and,. consequently,. with. the. public.. This. has. at. times. occurred. with. painful. results,. not. just. for. Florida’s. DCF,. but. also. for. other. SMHAs. that. have. implemented. CCPs.. The. media. have. sometimes. assumed. that. crisis. counseling. refers. to. clinical. counseling,. and. various. news.stories.have.criticized.CCPs.for.failing.to.provide.clinical.services..For.example,.in.October. 2006,.the.New Orleans Times-Picayune.published.a.news.story.(Varney.2006).about.the.SMHA’s. Louisiana.Spiritk.wherein.it.criticized.FEMA.for.not.allowing.CCP.funding.to.be.spent.on.“medical. doctors”.and.instead.implied.it.was.being.spent.on.“muffins.and.coffee.”.The.article.further.stated. that. research. concerning. the. CCP’s. effectiveness. is. lacking. and. an. expert. source. was. quoted. as. suggesting.that.the.program.possibly.causes.more.harm.than.good.(Varney.2006)..The.fact.that.the. trauma. expert. cited. in. the. story. referred. to. the. CCP’s. intervention. as. “psychological. debriefing”l. suggests.he.was.unaware.that.the.CCP.does.not.permit.use.of.psychological.debriefing.(SAMHSA. CCP.Program.Guidance.nd,.14),.which.indeed.has.come.under.fire.as.a.means.of.assisting.disaster. survivors.and.has.been.discouraged.from.practice.by.some.researchers.(Rose.et al..1999;.Mayou,. Ehlers,.and.Hobbs.2000;.Rose.et.al..2001;.Litz.et.al..2002;.NIMH.2002)..

It.is.true,.however,.that.there.have.been.few.studies.of.the.CCP.that.sought.to.examine.the. program’s.effectiveness.(Elrod,.Hamblen,.and.Norris.2006;.Norris,.Hamblen,.and.Rosen.2009;. Drury,. Scheeringa,. and. Zeanah. 2008).. Evaluating. the. CCP’s. effectiveness. has. been. difficult. because,.unlike.clients.in.traditional.mental.health.systems,.crisis.counseling.services.are.short. term.(CMHS.recommends.assessment.and.referral.after.three.visits;.SAMHSA.CCP.Program. Guidance. nd,. 19). and. no. personally. identifying. information. is. retained.. Therefore,. it. is. not. possible. to. obtain. pre-. and. posttest. measures. of. the. program’s. efficacy. in. ameliorating. post- disaster.distress.(Norris,.Hamblen,.and.Rosen.2009;.Drury,.Scheeringa,.and.Zeanah.2008)..It. is.also.true.that.FEMA.and.CMHS.have.allowed.SMHAs.wide.latitude.in.administering.CCPs.. CCPs.use.a.wide.variety.of.outreach.and.engagement.strategies.to.identify.survivors.who.might. benefit. from. services.. In. October. 2006,. Florida’s. Hurricane. Wilma. and. Hurricane. Katrina. Regular.Services.Programs.were.criticized.by.the.Fort.Lauderdale.Sun-Sentinel.(Kestin.2006a). as.a.ridiculous.waste.of.taxpayer.money.because.of.the.staff.time.expended.on.what.the.paper. alleged.to.be.frivolous,.ineffective.strategies.to.identify.and.engage.survivors..These.strategies. included. dressing. in. costume. and. singing. songs. for. preschoolers.. The. news. story. featured. a. performance.by.crisis.counselors.dressed.in.costumes.at.a.preschool.where.they.sang,.“Windy.

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295Initial Behavioral Health Response

Biggie.is.our.friend..Windy.Biggie.is.strong.wind..She.turns,.turns,.turns,.turns.around..She’s. knocking.things.to.the.ground.”

