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17 Long-Term Mental Health Treatment for Adult Disaster Survivors

Jessica L. Hamblen, Erin Barnett, and Fran H. Norris

17.1  INTRODUCTION

The. impact. of. major. disasters. on. mental. health. is. well. understood.. Posttraumatic. stress. disorder. (PTSD).is.the.most.commonly.studied.mental.health.problem.observed.in.these.studies.(Norris.and. Elrod.2006;.Norris.et.al..2002)..Prevalence.rates.range.from.30.percent.to.40.percent.among.direct. victims,. 10. percent. to. 20. percent. among. rescue. workers,. and. 5. percent. to. 10. percent. among. the. general.population.(Galea,.Nandi,.and.Vlahov.2005).

In.this.chapter.we.review.long-term.mental.health.treatments.for.adult.disaster.survivors..Bryant. and. Litz. (2009). distinguished. intermediate. or. long-term. interventions. designed. to. prevent. or. treat. psychopathological.responses.from.immediate.or.short-term.interventions.designed.to.promote.safety. and.stabilization..They.made.the.important.point.that.the.decision.about.which.intervention.to.imple- ment.is.not.based.on.the.amount.of.time.that.has.passed,.but.rather.on.the.degree.of.ongoing.threat.and. stability.(Bryant.and.Litz.2009)..A.survivor.who.is.worried.about.the.life.of.a.loved.one,.caring.for.an. injured.family.member,.homelessness,.or.being.unemployed.cannot.focus.on.his.or.her.own.mental. health. needs.. Thus,. a. World. Trade. Center. survivor. might. be. ready. for. long-term. treatment. several. months.after.the.attack.while.a.Katrina.survivor.might.not.be.ready.for.close.to.a.year.because. the.infrastructure.in.Louisiana.was.severely.disrupted.due.to.the.massive.flooding.after.Katrina.

CONTENTS

17.1. Introduction........................................................................................................................... 301 17.2. Long-Term.Treatments........................................................................................................... 302

17.2.1. PTSD.Treatment........................................................................................................ 302 17.2.2. CBT.for.Disaster-Related.PTSD................................................................................ 304 17.2.3. Disaster-Specific.Treatments..................................................................................... 305 17.2.4. Considering.Comorbidity.......................................................................................... 306 17.2.5. Treatment.Summary.................................................................................................. 307

17.3. Barriers.to.Care..................................................................................................................... 308 17.3.1. Utilization.of.Mental.Health.Services....................................................................... 308

17.3.1.1. Utilization.Rates......................................................................................... 308 17.3.1.2. Variables.Related.to.Utilization.................................................................. 308 17.3.1.3. Utilization.of.At-Risk.Groups..................................................................... 309 17.3.1.4. Recommendations.for.Improving.Utilization............................................. 310

17.3.2. Treatment.Dissemination........................................................................................... 310 17.3.2.1. Recommendations.for.Improving.Dissemination....................................... 312

17.4. Summary.and.Conclusions.................................................................................................... 312 References....................................................................................................................................... 313

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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302 Behavioral Health Response to Disasters

The.best.information.on.effective.treatments.for.disaster.comes.from.the.strong.treatment.out- come. literature. on. PTSD.. Although. only. a. minority. of. these. studies. include. disaster. samples,. this broader.literature.has.been.shown.to.generalize.across.trauma.types..Additional.information. comes. from. the. small. but. emerging. literature. on. disaster-specific. treatments.. We. review. each. of. these.areas.with.a.focus.on.interventions.appropriate.for.long-term.recovery..We.consider.issues.of. comorbidity.and.how.conditions.such.as.depression,.substance.abuse,.and.grief.can.be.addressed.. We.end.with.a.review.of.barriers.to.care.and.what.factors.might.prevent.survivors.from.utilizing. effective.treatments.and.clinicians.from.delivering.them..We.pay.specific.attention.to.cultural.and. socioeconomic.barriers.

17.2  LONG-TERM TREATMENTS

17.2.1  pTsd TreaTMenT

Several.clinical.practice.guidelines.from.different.federal.agencies,.professional.organizations,.and. countries.offer.recommendations.for.the.treatment.of.PTSD.(Australian.Centre.for.Posttraumatic. Mental. Health. 2007;. Foa,. Keane,. and. Friedman. 2009;. National. Collaborating. Centre. for. Mental. Health.2005;.Ursano.et.al..2004;.VA/DoD.Clinical.Practice.Guideline.Working.Group.2003)..The. Institute.of.Medicine.(IOM).also.recently.published.a.report.evaluating.the.evidence.on.PTSD.treat- ment.(Institute.of.Medicine.2008)..The.guidelines.unanimously.recommend.cognitive.behavioral. therapies.as.the.most.effective.treatment.for.PTSD.

Cognitive. behavioral. treatments. (CBTs). typically. include. a. number. of. components,. including. psychoeducation,.anxiety.management,.exposure,.and.cognitive.strategies..Exposure.and.cognitive. restructuring.are.thought.to.be.the.most.effective.components..Exposure.involves.having.survivors. repeatedly.reexperience.their.traumatic.event.by.confronting.feared.situations.by.imagining.their. traumatic.event.(imaginal.exposure).and/or.by.entering.previously.avoided.situations.that.elicit.fear. (in vivo.exposure)..Cognitive.strategies.have.a.primary.focus.on.challenging.and.modifying.mal- adaptive.beliefs.related.to.the.trauma..We.will.review.exposure.interventions.first,.followed.by.the. cognitive.ones..Many.cognitive.behavioral.treatments.include.both.components.or.aspects.of.both. components.

There. is. strong. evidence. for. exposure. therapy’s. effectiveness. in. a. wide. range. of. populations,. including.those.who.have.experienced.sexual.assault,.childhood.sexual.abuse,.motor.vehicle.acci- dents,.crime,.and.mixed.trauma.samples.(e.g.,.Bryant.et.al..2003;.Cloitre.et.al..2002;.Foa.et.al..1999;. Foa.et.al..2005;.Blanchard.et.al..2003;.Marks.et.al..1998;.Schnurr.et.al..2007)..Further,.although. study.samples.have.included.mainly.middle-aged.survivors,.exposure.therapies.have.been.found.to. be.effective.in.women.and.men.of.various.racial.backgrounds.(Cloitre.et.al..2002;.Foa.et.al..1999;. Foa.et.al..2005;.Schnurr.et.al..2007)..Of.these.various.approaches,.prolonged.exposure.(PE),.devel- oped.by.Edna.Foa,.has.received.the.most.attention..In.Foa’s.first.trial,.PE,.stress.inoculation.training. (SIT),.and.to.a.lesser.extent.supportive.counseling.were.all.more.effective.in.reducing.PTSD,.rape- related.distress,.anxiety,.and.depression.than.a.waitlist.control.in.a.small.sample.of.45.female.sexual. assault.survivors.(Foa.et.al..1991).

In.an.attempt.to.optimize.the.effects.of.exposure,.PE.was.combined.with.other.effective.treat- ments.in.the.next.two.trials..Unexpectedly,.the.combined.treatments.fared.worse..In.the.first,.PE. alone.was.more.effective.than.the.combination.of.PE.plus.SIT,.SIT.alone,.or.a.waitlist.control.(Foa. et.al..1999).on.symptoms.of.PTSD,.depression,.and.anxiety..The.authors.concluded.that.the.com- bination.of.PE.plus.SIT,.which.was.expected.to.be.superior,.may.have.overloaded.the.client.with. techniques.since.SIT.included.a.variety.of.techniques.