The. story. also. discussed. how. CCP. funds. were. expended. on. staff. organizing. hurricane. bingo,. puppet.shows,.and.yoga.for.various.organizations.as.a.way.to.try.to.identify.and.reach.out.to.sur- vivors..The.crisis.counselors.interviewed.admitted.that.finding.survivors.who.might.really.benefit. from. the. CCP. was. difficult. because,. despite. the. fact. that. the. program. is. FEMA. funded,. FEMA. would.not.share.the.names.and.addresses.of.FEMA.aid.registrants.due.to.privacy.concerns.(Kestin. 2006a)..This.was.not.always.the.case,.however,.but.transpired.after.FEMA.instituted.a.policy.change. in.the.late.1990s.due.to.privacy.concerns.(Elrod,.Hamblen,.and.Norris.2006).

Following. the. Sun-Sentinel’s. report,. The. Honorable. Susan. M.. Collins,. Chairman. of. the. Committee. on. Homeland. Security. and. Governmental. Affairs,. requested. both. FEMA. and. HHS. to. investigate. Project. H.O.P.E.’s. Hurricane. Wilma. and. Katrina. programs. to. determine. if. federal. funding.was.being.wasted.(Department.of.Homeland.Security.2008).m.The.Sun-Sentinel.continued. publishing. articles. critical. of. Florida’s. CCPs. over. the. next. few. months.. In. December. 2006,. the. newspaper.reported.CCPs.administered.in.states.other.than.Florida.had.also.engaged.in.allegedly. inappropriate. activities. (Kestin. 2006b).. The. article. referred. to. other. CCPs. (California,. Virginia,. Wisconsin,.and.Colorado).offering.classes.on.crafts,.martial.arts,.canning.and.freezing.foods,.pro- viding. massages,. haircuts,. and. gumbo. cook-offs,. among. other. engagement. strategies,. to. identify. survivors. and. offer. crisis. counseling. services. (Kestin. 2006b).. Later,. in. January. 2007,. the. Sun- Sentinel. (Kestin. 2007). reported. that. Rep.. Tom. Feeney,. R-Oviedo,. and. Rep.. Mario. Diaz-Balart,. R-Miami,.intended.to.file.a.bill.to.prevent.future.federal.disaster.funding.from.being.spent.on.crisis. counseling.activities.ensuring.that.“no.disaster.relief.funds.are.used.for.any.type.of.crisis.counsel- ing,.recreation.or.self-esteem.building.classes.or.instruction,.including.but.not.limited.to.dance.and. exercise.classes,.bingo,.gardening.workshops,.puppet.shows.or.theater.productions.”.FEMA’s.initial. response.to.Sen..Collins.in.December.2008.found.that.Project.H.O.P.E..was.spending.its.funding.on. “reasonable.and.approved.items.and.activities”.under.federal.guidelines.(Kestin.2007;.Department. of.Homeland.Security.2008)..FEMA’s.final.report.of.its.findings.was.not.released.until.September. 2008.(Department.of.Homeland.Security.2008)..Suffice.it.to.say.that.there.is.a.genuine.need.to.cre- ate.a.more.realistic.public.perception.of.crisis.counseling.

16.6  TEMPORARY DISASTER EMPLOYMENT

From. 2004. to. 2007,. DCF. had. to. overcome. many. challenges. to. the. program,. and. the. unfavor- able.media.coverage.of.the.Fort.Lauderdale.Sun-Sentinel.was.just.one.head.of.the.hydra..Other. barriers. to. the. CCP. included. the. use. of. temporary. disaster. workers. and. unemployment. com- pensation.issues..Until.2006,.DCF.used.two.options.for.hiring.disaster.teams:.the.teams.were. either.contracted.through.community.behavioral.health.agencies,.or.they.were.hired.directly.as. temporary.departmental.staff.by.the.service.districts.in.the.impacted.areas..Contracting.through. a. community. agency. meant. the. workers. could. receive. certain. fringe. benefits. that. temporary. departmental. disaster. staff. members. were. not. given.. No. line. item. expenses. for. vacation. or. sick.leave,.pension.or.unemployment.benefits.were.included.in.the.CCP.budgets.for.temporary. departmental workers.