In. response. to. the. previous. study,. in. the. next. trial. a. single. technique,. cognitive. restructuring. (CR),. was. added.. One. hundred. seventy-one. female. survivors. of. sexual. assault,. physical. assault,. or.childhood.sexual.abuse.were.randomized.to.PE.alone,.PE.plus.CR,.or.waitlist.(Foa.et.al..2005).. While.both.active.treatments.were.superior.to.waitlist.on.PTSD.and.depression,.again.the.combined.

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303Long-Term Mental Health Treatment for Adult Disaster Survivors

treatment.was.no.more.effective.than.PE.alone..The.authors.offered.two.possible.explanations.(Foa. et. al.. 2005).. The. first. was. that. the. effect. of. equating. treatments. reduced. the. necessary. dose. of. PE..That.is,.in.order.to.equate.the.amount.of.time.in.the.two.active.treatments.the.dose.of.PE.was. reduced.and.may.not.have.reached.a.therapeutic.level..A.second.suggestion.was.that.the.approaches. included.similar.elements,.and.therefore.the.effect.of.combining.elements.amounts.to.switching.one. effective.element.for.another.

Other.investigators.who.have.added.a.novel.component.to.an.exposure.treatment.in.an.effort.to. optimize.the.treatment.have.found.similar.results.(e.g.,.Arntz,.Tiesema,.and.Kindt.2007;.Cloitre.et.al.. 2002;.Falsetti,.Resnick,.and.Davis.2008;.Glynn.et.al..1999)..For.example,.behavioral.family.therapy. following.exposure.therapy.added.nothing.to.exposure.therapy.alone.in.terms.of.PTSD.improve- ment.(Glynn.et.al..1999)..In.addition,.imagery.rescripting.(or.modifying.an.image.to.decrease.dis- tress),. in. conjunction. with. imaginal. exposure,. added. nothing. to. imaginal. exposure. alone. (Arntz. et al..2007)..These.findings.suggest.that.the.novel.components.were.not.necessary.

Several.others.have.evaluated.PE.and.found.it.effective.(e.g.,.Schnurr.et.al..2007;.Taylor.et.al.. 2003).. For. example,. in. a. recent. multisite. randomized. controlled. trial. of. PE. with. female. veterans. and. active-duty. personnel. with. PTSD,. women. who. received. PE. experienced. a. greater. reduction. of. PTSD. symptoms. and. were. less. likely. to. meet. diagnostic. criteria. for. PTSD. relative. to. women. who.received.present-centered.therapy.(Schnurr.et.al..2007)..In.another.investigation.(Resick.et.al.. 2002),.PE.alone.was.compared.to.a.cognitive.intervention,.Cognitive.Processing.Therapy.(CPT),. and.a.waitlist.control..Both.PE.and.CPT.were.superior.to.waitlist,.but.there.were.few.differences. between.the.active.treatments.

Exposure.has.also.been.compared.to.eye.movement.desensitization.and.reprocessing.(EMDR),. a.CBT.that.involves.engaging.in.imaginal.exposure.to.a.trauma.while.simultaneously.performing. saccadic.eye.movements..Several.clinical.practice.guidelines.list.EMDR.as.an.effective.treatment.. Two.well-controlled.studies.compared.EMDR.to.PE..One.study.(Rothbaum,.Astin,.and.Marsteller. 2005).found.equivalent.results.while.the.other.found.PE.to.be.superior.(Taylor.et.al..2003)..However,. although.studies.support.the.effectiveness.of.EMDR,.additional.research.has.raised.questions.about. the. mechanism. of. action.. There. is. growing. evidence. that. the. theorized. eye. movements. are. an. unnecessary.component.(Davidson.and.Parker.2001),.which.suggests.that.the.mechanism.for.action. might.be.the.exposure.component.

Although.widely.researched,.prolonged.exposure.is.not.the.only.form.of.exposure.therapy..Others. have.used.imaginal.and.in.vivo.exposure.with.and.without.cognitive.components.with.equal.success. (e.g.,.Arntz.et.al..2007;.Blanchard.et.al..2003;.Glynn.et.al..1999;.Marks.et.al..1998)..Thus,.exposure. is. effective. in. various. forms. and. with. a. range. of. trauma. types.. Exposure. therapy. for. PTSD. also. seems.to.have.a.significant.effect.on.reducing.comorbid.depression.and.anxiety..However,.add-ons. to.exposure.do.not.appear.to.boost.its.effectiveness.

Cognitive.interventions.also.are.widely.supported.in.treatment.guidelines.(Duffy,.Gillespie,.and. Clark.2007;.Ehlers.et.al..2005;.Marks.et.al..1998;.Mueser.et.al..2008)..CPT.(Resick.and.Schnicke. 1996),. one. of. the. most. well-researched. cognitive. approaches,. has. a. primary. focus. on. challeng- ing.and.modifying.maladaptive.beliefs.related.to.the.trauma,.but.also.includes.a.written.exposure. component.. Developed. by. Patricia. Resick,. CPT. was. initially. shown. to. be. as. effective. as. PE. and. more.effective.in.treating.PTSD,.depression,.and.guilt.than.a.minimal.attention.control.condition. in. a. study. of. 171. female. sexual. assault. survivors. (Resick. et. al.. 2002).. CPT. has. also. been. shown. to. be. effective. for. male. and. female. veterans. with. military-related. PTSD. (Monson. et. al.. 2006).. Sixty.veterans.were.randomized.to.CPT.or.a.waitlist..Intention-to-treat.analyses.revealed.significant. improvements.in.PTSD.and.comorbid.symptoms.in.the.CPT.condition.compared.with.the.waitlist. condition..After.treatment,.40.percent.of.the.CPT.group.no.longer.met.criteria.for.PTSD.

In. contrast. to. the. study. of. PE,. once. CPT. was. shown. to. be. effective,. the. treatment. developers. conducted.a.dismantling.study.to.determine.the.relative.utility.of.the.full.protocol.compared.with. its.components:.cognitive.therapy.and.written.exposure.(Resick.et.al..2008)..All.three.treatments. resulted.in.significant.improvement. in.PTSD..However,.cognitive.therapy.alone.resulted.in.faster.

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304 Behavioral Health Response to Disasters

improvement.than.written.exposure,.with.the.effects.of.the.full.protocol.falling.in.between.(Resick. et.al..2008).

Just. as. there. are. various. approaches. to. exposure,. there. are. also. different. forms. of. cognitive. therapy..For.example,.Ehlers.and.Clark.developed.a.cognitive.therapy.for.PTSD.that.involves.three. goals:.(1).modifying.excessively.negative.appraisals,.(2).correcting.disturbances.in.autobiographi- cal. memory,. and. (3). removing. problematic. behavioral. and. cognitive. strategies. (Ehlers. and. Clark. 2000)..In.a.small,.randomized.controlled.trial,.28.survivors.of.accident,.assault,.or.witnessing.death. improved. significantly. more.on.PTSD,. depression,.and.anxiety.in.cognitive.therapy. compared. to. waitlist.(Ehlers.et.al..2005)..Mueser.and.Rosenberg.(Mueser.et.al..2004).developed.a.CR.for.PTSD. program.that.includes.education,.breathing.retraining,.and.CR.taught.as.a.general.self-management. skill.for.dealing.with.any.negative.feeling.rather.than.solely.using.it.to.target.trauma-related.cogni- tions.. Results. showed. that. CR. was. more. effective. than. usual. care. for. treating. PTSD,. depression,. and. anxiety. in. people. with. severe. mental. illness,. including. borderline. personality. disorder. and. psychotic.disorders.(Mueser.et.al..2008).

In. sum,. like. exposure-based.treatments,. there. is. strong. support. for. the. effectiveness. of. cogni- tive.therapy..Cognitive.interventions.have.been.evaluated.in.women.and.men,.sexual.assault.survi- vors,.veterans,.people.with.severe.mental.illness,.and.mixed.trauma.samples,.and.with.a.variety.of. approaches..However,.aside.from.the.CPT.dismantling.study.(Resick.et.al..2008),.racial.diversity. has.been.limited,.and.each.study.sample.consists.primarily.of.middle-aged.survivors..Nevertheless,. these.treatments.appear.to.target.depression.and.anxiety.in.addition.to.PTSD..

Currently,. there. is. more. consistent. support. for. CBT. than. for. medications. in. the. treatment. of. PTSD..In.fact,.there.is.some.disagreement.among.the.clinical.practice.guidelines.as.to.whether.phar- macotherapy.should.be.considered.a.frontline.treatment.for.PTSD.(see.Friedman.2008)..However,. at.times.survivors.may.choose.a.medication.over.psychotherapy.or.may.want.a.combination.of.both.. Two.selective.serotonin.reuptake.inhibitors.(SSRIs),.sertraline.and.paroxetine,.have.been.approved. by.the.U.S..Food.and.Drug.Administration.for.the.treatment.of.PTSD..Both.have.been.evaluated. in.multisite.randomized.controlled.trials.with.survivors.(Brady.et.al..2000;.Davidson,.Pearlstein,. et al..2001;.Davidson,.Rothbaum,.et.al..2001;.Marshall.et.al..2001).with.positive.results..There.is. also.a.positive.trial.of.the.SSRI.fluoxetine.(Martenyi.et.al..2002)..However,.negative.trials.have.been. reported.as.well.(Friedman.et.al..2007;.Martenyi,.Brown,.and.Caldwell.2007).and.the.results.for. medications.are.typically.less.impressive.than.those.found.with.CBT.(see.Friedman,.Davidson,.and. Stein.2009.for.a.review.of.medications.for.PTSD).

17.2.2  cBT for disasTer-relaTed pTsd

A.few.studies.have.evaluated.treatment.for.disaster-related.PTSD..In.early.studies.with.earthquake. survivors. in. Turkey,. Basoglu. and. colleagues. found. that. one. to. two. sessions. of. CBT. or. exposure. to. artificial. tremors. in. an. earthquake. simulator. significantly. reduced. PTSD. symptoms. (Basoglu,. Livanou,.and.Salcioglu.2003;.Basoglu.et.al..2003)..Two.later.randomized.controlled.trials.involved. a.single-session.exposure.intervention.compared.to.either.a.wait-list.control.or.repeated.assessment. (Basoglu,.Salcioglu,.and.Livanou.2007;.Basoglu.et.al..2005)..Findings.suggested.the.single-session. behavioral.treatment.given.approximately.three.years.post-disaster.produced.a.substantial.decrease. in.PTSD.symptoms..Given.the.promising.implications.of.this.trial.for.expedient.and.cost-effective. treatment,.these.results.are.in.need.of.replication.

In. other. preliminary. work,. Gillespie. and. colleagues. (Gillespie. et. al.. 2002). studied. the. effec- tiveness.of.Ehlers.and.Clark’s.cognitive.therapy.in.91.survivors.of.a.bombing.in.Northern.Ireland. 10 months.post-bombing..All.survivors.had.PTSD.related.to.the.bombing..After.treatment,.the.sur- vivors.had.significant.improvement.in.PTSD,.depression,.and.general.health..In.response.to.these. promising.results,.the.research.team.randomized.58.survivors.of.terrorism.and.other.civil.conflict. to.either.cognitive.therapy.or.waitlist.(Duffy.et.al..2007)..At.posttreatment,.participants.in.cognitive. therapy. demonstrated. significantly. greater. improvement. in. self-reported. PTSD,. depression,. and.

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305Long-Term Mental Health Treatment for Adult Disaster Survivors

functioning.than.those.in.the.waitlist.with.continued.improvement.in.those.who.received.additional. sessions.(Duffy.et.al..2007)

A. third. research. team. focused. on. providing. treatment. to. survivors. and. disaster. workers. from. the.World.Trade.Center..One.study.utilized.a.quasi-experimental.design.in.which.survivors.were. assigned. to. a. virtual. reality. or. a. matched. waitlist. control. group.. Results. indicated. significant. improvement.in.PTSD.in.the.virtual.reality.group.compared.to.waitlist.(Difede,.Cukor.et.al..2007).. In. the. other. study,. 31. disaster. workers. were. randomized. to. CBT. or. “treatment. as. usual”. (TAU;. Difede,.Malta.et.al..2007)..CBT.included.psychoeducation,.breathing.retraining,.imaginal.and.in. vivo. exposure,. cognitive. reprocessing,. and. relapse. prevention.. TAU. included. an. assessment. with. referral. for. PTSD. treatment. with. a. community. provider.. Over. half. of. the. CBT. and. an. eighth. of. the.TAU.participants.dropped.out.of.treatment..For.those.who.completed.treatment,.participants.in. CBT.showed.significant.improvement.in.PTSD.relative.to.those.in.TAU,.although.no.participants. followed. through. on. the. referral.. Intention-to-treat. analyses. yielded. no. significant. effects,. likely. because.of.the.high.dropout.rate.

In. another. study. of. World. Trade. Center. victims,. therapists. at. an. outpatient. clinic. were. taught. Skills.Training.in.Affective.and.Interpersonal.Regulation/Modified.Prolonged.Exposure.(STAIR/ MPE),.a.CBT.that.adds.affect.regulation.and.interpersonal.skills.into.a.prolonged.exposure.treat- ment.. Significant. decreases. in. PTSD,. depression,. and. social. adjustment. were. observed. and. were. similar.to.results.found.in.a.randomized.controlled.trial.of.the.same.treatment.(Levitt.et.al..2007).

One.other.study.is.worth.mentioning.for.its.novelty.in.responding.to.disaster..The.study.involved. a.public.mental.health.program.initiated.in.response.to.the.London.bombings..The.program.involved. two.components,.screening.and.treatment.(Brewin.et.al..2008)..Extensive.efforts.were.made.to.iden- tify. and. screen. individuals. involved. in. the. bombings. to. identify. either. preexisting. mental. health. problems.or.mental.health.problems.stemming.from.the.bombings..If.new.problems.were.identified,. individuals.could.either.be.referred.for.immediate.trauma-focused.treatment.or.monitored.to.deter- mine.if.the.problem.would.resolve.on.its.own.and.then.referred.if.necessary..Treatment.resources. included. existing. programs. that. utilized. licensed. clinical. psychologists. offering. trauma-focused. CBT. or. EMDR.. Therapists. were. supervised. by. specialists,. and. treatment. and. travel. costs. were. reimbursed.

The. program. screened. 596. individuals,. 346. of. whom. received. a. more-detailed. assessment. to. determine. whether. a. referral. was. indicated.. PTSD. was. the. predominant. diagnosis.. Seventy-four. percent. were. referred. for. treatment,. while. 26. percent. were. judged. to. require. monitoring. only.. Preliminary. outcome. data. were. available. for. 82. individuals,. 72. of. whom. completed. treatment.. Treatment.yielded.large-effect.sizes.for.PTSD.and.depression.(Brewin.et.al..2008).

Overall,.there.is.a.strong.and.growing.literature.supporting.the.use.of.cognitive.behavioral.treat- ments.for.disaster-related.PTSD..These.treatments.have.been.used.with.survivors.of.terrorism.and. natural. disaster.. In. each. trial,. survivors. who. receive. CBT. improve. relative. to. waitlist. conditions.. Importantly,.improvements.are.regularly.seen.in.depression,.anxiety,.and.functioning.in.addition.to. PTSD..These.findings.do,.however,.need.to.be.extended.to.diverse.populations,.as.most.of.the.survi- vors.studied.were.middle-aged.women.(Basoglu.et.al..2007;.Basoglu.et.al..2005;.Brewin.et.al..2008;. Gillespie.et.al..2002;.Levitt.et.al..2007)..Many.authors.did.not.report.racial/ethnic.backgrounds.of. their.samples.