The.decision.to.hire.teams.as.temporary.departmental.staff.or.on.contract.was.left.up.to.indi- vidual. DCF. service. district. managers.. Some. of. the. service. districts. elected. to. hire. CCP. teams. directly.rather.than.contract.them.out.to.community.behavioral.health.agencies..A.disadvantage. to.this.hiring.method.was.that.the.district.supervisors.were.then.responsible.for.supervising.many. more.staff,.which.could.be.quite.challenging..Direct.control.and.close.monitoring.of.team.activi- ties.by.the.DCF.service.districts,.and.a.relatively.quick.hiring.process,.on.the.other.hand,.were. distinct.advantages.to.hiring.temporary.departmental.workers..Even.when.there.is.a.gubernato- rial.declaration.of.emergency,.which.waives.normal.state.procurement.regulations.(F.S..252.36),. the.contract.execution.process.can.be.very.time.consuming..Further,.some.service.districts.did.

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296 Behavioral Health Response to Disasters

not.have.any.providers.that.were.willing.or.had.the.capacity.to.host.large.teams.of.disaster.out- reach.workers.

16.7  PROVIDER AGENCY CAPACITY

Since.no.indirect.costs.are.permitted.in.the.CCP.(SAMHSA.CCP.Program.Guidance.nd),.con- tracting. CCP. teams. can. present. a. significant. hardship. on. community. agencies. that. are. already. financially.strained..Contracted.community.agencies.are.therefore.forced.to.provide.supervision,. financial. management,. and. frequently,. office. space,. free. of. charge.. Nevertheless,. a. number. of. agencies. agreed. to. host. teams. citing. reasons. such. as. goodwill. for. their. communities. and. con- cern.that.untreated.postdisaster.distress.can.develop.into.long-term.mental.illness..In.the.latter. instance,.this.means.that.more.people.might.eventually.become.long-term.clients.of.an.already. beleaguered.and.overburdened.health.care.system..Some.of.Florida’s.contracted.agencies,.how- ever,.simply.did.not.have.the.capacity.to.sustain.teams,.which.DCF.discovered.in.a.very.painful. circumstance.

In.2006,.DCF’s.contract.with.a.small.agency.in.southwest.Florida.had.to.be.terminated.abruptly. because.it.could.not.handle.the.expenses.for.the.large.number.of.CCP.staff.on.its.payroll..Unable.to. meet.its.payroll.obligations,.the.agency.reached.a.point.where.it.was.giving.staff.only.half.of.their. paychecks.or.no.paychecks.at.all..The.team.members.were.understandably.anxious.and.alarmed.. The.funding.shortfall.was.attributed.in.large.part.to.the.agency’s.cost.reimbursement-based.con- tracts,.the.payment.methodology.used.by.DCF.to.ensure.compliance.with.the.CCP.prohibition.on. indirect.costs..The.state’s.cost.reimbursementn.methodology,.however,.can.seem.bewildering.since. it.requires.copious.amounts.of.documentation.to.demonstrate.that.monies.were.spent.on.approved. items.and.activities..It.was.sometimes.several.months.before.providers.were.reimbursed.for.their. CCP.expenses..The.service.district.eventually.hired.the.teams.directly.as.temporary.departmental. staff.. Thus,. Florida. joined. ranks. with. other. states. that. have. experienced. similar. reimbursement. problems.according.to.one.study.of.state.disaster.crisis.counseling.programs.(Elrod,.Hamblin,.and. Norris.2006).