17.2.3  disasTer-specific TreaTMenTs

To. our. knowledge,. our. Hamblen. and. colleagues. (Hamblen. et. al.. 2006). are. the. only. ones. to. develop. a. treatment. for. the. long-term. response. that. is. focused. more. broadly. on. postdisaster. distress.rather.than.PTSD.specifically..Postdisaster.distress.encompasses.a.range.of.cognitive,. emotional,.and.behavioral.reactions.to.disaster,.including.symptoms.of.PTSD,.depression,.stress. vulnerability,. and. functional. difficulties.. Postdisaster. distress. is. not. a. psychiatric. diagnosis.. Within.certain.limits,.distress.is.perfectly.natural.and.normal.and.can.be.expected.to.improve.

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306 Behavioral Health Response to Disasters

on.its.own..Sometimes,.however,.this.distress.becomes.severe.and/or.prolonged.enough.to.inter- fere.with.quality.of.life.

There.are.several.advantages.to.this.approach.(Hamblen.et.al..2006)..First,.it.could.assist.indi- viduals.who.present.with.other.primary.reactions,.such.as.depression,.mixed.conditions,.or.sub- clinical.conditions..Although.the.PTSD.treatment.studies.reviewed.previously.demonstrate.effects. beyond.PTSD,.disaster.survivors.without.a.primary.PTSD.diagnosis.are.excluded.from.these.treat- ments..Second,.a.treatment.focused.on.postdisaster.distress.or.stress.is.potentially.more.acceptable. to.survivors.who.may.be.suffering.from.mental.health.problems.for.the.first.time..Finally,.a.single. treatment.focused.on.distress.as.opposed.to.diagnosis.reduces.the.need.for.extensive.assessment. and.can.be.disseminated.to.community.clinicians.through.a.single.training.(rather.than.through. multiple.trainings.for.disorders).and.increases.the.feasibility.of.the.treatment’s.use.in.community. settings.

Cognitive. Behavioral. Therapy. for. Postdisaster. Distress. (CBT-PD;. Hamblen. et. al.. 2006). is. a. manualized.disaster-specific.intervention.that.has.a.primary.focus.on.identifying.and.challenging. maladaptive.disaster-related.beliefs..It.includes.psychoeducation,.breathing.retraining,.behavioral. activation,.and.cognitive.restructuring..Evaluation.was.minimal.in.the.first.pilots.of.the.approach,. taking.place.in.New.York.after.the.World.Trade.Center.bombings.(Donahue.et al..2006).and.in. Florida. after. the. 2004. Hurricanes. Bonnie,. Charley,. Frances,. Ivan,. and. Jeanne. (Hamblen. and. Norris.2007),.but.preliminary.results.were.promising..In.a.subsequent.study.employing.a.quasi- experimental.repeated.measures.design,.88.racially.diverse.adult.survivors.of.Hurricane.Katrina. were.given.CBT-PD.and.were.assessed.at.referral,.pretreatment,.intermediate.treatment,.and.post- treatment.(Hamblen.et al..2009)..The.overall.pre-posteffect.size.was.1.4.in.intention-to-treat.anal- yses,.demonstrating.CBT-PD.resulted.in.large.and.significant.improvements.in.distress..Benefits. were.maintained.at.five-month.follow-up.

17.2.4  considering coMorBidiTy

Although.PTSD.is.the.most.common.mental.health.problem.after.disaster,.depression,.anxiety,.and. increased. substance. use. are. frequent. as. well.. Depending. on. the. nature. of. the. disaster,. prolonged. grief. can. also. be. an. area. of. concern. if. there. was. significant. loss. of. life.. In. our. opinion,. depres- sion.and.anxiety.can.often.be.addressed.as.part.of.the.PTSD.treatment..As.reviewed.before,.most. CBTs.for.PTSD.also.significantly.reduce.depression.and.anxiety..Similarly,.medications.effective. for.PTSD.also.target.symptoms.of.anxiety.and.depression.

Substance.abuse.problems.are.another.area.of.concern.after.disaster.(see.Chapter.18,.this.vol- ume,.for.more.on.this.topic)..After.a.disaster,.survivors.may.relapse.or.use.more.heavily.than.before. the.disaster,.but.new.onset.substance.abuse.problems.are.rare.(North.et.al..1999)..A.series.of.studies. on. the. use. of. cigarettes,. alcohol,. and. marijuana. among. New. York. City. residents. after. the. World. Trade. Center. attack. demonstrated. an. increase. in. substance. use. immediately. following. the. attack. (Vlahov.et.al..2002);.however,.it.was.still.true.that.the.percentage.of.new.onset.cases.was.relatively. small.(2.2 percent).compared.to.the.number.of.new.onset.cases.of.PTSD.(Vlahov.et.al..2006).

Few.treatments.exist.to.treat.comorbid.PTSD.and.substance.use..The.most.popular.treatment.is. Seeking.Safety.(SS)..SS.is.a.present-focused.therapy.that.focuses.on.teaching.coping.skills.that.are. relevant.to.both.PTSD.and.substance.use..There.are.25.topics.that.address.cognitive,.behavioral,. interpersonal,.and.case.management.issues..Data.from.two.large.randomized.controlled.trials.of.SS. both. demonstrated. significant. reductions. in. PTSD. symptoms,. but. SS. was. no. more. effective. than. either.active.control.condition.(relapse.prevention.or.women’s.health.education).in.reducing.PTSD. symptoms..Outcomes.related.to.substance.use.were.inconsistent..While.both.SS.and.relapse.preven- tion.resulted.in.improved.substance.outcomes.in.the.first.study,.there.was.no.effect.of.SS.or.women’s. health.education.on.substance.use.in.the.second.study.(Hien.et.al..2004;.Hien.et.al..2009)..Thus,.at. this.point.the.literature.does.not.support.its.use.as.a.PTSD.or.substance.abuse.treatment,.although.it. may.be.an.effective.treatment.engagement.strategy.

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307Long-Term Mental Health Treatment for Adult Disaster Survivors

Two. models. have. been. proposed. to. account. for. the. association. between. PTSD. and. SUD. (Jacobsen,.Southwick,.and.Kosten.2001)..In.one.case,.the.PTSD.is.primary.and.patients.drink.to. cope.with.PTSD.symptoms..In.the.other.case,.SUD.is.primary.and.patients’.substance.use.places. them. in. risky. environments. where. they. are. more. likely. to. be. traumatized.. Data. support. the. first. model. (Chilcoat. and. Breslau. 1998a,. 1998b),. sometimes. called. the. self-medication. theory,. where. patients.use.substances.to.manage.their.PTSD.symptoms..Given.the.state.of.the.literature.and.the. proposed.relationship.between.PTSD.and.substance.use,.our.current.recommendation.is.that.when. possible,. individuals. with. substance. abuse. problems. should. be. included. in. cognitive. behavioral. treatments. for. PTSD.. Pilot. work. under. way. suggests. that. both. PE. and. CPT. can. be. effective. in. treating.PTSD.in.people.with.the.comorbid.condition.and.may.reduce.substance.use.as.well.(E..Foa. personal.communication,.October.14,.2009;.K..Chard.personal.communication,.October.6,.2009).

Prolonged.grief.is.a.condition.that.can.be.observed.after.trauma.when.there.is.a.major.loss,.such. as.the.death.of.a.spouse.or.child..Prolonged.grief.has.also.been.called.complicated.grief.or.traumatic. grief.(Prigerson.et.al..2009)..Prolonged.grief.is.more.persistent,.consuming,.and.debilitating.than.is. normal.grief..Now.under.evaluation.for.inclusion.in.the.Diagnostic and Statistical Manual,.5th.ed.. (APA,.in.press),.prolonged.grief.disorder.describes.a.severe.condition.wherein.the.bereaved.person. has. experienced. both. separation. distress,. characterized. as. an. intense. yearning. for. the. deceased. person,.and.a.high.co-occurring.frequency.of.cognitive,.emotional,.or.behavioral.symptoms.such.as. avoidance,.shock,.confusion,.trouble.accepting.loss,.difficulty.trusting.others,.bitterness,.difficulty. moving.on,.emotional.numbness,.and.sense.of.meaninglessness..Symptoms.must.persist.for.at.least. six.months.and.result.in.significant.functional.impairment.(Prigerson.et.al..2009).

Although. prolonged. grief. disorder. shares. some. symptoms. with. depression. and. anxiety. (most. notably.PTSD),.it.has.repeatedly.been.shown.to.differentiate.from.the.two.(Prigerson.et.al..2009).. Few.treatments.exist.for.prolonged.grief;.we.were.able.to.identify.only.one.randomized.controlled. trial..Shear.and.colleagues.developed.a.complicated.grief.treatment.that.includes.both.interpersonal. psychotherapy. (IPT). components. for. the. depressive. symptoms. and. cognitive. behavioral. therapy. components. for. the. intrusive. and. avoidant. symptoms. (Shear. et. al.. 2005).. IPT. focuses. on. helping. patients.arrive.at.a.more.realistic.assessment.of.the.relationship.with.the.deceased.and.identifying. positive.and.negative.aspects.of.the.relationship..Cognitive.behavioral.therapy.includes.both.in.vivo. and.imaginal.exposure..The.patient.is.asked.to.complete.a.“revisiting”.exercise.in.which.they.tell. the.story.of.the.deceased’s.death..They.are.also.asked.to.have.an.imaginary.conversation.with.the. deceased.in.which.the.patient.asks.questions.and.then.takes.on.the.role.of.the.deceased.to.answer..In. a.randomized.controlled.trial.comparing.the.complicated.grief.treatment.to.IPT.alone,.51.percent.of. participants.in.the.complicated.grief.treatment.responded.to.the.treatment.compared.to.28.percent. of.participants.in.IPT.alone.(Shear.et.al..2005).

While.the.results.of.the.trial.were.promising,.more.than.half.of.participants.in.the.grief.treatment. continued.to.present.with.symptoms.following.the.treatment..In.addition,.only.a.minority.of.deaths. were.from.unnatural.causes.such.as.a.natural.disaster.or.terrorism..Thus,.it.is.not.clear.whether.par- ticipants.who.were.grieving.from.“traumatic”.deaths.would.respond.similarly..Another.limitation. was.that.while.almost.half.of.participants.had.current.PTSD,.PTSD.was.not.assessed.as.an.outcome. measure..Thus,.it.is.impossible.to.determine.if.the.grief.treatment.targeted.the.PTSD.symptoms.as. well..It.may.be.that.when.loss.of.life.is.due.to.a.traumatic.event,.a.PTSD-specific.treatment.may.be. indicated.

17.2.5  TreaTMenT suMMary

The. previous. treatment. review. should. help. inform. clinicians. and. policy. makers. on. the. range. of. treatments.that.are.available.following.disaster..There.is.a.strong.evidence.base.for.using.cognitive. behavioral.treatments.for.PTSD.and.a.growing.one.in.support.of.their.use.with.disaster.survivors,. although.findings.need.to.be.extended.to.diverse.populations,.particularly.to.the.young,.the.elderly,. and.members.of.racial.minority.groups..These.treatments.are.highly.effective.for.PTSD,.but.also.

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308 Behavioral Health Response to Disasters

often. treat. comorbid. problems.. Novel. treatment. approaches. are. also. in. development. for. use. with. survivors. with. postdisaster. distress. who. may. either. not. have. PTSD. or. may. be. resistant. to. being. labeled. with. a. mental. disorder.. Finally,. researchers. are. starting. to. consider. how. to. provide. more. integrated.care.for.some.conditions.such.as.substance.abuse.and.prolonged.grief.

17.3  BARRIERS TO CARE

In.the.second.half.of.the.chapter,.we.turn.to.barriers.to.care..Even.if.we.can.identify.the.best.treat- ments.for.the.long-term.response.to.disaster,.they.are.only.effective.if.survivors.access.them.and. providers.deliver.them.with.efficacy..We.begin.by.defining.the.relevant.concepts..By.utilization,. we.mean.connecting.with.and.using.available.services;.retention.refers.to.completing.an.adequate. “dose”.of.an.intervention.so.improvements.are.possible..Other.important.concepts.include.“need”. and. “demand”. for. mental. health. services.. We. believe. that. at. times. these. constructs. are. used. interchangeably.when.they.really.should.be.considered.distinct..At.the.population.level,.need.can. be. defined. as. the. number. of. individuals. directly. affected. by. a. disaster. who. could. benefit. from. receiving.mental.health.services..However,.it.has.repeatedly.been.shown.that.not.all.people.who. need.services.seek.them..Thus,.we.define.demand.as.those.individuals.who.actually.seek.mental. health.care.

The.distinction.between.need.and.demand.is.important.because.some.researchers.have.asserted. that.mental.health.“needs”.following.disasters.often.exceed.the.services.available.in.a.community. (Marshall.et.al..2006)..Some.researchers.have.also.predicted.that.optimal.mental.health.response. programs,.those.predicted.to.have.high.recovery.rates.and.avert.long-term.public.health.costs,.would. exceed.available.providers.(Schoenbaum.et.al..2009)..However,.the.ways.in.which.need.has.been. defined.in.the.literature.likely.includes.many.individuals.who.will.neither.desire.nor.seek.care..In. our. experience,. demand. is. rarely. equivalent. to. need,. and. only. a. small. portion. of. those. who. may. need.services.ever.demand.them..However,.there.are.many.barriers.to.utilization.

17.3.1  uTilizaTion of MenTal healTh serVices

17.3.1.1  Utilization Rates It.is.no.surprise.that.disasters.are.followed.by.increases.in.psychological.symptoms.(Norris.et al.. 2002). and. that. many. who. likely. need. or. demand. services. do. not. receive. care.. For. example,. researchers. estimated. that. six. months. after. Hurricane. Katrina,. 31. percent. of. individuals. living. in.the.areas.affected.by.the.hurricane.acquired.mental.health.disorders.(need);.yet.only.one-third. (32  percent). of. these. individuals. had. utilized. services. (Wang. et. al.. 2007).. Following. the. 9/11. terrorist. attacks,. estimates. of. between. 11. percent. and. 36. percent. of. those. with. mental. health. disorders. sought. mental. health. care. (DeLisi. et. al.. 2003;. Stuber. et. al.. 2006).. Further,. among. individuals.who.do.demand.and.enroll.in.services,.retention.rates.are.poor..Wang.et.al..reported. that.64.percent.attended.only.one.or.two.visits.to.health.or.mental.health.care.agencies.follow- ing. Hurricane. Katrina.. Similarly,. 55. percent. of. those. enrolled. in. a. cognitive-behavioral. treat- ment.study.following.Hurricane.Katrina.did.not.complete.treatment.(Hamblen.et.al..2009),.even. thought.the.treatment.was.free.and.offered.in.many.convenient.locations..The.high.proportion.of. individuals.who.need.care.yet.do.not.seek.or.receive.it.is.alarming.considering.the.public.health. relevance.of.psychiatric.conditions.after.disasters,.such.as.PTSD,.major.depression,.and.anxiety. (Norris.et.al..2002).