16.8  UNEMPLOYMENT COMPENSATION

As.temporary.departmental.workers,.the.staff.from.the.aforementioned.agency.were.paid.wages. but. no. fringe. benefits,. including. unemployment. compensation,. because,. under. Florida. law,. employees.hired.to.serve.on.a.temporary.basis.“in.case.of.fire,.storm,.snow,.earthquake,.flood,. or.similar.emergency”.are.exempt.[F.S..443.1216.(4)(c)3]..At.that.time,.almost.half.of.the.CCP’s. 450. workers. were. hired. as. temporary. departmental. staff.. Despite. awareness. of. the. temporary. nature. of. the. work,. some. of. these. temporary. staff. submitted. claims. for. benefits. to. the. state’s. employment.security.agency.after.the.grants.ended..DCF.service.districts.fought.these.claims,. and.at.least.some.of.the.cases.were.denied.on.appeal.by.state.employment.security.adjudicators.o. Consequently,.it.came.as.quite.a.shock.when.DCF.discovered.that.federal.law.did.not.exclude.its. temporary.departmental.workers.from.unemployment.benefits..In.fact,.only.very.short-term.and. immediate.activities.such.as.firefighting,.storm.debris.removal,.public.works,.and.similar.activi- ties.that.must.be.performed.to.avoid.further.harm.to.individuals,.property,.or.the.environment,. meet. the. exclusion.. Disasters,. on. the. other. hand,. suggest. extensive. devastation. and. suffering,. which.require.services.long.after.the.need.for.immediate.action.has.ceased..Therefore,.person- nel.engaged.in.such.activities.may.not.be.excluded.from.unemployment.compensation.benefits. (Kilbane.1997).

Consequently,. DCF. had. to. request. permission. from. FEMA. and. CMHS. to. allow. grant. bud- get. adjustments. to. accommodate. unemployment. compensation. for. temporary. disaster. work- ers..Due.to.DCF’s.unemployment.compensation.rate.setting.methodology,.however,.forecasting.

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297Initial Behavioral Health Response

these. expenses. accurately. was. very. difficult.. As. a. “reimbursing”. employer. (F.S.. 443.1313),. the. Department.had.to.reimburse.the.state.employment.security.agency.dollar.for.dollar.on.all.actual. individual.claims.paid..In.contrast,.most.community.agencies.have.established.unemployment.tax. rates.that.could.be.easily.budgeted.into.the.CCP.grants.for.reimbursement.of.claims.p.Fortunately,. there.were.sufficient.unspent.grant.funds.available.to.cover.all.of.the.estimated.claims.and.DCF. received.approval.from.FEMA.and.CMHS.to.adjust.CCP.budgets.accordingly..There.was,.how- ever,.the.possibility.that.individual.unemployment.compensation.expenses.could.arise.after.the. end.of.the.grants’.service.period,.a.circumstance.that.would.unlikely.be.remedied.by.FEMA.and. CMHS,.and.had.to.receive.approval.from.the.Florida.Legislative.Budget.Commission.(LBC;.F.S.. 11.90).. This. is. necessary. because. the. Florida. Appropriations. Act. (Chapter. 216,. F.S.). provides. funding.for.state.agencies.to.pay.routine.expenses.only.and.does.not.anticipate.special.funding. for.infrequent.programs.like.the.CCP..Needless.to.say,.after.the.turmoil.and.frustration.of.dealing. with.the.unemployment.compensation.issue,.DCF.elected.to.contract.all.field-based.CCP.services. from.that.point.forward.

Indeed,.the.very.existence.of.the.CCP.hinged.on.the.Department’s.ability.to.obtain.spending. authority. because. each. Notice. of. Grant. Award. (NOGA). required. approval. from. either. the. state. legislature,.which.convenes.annually.in.the.spring,.or.the.LBC,.which.typically.meets.only.a.few. times.each.year.(Kimber.2007,.7)..Since.the.statutory.exemption.from.state.procurement.regula- tions.in.a.state.of.emergency.expires.after.60.days.(F.S..252.36),.DCF.frequently.required.urgent. assistance.from.the.state.emergency.management.agency.and.the.governor’s.office.to.ensure.the. CCP. was. explicitly. authorized. in. any. extended. executive. orders.. Further,. receipt. of. a. Regular. Services. Program. NOGA. requires. the. state. to. terminate. its. Immediate. Services. Program. right. away.(SAMHSA.CCP.Program.Guidance.nd)..This.requirement.poses.another.conundrum.since. budget. authority. requests. must. be. presented. to. the. LBC. at. least. one. month. before. it. convenes,. accompanied. by. substantiating. documentation. of. need. (i.e.,. the. NOGA. or. other. official. federal. communication. of. grant. approval;. Kimber. 2007).. Consequently,. DCF. personnel. were. often. in. a.state.of.panic.to.get.budget.authority.requests.for.new.Regular.Services.Programs.to.the.LBC. before. the. Immediate. Services. Programs. ended.. The. absence. of. budget. authority. would. have. forced.DCF.to.stop.the.CCP.at.a.crucial.time.in.the.postdisaster.recovery.period.and.deprive.sur- vivors.of.the.emotional.and.educational.supports.they.needed.to.deal.with.the.disaster’s.aftermath. (Kimber.2007,.7).