17.3.1.2  Variables Related to Utilization Recent.investigations.in.postdisaster.contexts.have.begun.to.uncover.factors.that.relate.to.utiliza- tion..Because.the.literature.often.does.not.distinguish.between.need.and.demand,.we.will.attempt. to.disentangle.these.concepts.throughout.our.discussion..Anderson’s.Behavioral.Model.of.health.

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309Long-Term Mental Health Treatment for Adult Disaster Survivors

care.utilization.(Andersen.and.Newman.1973).has.been.applied.and.validated.in.numerous.stud- ies. of. trauma. and. disaster. victims. (Anderson. 1995;. Elhai. and. Ford. 2009;. Koenen. et  al.. 2003).. The.model.outlines.three.factors.that.impact.utilization:.need,.predisposing.factors,.and.enabling. factors.. In. this. model,. need. refers. to. both. perceived. need. for. help. and. severity. of. symptoms.. Predisposing. factors. include. historical. or. sociodemographic. characteristics.. Enabling. factors. encompass.access.to.resources.and.availability.of.interventions..In.a.recent.meta-analysis.of.25. studies.investigating.utilization.of.mental.health.services.after.disasters,.Elhai.and.Ford.(2009). found.that.the.need.variables.of.severity.of.PTSD,.depression,.and.anxiety.had.the.largest.bear- ings. on. utilization.. The. predisposing. variables. of. more. stressful. life. events,. more. exposure. to. trauma.and.disaster,.and.being.middle-aged.were.also.positively.related.to.utilization..Enabling. factors.were.not.strongly.related.to.utilization,.although,.notably,.these.variables.were.the.least. likely.to.be.included.in.studies.

Although. enabling. factors. did. not. strongly. relate. to. utilization. in. the. meta-analysis,. raising. awareness.and.increasing.availability.of.psychological.care.is.an.obvious.important.step.following. disasters..Survivors.cannot.utilize.treatment.unless.they.are.aware.of.it.and.it.is.available.to.them.. To.this.end,.large-scale.mental.health.response.programs.have.been.implemented.in.the.wake.of. disasters..One.such.program.following.the.9/11.World.Trade.Center.attacks,.Project.Liberty,.spent. $9.4.million.on.marketing.in.the.three.months.following.the.event.(Frank.et.al..2006)..Researchers. reported.that.24.percent.of.New.York.City.inhabitants.were.aware.of.the.project..However,.aware- ness. was. not. enough. to. improve. utilization.. Of. those. who. were. aware,. 67. percent. had. a. good. impression. of. the. project,. yet. only. 23. percent. reported. they. would. call. the. hotline. for. services. (estimate.of.demand;.Rudenstine.et.al..2003)..Higher.socioeconomic.status.was.related.to.aware- ness. of. the. program,. whereas. indications. of. underprivileged. status. (e.g.,. racial. minority,. lower. income,.immigrant),.as.well.as.severity.of.PTSD.symptoms.(need),.were.positively.related.to.esti- mated.demand.

In. an. effort. to. further. assess. whether. mental. health. needs. were. met. following. the. 9/11. World. Trade. Center. attacks,. a. random. digit. dial. phone. survey. was. initiated. in. the. NYC. metropolitan. area.six.months.following.the.attack.(Stuber.et.al..2006)..Seventeen.percent.of.those.with.probable. PTSD.or.depression.(need).considered.mental.health.treatment..Of.those.with.probable.diagnoses. who.considered.but.did.not.seek.care,.the.most.frequently.reported.barriers.included.believing.that. other.people.needed.the.help.more.than.they.did.(58.percent),.perceptions.of.not.having.enough.time. (42.percent).and.money.(39.percent),.perceived.stigma.associated.with.having.a.mental.illness.(27. percent),.lack.of.knowledge.of.services.(17.percent),.and.preferences.to.take.care.of.the.problems. on.their.own.or.with.the.help.of.family.(14.percent)..Prior.emotional.problems.and.sexual.abuse,. previous.mental.health.services,.and.current.physical.health.problems.increased.the.likelihood.of. utilization.(Stuber.et.al..2006).

Other. investigators. have. found. that. many. people. who. need. mental. health. care. do. not. utilize. services.because.they.do.not.know.or.do.not.believe.that.effective.treatments.are.available.(Pietrzak. et al..2009)..In.our.experience,.the.competing.demands.and.stressors.that.accompany.disasters,.such. as.property.damage,.displacement,.and.financial.and.resource.loss,.also.serve.as.significant.barriers. to.mental.health.care.utilization.

17.3.1.3  Utilization of At-Risk Groups Although.being.a.member.of.an.underprivileged.or.minority.group.(racial.minority,.physical.dis- ability,.etc.).did.not.significantly.relate.to.utilization.in.Elhai.and.Ford’s.(2009).meta-analysis,.much. attention. has. been. focused. on. the. vulnerability. of. at-risk. groups.. Some. research. has. shown. that. not.only.are.marginalized.groups.at.greater.risk.for.psychiatric.problems.following.disasters.than. nonmarginalized.groups,.they.also.have.unequal.access.to.information.about.impending.disasters. and.are.treated.differently.during.relief.efforts.(Stough.2009)..For.example,.statistics.show.that.the. elderly. and. persons. with. disabilities. in. institutions. are. overrepresented. among. disaster. fatalities. (Cook.and.Elmore.2009)..As.a.result,.recent.attention.has.been.given.to.the.complexities.of.disaster.

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310 Behavioral Health Response to Disasters

preparedness,. response,. and. recovery. for. long-term. care. facilities. (Dosa. et. al.. 2008;. Hyer. et. al.. 2006).

In. addition,. professionals. argue. that. members. of. marginalized. groups. have. more. barriers. to. recovery.than.do.able-bodied.and.able-minded.persons.and.are.at.higher.risk.for.postdisaster.psy- chiatric.problems.(Hawkins.et.al..2009;.Stough.2009)..Researchers.assert.that.this.increased.risk.is. accounted.for.by.an.interaction.of.various.pre-,.peri-,.and.postdisaster.factors,.including.important. socioeconomic. and. sociocultural. variables. (Hawkins. et. al.. 2009).. For. example,. key. differences. between.groups.exist.in.terms.of.risk.perceptions,.disaster.preparation,.prior.traumatic.experiences,. cultural.beliefs.(e.g.,.external.locus.of.control,.mistrust.of.professionals),.and.help-seeking.behaviors. (e.g.,.use.of.family.or.kin.rather.than.professionals)..Taken.together.with.the.reality.that.marginal- ized. communities. often. have. weaker. infrastructures. to. support. interventions. and. less. access. to. culturally. competent. interventions. and. resources. (e.g.,. documents. and. services. only. provided. in. English),.we.can.glean.a.clearer.picture.of.why.these.groups.might.not.utilize.mental.health.services. (Hawkins.et.al..2009).

17.3.1.4  Recommendations for Improving Utilization It.is.our.belief.that.it.is.not.enough.just.to.set.up.a.disaster.treatment.program.and.hope.that.survivors. will.access.it..Even.the.most.expensive.media.campaigns.fail.to.enroll.the.majority.of.survivors.in. need.of.treatment..Special.attention.must.be.paid.to.identifying.those.survivors.in.the.greatest.need. of.services.and.finding.ways.of.making.the.treatments.more.acceptable.to.these.groups..We.sug- gest.that.disaster.treatment.programs.work.with.social.service.and.crisis.agencies.to.determine:.the. groups.most.in.need,.appropriate.outreach.strategies.to.reach.these.groups,.and.unique.barriers.to. care.for.these.groups..Marketing.and.recruitment.should.also.aim.to.make.individuals.aware.that. there.are.enough.services.to.go.around.and.that.they.personally.deserve.treatment..Individuals.also. need.to.be.informed.that.mental.health.care.is.often.of.no.cost.to.them.following.disasters;.govern- ment.and.grant-funded.programs.are.put.into.place.due.to.the.expected.mental.health.problems.that. can.occur.