16.9  CONCLUSION

The.issues.discussed.in.this.chapter.represent.a.sampling.of.those.experienced.by.Florida’s.SMHA. staff.as.they.were.attempting.to.develop.and.manage.CCPs.during.the.2004–2007.hurricane.sea- sons..Since.then,.Florida’s.SMHA.has.developed.zero-dollar.funded.contracts.within.a.provider. network. consisting. of. 12. community. behavioral. health. agencies. (DCF. nd).. This. network. now. covers.62.of.Florida’s.67.counties..The.zero-dollar.contracts.can.be.easily.amended.after.the.state. receives.a.grant.award.following.a.major.disaster.declaration.to.immediately.begin.implementing. a. CCP,. thereby. substantially. reducing. the. time. needed. to. execute. contracts.. This. development. was. largely. due. to. the. ingenuity. and. technical. skills. of. the. current. Disaster. Behavioral. Health. Coordinator.. The. SMHA. still. endeavors. to. maintain. a. functional. disaster. cadre. for. immediate. response.

Beginning.with.Tropical.Storm.Fay.in.2007,.Florida’s.DCF.and.other.state.SMHAs.have.been. granted. limited. access. to. FEMA’s. disaster. assistance. registry.. This. has. allowed. CCP. teams. to. focus. their. outreach. during. the. Immediate. Services. Program. with. known. survivors. potentially. in.need.of.crisis.counseling..During.the.Regular.Services.Programs,.the.teams.can.attempt.con- tact.with.any.survivors.missed.previously.or.recontact.other.registrants.who.may.still.need.crisis. counseling.or.referrals.to.recovery.resources.q.Without.confirmation,.it.is.difficult.to.determine.if. this.change.in.information.sharing.is.due.to.the.negative.media.publicity.mentioned.earlier.or.if.it.

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298 Behavioral Health Response to Disasters

is.the.result.of.resourceful.individuals.who.have.learned.ways.to.work.with.existing.policies.and. regulations.

There.are.several.lessons.to.take.away.from.this.chapter.to.inform.future.crisis.counseling.pro- grams..First,.personnel.tasked.with.implementing.disaster.crisis.counseling.services.should.expect. delays.and.recognize.that.there.may.be.“extra.costs”.to.administering.crisis.counseling.programs.. SMHAs.need.to.ensure.disaster.cadres.are.maintained.and.trained,.and.that.cooperative.relation- ships.with.disaster.partners.are.in.place.before.a.disaster.occurs.because.federal.assistance.may.be. delayed.or.difficult.to.obtain..State.behavioral.health.agencies.should.also.maintain.records,.current. disaster.plans,.standard.operating.procedures.and.checklists,.and.conduct.disaster.exercises.to.miti- gate.against.institutional.memory.loss..Furthermore,.program.advertising.should.include.funding. for.public.“attitude.shaping”.to.explain.not.only.how.behavioral.health.services.can.assist.survivors. in.postdisaster.recovery,.but.provide.a.rationale.for.services.limitations..Finally,.while.state.statutes. and.agency.policies.may.differ,.the.solutions.to.program.challenges.often.lay.hidden.within.them..It. sometimes.takes.resourceful.and.dedicated.personnel.to.tease.out.the.solutions.in.order.to.overcome. program.barriers.