The.needs.of.special.populations.should.be.considered.as.well..For.example,.following.the.World. Trade.Center.attack,.a.special.effort.was.made.to.reach.out.to.undocumented.workers.who.may.have. been.working.in.the.World.Trade.Center..In.addition,.materials.had.to.be.translated.into.multiple. languages.in.order.to.make.the.treatments.acceptable.to.non-English-speaking.survivors..Similarly,. in.Florida.the.elderly.were.a.population.of.concern.after.the.2004.hurricanes..Older.adults.are.often. not.able.to.come.to.the.therapist.for.an.office.visit.and.may.require.more.time.to.comprehend.the. treatment.material..More.generally.as.a.field,.we.need.to.understand.more.about.why.individuals. underutilize.and.drop.out.of.treatment..Investigators.are.encouraged.to.consider.this.research.ques- tion.when.designing.studies.and.analyzing.outcomes.

17.3.2  TreaTMenT disseMinaTion

Even.if.effective.treatments.exist.and.survivors.want.to.access.them,.both.systemic.and.clinician. barriers.may.exist. Several.unique.systemic.issues.arise.when.attempting.to.disseminate.effective. treatments.in.the.wake.of.disaster.(see.Marshall.et.al..2006.for.review)..Treatments.are.often.imple- mented.through.a.community.response,.which.brings.with.it.distinctive.systems.issues.regarding. referral.and.treatment.delivery..Training.programs.often.need.to.be.implemented.quickly,.inexpen- sively,.and.to.many.providers.with.a.range.of.backgrounds..There.is.often.less.time.to.offer.com- prehensive.didactics.and.supervision.to.providers.than.in.other.training.contexts..Further,.effective. treatments.compete.with.other.types.of.interventions,.and.service.planners.and.organizations.may. fail. to. work. together,. experience. communication. problems,. feel. ambivalent. toward. trainers. who. might.be.considered.“outsiders,”.and.have.limited.funding.and.resources.(Norris.et.al..2005).

Clinician.barriers.can.exist.both.in.terms.of.training.needs.and.in.terms.of.resistance.to.deliver- ing.the.identified.treatments..With.respect.to.training,.a.review.of.the.CBT.dissemination.literature.

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311Long-Term Mental Health Treatment for Adult Disaster Survivors

in-.and.outside.of.the.postdisaster.context.indicates.that.community-based.therapists.can.be.trained. to. implement. effective. treatments. in. local. crisis. and. community. agencies.. Rape. crisis. counsel- ors,. community. mental. health. clinicians,. and. school-based. counselors. have. been. shown. to. be. able.to.learn.specific.CBT.interventions.and.to.provide.them.with.good.outcome.(Foa.et.al..2005;. Gillespie et.al..2002;.Stein.et.al..2003)..Together.these.studies.indicate.that.it.may.be.possible.to. train. clinicians. in. a. variety. of. nonacademic. settings. to. provide. effective. manualized. CBT. treat- ments.for.PTSD.

Only. two. studies. report. on. training. therapists. to. provide. CBT. following. a. disaster.. The. first. involved.a.two-day.training.of.PE.to.more.than.100.frontline.clinicians.following.the.9/11.World. Trade.Center.attacks.(Marshall.et.al..2006)..Results.from.the.pretraining.assessment.indicated.that. therapists.were.moderately.favorable.regarding.the.active.components.of.the.treatment,.but.felt.that. they.lacked.the.skill.to.adequately.deliver.the.exposure.treatment..No.posttraining.assessment.was. completed.

The.second.study.involved.a.two-day.training.of.community.clinicians.in.Baton.Rouge,.Louisiana,. to.deliver.CBT-PD.following.Hurricane.Katrina.(Hamblen.et.al..2010)..Results.indicated.that.the. training.was.effective.in.educating.therapists.about.CBT-PD..Therapists,.especially.those.who.were. not.already.at.the.maximum.score.at.pretraining,.showed.significant.improvements.in.their.ratings. of. the. importance. of. various. elements. of. CBT. in. therapy,. their. knowledge. and. understanding. of. those.elements,.and.their.confidence.that.they.could.use.them.effectively.

These.studies.indicate.that.it.may.be.possible.to.train.community-based.clinicians.in.manu- alized.interventions.for.PTSD.or.postdisaster.distress..A.large.number.of.therapists.from.dif- ferent. agencies. were. taught. to. deliver. these. interventions. with. relatively. little. training. and. significantly.less.intensive.supervision.than.in.a.typical.randomized.controlled.trial..The.two. disaster. studies. also. support. the. success. of. “just-in-time”. trainings. of. evidence-based. CBT. interventions. that. can. be. implemented. in. the. aftermath. of. a. disaster. (Hamblen. et. al.. 2010;. Marshall.et.al..2006).

Another.barrier.to.treatment.can.be.resistance.on.the.part.of.the.clinician..Many.clinicians.are. reluctant.to.delivering.manualized.treatments,.either.because.they.think.they.do.not.“fit”.their. clients.or.they.believe.that.their.clinical.techniques.and.interventions.are.more.effective.(Addis,. Wade,.and.Hatgis.1999)..Therefore,.a.training.goal.should.be.helping.clinicians.understand.that. most. CBTs. are. quite. adaptive. to. specific. client. presentations. and. can. be. tailored. to. meet. the. specific.client.needs..The.cognitive.and.behavioral.components.of.the.treatments.are.focused.on. the.unique.issues.of.the.client..No.two.clients.will.ever.receive.the.exact.same.treatment.because. it.is.their.own.values,.beliefs,.and.fears.that.shape.the.treatment..It.may.also.be.that.manuals.can. be.used.more.flexibly.than.once.thought..Two.disaster.treatment.models.have.been.used.flexibly. with. success.. One. such. model. is. specialized. crisis. counseling. services. (SCCS),. a. team-based. program.that.was.implemented.as.part.of.Project.Recovery.following.Hurricane.Katrina.(Jones. et. al.. 2009).. SCCS. is. a. blend. of. CBT,. solution-focused,. and. person-centered. approaches. that. involves. flexible,. stand-alone. sessions.. Clinicians. could. identify. what. techniques. they. wanted. to.implement.in.each.session..Not.only.were.satisfaction.ratings.high.and.outcomes.promising,. researchers. found. that. master’s. level. clinicians. with. various. backgrounds. could. be. effectively. trained.in.the.approach.

The. other. model. is. a. flexible. application. of. STAIR/MPE. (reviewed. previously;. Levitt. et. al.. 2007).. In. this. model,. therapists. received. limited. training. and. had. little. or. no. CBT. experience.. They.were.encouraged.to.follow.the.manual,.but.to.use.it.flexibly.as.determined.by.their.judgment.. This.included.skipping.sessions,.repeating.sessions,.ending.before.the.full.16.sessions,.and.adding. nonprotocol.sessions.if.a.crisis.needed.to.be.addressed..On.average,.therapists.delivered.one.extra. session.of.STAIR.and.one.extra.session.of.MPE,.with.one.additional.nonprotocol.session.(Levitt. et  al.. 2007).. This. study. suggests. that. strict. adherence. to. manuals. may. not. be. necessary. and. that. training.should.help.clinicians.understand.the.rationale.for.each.treatment.component.so.that.they. can.determine.the.best.pacing.of.the.intervention.

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312 Behavioral Health Response to Disasters

17.3.2.1  Recommendations for Improving Dissemination Lack. of. training. is. one. barrier. to. care. that. can. be. overcome.. Evidence. suggests. that. community. clinicians.can.learn.to.deliver.these.treatments,.but.most.will.require.training..While.training.cli- nicians.in.advance.of.a.disaster.has.advantages,.we.believe.this.is.not.realistic..First,.community. mental.health.centers.do.not.have.the.resources.to.send.clinicians.to.trainings.if.they.may.not.be. needed..Second,.clinicians’.skills.will.likely.deteriorate.if.they.do.not.have.the.option.to.treat.clients. immediately.after.the.training..Therefore,.we.recommend.“just-in-time”.training..We.also.suggest. that.there.may.be.some.advantages.to.training.clinicians.in.a.model.like.CBT-PD.that.requires.only. a.single.training.but.is.effective.for.a.range.of.postdisaster.responses.and.disorders,.rather.than.tak- ing.the.time.to.train.clinicians.in.two.or.more.effective.treatments,.such.as.one.for.PTSD.and.one. for.depression.

Finally,.it.is.important.for.administrators.to.understand.that.just.because.clinicians.receive.train- ing.in.effective.treatments,.this.does.not.ensure.that.they.will.utilize.those.treatments..Significant. attention. must. be. directed. at. helping. clinicians. understand. how. these. treatments. can. be. specifi- cally.tailored.to.respond.to.their.client’s.unique.needs.while.still.keeping.faithful.to.the.manual..A. remaining.empirical.question.is.the.extent.to.which.clinicians.can.go.off.protocol.without.reducing. treatment.effectiveness.

17.4  SUMMARY AND CONCLUSIONS

In.this.chapter.we.reviewed.the.literature.on.the.range.of.long-term.treatments.available.after.a. disaster.and.on.issues.that.may.prevent.survivors.from.receiving.these.treatments..There.is.a.sub- stantial.literature.supporting.the.use.of.CBT.for.PTSD,.the.condition.most.commonly.observed. after.a.disaster..These.studies.include.a.few.studies.of.CBT.for.disaster-related.PTSD..We.also. reviewed. the. literature. on. CBT-PD,. a. treatment. that. can. be. delivered. more. broadly. to. survi- vors.with.postdisaster.distress..The.ultimate.decision.regarding.which.treatment.to.choose.may. depend.most.on.a.program’s.specific.goals.or.needs..For.example,.a.statewide.crisis.counseling. program.may.well.want.to.treat.everyone.who.is.significantly.upset.by.the.disaster..Therefore,. CBT-PD.may.be.the.right.choice..Conversely,.a.local.treatment.center.or.program.may.want.to. offer.services.to.only.those.who.are.most.severely.impaired.and.may.therefore.choose.a.PTSD. treatment.

The.review.on.barriers.to.care.reveals.a.complex.literature..There.are.many.factors.and.levels.to. contend.with..We.focused.primarily.on.survivor-level.barriers.and.clinician.barriers..For.survivors. to. seek. care,. they. must. first. recognize. they. have. a. problem;. second,. know. that. help. is. available;. and.third,.access.the.help..We.suggest.that.it.is.critical.to.provide.outreach.to.at-risk.groups.and.to. specifically.address.unique.barriers.to.care.for.these.groups.

With.respect.to.clinician.barriers,.we.focused.on.training.and.resistance..It.appears.that.clini- cians.can.be.trained.to.use.these.interventions..The.bigger.question.is.how.to.most.efficiently.con- duct.the.training..It.is.likely.that.large-scale.trainings.in.advance.of.a.disaster.are.not.feasible.and. clinicians.would.likely.need.a.refresher.course.just.prior.to.delivering.them..Thus.we.recommend. just-in-time.training.and.raise.the.issue.whether.it.is.necessary.to.train.clinicians.in.more.than.one. approach..Obtaining.trainers.may.be.another.barrier..One.possible.solution.is.to.provide.the.training. over.the.Internet.or.by.video-.or.teleconferencing.

A.more.radical.suggestion.is.to.provide.the.therapy.itself.over.the.Internet..These.options.are.low. cost,.have.the.potential.to.reach.large.numbers.of.survivors,.and.can.be.interactive.and.personalized. (Ruggiero.et.al..2006)..Moreover,.individuals.may.be.more.apt.to.use.the.Internet.than.a.therapist. due. to. stigma. associated. with. seeking. therapy.. These. programs. can. also. be. easily. revised,. may. reduce.the.burden.on.CBT.clinicians,.gain.high.satisfaction.ratings,.and.obtain.successful.outcomes. (Litz.et.al..2007;.Ruggiero.et.al..2006)..However,.currently.there.is.not.enough.data.to.recommend. this.option.as.a.primary.treatment.strategy.

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313Long-Term Mental Health Treatment for Adult Disaster Survivors

Finally,.clinicians’.resistance.to.providing.these.treatments.must.be.addressed..The.goal.of.dis- semination.is.to.change.clinicians’.behaviors.in.order.to.effectively.implement.treatments.(Marshall. et.al..2006)..Training.research.has.shown.that.targeting.clinicians’.expected.values.of.the.outcome,. beliefs.about.existing.norms,.and.self-efficacy.through.didactics,.demonstrations,.and.role-playing. is.crucial.(Marshall.et.al..2006)..This.research.also.demonstrates.low.favorability.ratings.toward. using.a.manual,.as.well.as.fears.that.clients.will.decompensate.in.trauma-focused.models.(Marshall. et.al..2006;.Cahill.et.al..2006;.Becker.et.al..2004)..Thus.these.specific.points.must.be.addressed.as. part.of.the.training.

To.convey.the.importance.of.using.treatments.that.are.supported.by.science,.administrators.and. trainers.could.use.a.metaphor.from.the.medical.field.to.emphasize.the.importance.of.using.effective. treatments:.“If.your.loved.one.was.ill.and.research.showed.that.one.medication.was.more.helpful. than.another,.would.you.choose.the.less.effective.one?”.Finally,.to.motivate.clinicians.to.use.effec- tive.treatments,.some.have.advocated.for.policy.change.in.managed.health.care.organizations.such. that.effective.treatments.are.reimbursed.at.a.higher.rate.than.interventions.without.an.evidence.base. (K..Mueser,.personal.communications,.November.20,.2009).

A. final. clinician. barrier. unique. to. disasters. is. that. clinicians. are. likely. to. share. in. the. experi- ence.of.the.disaster.with.the.survivor.seeking.care,.which.we.have.found.to.create.special.issues.in. training. and. implementation. (Hamblen. et. al.. 2009).. Although. these. collective. experiences. might. increase.empathy,.it.might.decrease.clinician.objectivity..For.example,.local.clinicians.might.have. difficulty.challenging.distorted.beliefs.around.the.likelihood.of.future.disasters.or.whether.things. will.ever.improve.because.they.may.struggle.with.these.very.same.beliefs..When.they.have.shared. the.client’s.experience,.clinicians.are.more.likely.to.engage.in.self-disclosure.and.are.more.easily. led.off.topic.during.sessions..These.issues.can.be.addressed.effectively.if.they.are.acknowledged. in.training..In.conclusion,.effective.long-term.treatments.exist.for.disaster.survivors..However,.to. optimize.these.treatments.we.need.to.make.sure.that.survivors.are.aware.of.them.and.that.they.are. delivered.in.ways.that.make.them.accessible.and.acceptable..Special.attention.must.be.paid.to.at- risk.or.marginalized.groups..Finally,.training.considerations.should.include.when.and.how.to.train. clinicians,.as.well.as.how.best.to.reduce.resistance.to.delivering.the.treatments.

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