NOTES

. a.. As.Director.of.Federal.Disaster.Behavioral.Health.Projects.with.the.Florida.Department.of.Children. and. Families. from. 2005. through. 2008,. the. author. managed. the. Crisis. Counseling. Program. grants. and. Project. Recovery,. a. program. funded. by. the. Substance. Abuse. and. Mental. Health. Services. Administration.

. b.. These.temporary.disaster.staff.included.contract.and.Other-Personal-Services.(OPS).workers..Pursuant. to.Florida.Statutes.(F.S.),.Chapter.110.131,.OPS.staff.may.be.hired.by.state.agencies.to.work.on.a.tem- porary.basis.and.are.not.entitled.to.the.benefits.of.permanent.state.employees.

. c.. Charles.M..Kimber.served.as.the.Disaster.Behavioral.Health.coordinator.at.the.Florida.Department.of. Children.and.Families.until.his.death.in.August.2007.

. d.. Homeland. Security. Presidential. Directive. 5,. Management. of. Domestic. Incidents,. established. the. National.Response.Plan.on.February.28,.2003..It.was.amended.on.March.22,.2008,.and.renamed. the. National. Response. Framework.. See. http://www.fema.gov/emergency/nrf/. for. additional. information.

. e.. See.the.Florida.Comprehensive.Emergency.Management.Plan,.Appendix.VIII,.at.http://www.floridadi- saster.org/documents/CEMP/2010/ESF%208.pdf.

. f.. See.the.Florida.Comprehensive.Emergency.Management.Plan,.Appendix.VI,.at.http://www.floridadisas- ter.org/documents/CEMP/2010/ESF%206.pdf..

. g.. The. department. operated. a. Katrina. Evacuee. CCP. (Immediate. Services. Program,. with. extension,. and. Regular.Services.Program).from.September.2005.to.December.2006.

. h.. See.FEMA’s.web.page,.About DRCs,.at.http://www.fema.gov/assistance/opendrcs.shtm..

. i.. Besides.being.the.SMHA,.the.department.is.also.responsible.for.administering.the.Temporary.Assistance. for. Needy. Families. (TANF). program.. See. the. U.S.. Department. of. Health. and. Human. Services,. Administration. for. Children. &. Families. for. more. information. about. this. federally. funded. program. at. http://www.acf.hhs.gov/programs/ofa/.

. j.. Thanks.to.Marilyn.Juengst,.former.CCP.program.manager,.who.shared.this.experience.with.the.author.

. k.. The.Louisiana.SMHA’s.name.for.the.CCP;.each.state.brands.its.CCP.differently.

. l.. Psychological.debriefing.generally.refers.to.Critical.Incident.Stress.Debriefing.(CISD;.Mitchell.1983),. which. was. initially. designed. to. ameliorate. adverse. psychological. sequelae. in. “first. responders”. after. traumatic.events..It.was.designed.to.diffuse.the.intensity.of.acute.stress.reactions,.which,.in.turn,.reduces. the.risk.of.long-term.mental.disorders..

. m.. Florida’s.CCP.is.branded.under.the.name.of.Project.H.O.P.E..(“Helping.Our.People.in.Emergencies”).

. n.. Cost. reimbursement. allows. the. state. to. reimburse. providers. for. actual. expenditures. incurred,. based. on. a. line. item. budget,. which. makes. it. possible. to. demonstrate. that. all. expenditures. were. allowable. expenses.

. o.. The.author.spoke.with.several.adjudication.officers.in.2006.who.heard.the.appeals.of.temporary.depart- mental.staff.employed.in.the.department’s.CCPs..These.officers.cited.Florida.Statute.443.1216.(4)(c)3.as. the.basis.for.the.exclusion.

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299Initial Behavioral Health Response

. p.. Nevertheless,.laying.off.numerous.contracted.staff.at.the.end.of.a.CCP.may.negatively.impact.the.con- tributing.employer’s.unemployment.compensation.tax.rate.in.future.quarters.

. q.. A.heartfelt.thanks.to.James.(Jimmers).Micallef,.DCF’s.current.Disaster.Behavioral.Health.Coordinator,. for.sharing.information.about.recent.developments.in.Florida’s.CCPs.

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