For A-plus Writer Only

Book Reference

James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

A Brief History of Disaster Mental Health Provision When the first edition of this book was pub- IDJI lished in 1988, it didn't have a chapter on disaster re- sponse. The simple reason was that we would have been hard pressed to fill up three pages of print on theory, research, or practice with regard to the provision of mental health services after a large-scale disaster. Although the federal government has been involved in disaster relief since the 19th century, until recently it has paid very little attention to the psycho- logical aftershocks of a disaster. It wasn't until 1974, as part of a major overhaul of disaster policy, that the Disaster Relief Act was passed. In that bill was section 413, which authorized the National Institute of Mental Health (NIMH) to supply counseling ser- vices to victims of disasters and also provided funds to train professionals in the provision of mental health services to disaster victims. Since 1985 there has been close to a 400% increase in global natural disasters and on average over 1,000,000 people are killed a year by disaster and 216 million become victims (Center for Research on the Epidemiology of Disasters, 2014).

We believe that the notion that people would need mental health assistance after a disaster has roots similar to those of the crisis movement itself. It appears that at least four distinct variables fell into place prior to 2000 to make this happen. First was the birth of community mental health, authorized by the Community Mental Health Act of 1963, which put mental health workers in places like Rapid City, South Dakota, Wilkes-Barre, Pennsylvania, and Logan County, West Virginia. These were "hometown" folks, not bureaucrats in

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some far away capital city, and they would give voice to the mental misery survivors were suffering after a large-scale natural disaster.

Second was the classification of PTSD as a person- ality disorder in the DSM-III in 1980. That medical classification acknowledged and legitimized the con- cept of people suffering enduring mental problems after direct exposure to a life-threatening event. That diagnosis can admirably fit survivors of disasters.

Third was the American Red Cross's decision in the early 1990s to establish a mental health certifi- cation program after hurricane Hugo and the Loma Prieta earthquake in 1989. Indeed, the American Red Cross separated out disaster mental health from its disaster nursing mainly because of its workers' breaking down from prolonged field placements in

579

580 • PART FOUR No Man's Land: Facing Disaster

the back-to-back disasters of hurricane Hugo and the Loma Prieta earthquake (Morris, 2011).

Fourth was the women's movement during the 1960s and 1970s, which brought increased awareness of how often trauma strikes families and what its aftershocks do to a family whose entire belongings have been swept, blown, or burned away. When combined, these variables would play a major role in moving the concept of disaster mental health from an idle backwater into a tsunami of disaster mental health assistance in 2011. Given that movement, you are now going to read a whole lot more in this eighth edition than the few pages we might have scraped together in the first edition back in 1987.

If you harken back to Chapter 1, where we talked about the coalescing of grassroots movements into a large voice that attracts attention from the media, and soon after that legislatures, you will begin to understand why specific places like Rapid City, South Dakota, Wilkes-Barre, Pennsylvania, and Logan County, West Virginia, became important players in the birthing of disaster mental health. All three of these places suffered terrible flooding in 1972, and Logan County became particularly notorious because of a mining company's failure to maintain the Buffalo Creek dam, which ruptured. The resulting flood waters at Buffalo Creek killed 125 people and wrecked or badly damaged 1,500 homes. To make matters worse, God or Mother Nature didn't cause the disaster but the coal company did, so there was someone to focus attention on that could have prevented the disaster.

Local mental health providers were overwhelmed by survivors needing psychological assistance in all three places, and both state and federal officials were slow to react in providing help. This issue caught the eyes and ears of reporters, and a great deal of publicity was garnered in support of providing mental health assistance to disaster survivors. So legislators who were already attuned to the notion that victims would need psychological help thought it made good common sense (and particularly good reelection sense) to include mental health funding in the 1974 bill.

There was little researcJ;i. to back up the notion that a lot of people would need psychotherapy after a disaster, but that made little difference given the publicity these three floods received. The few mental health workers that were on scene and their cries for help made good subjects for interviews. One of the best examples of how well disaster mental health assistance could be played in the media was the San Fernando Child Guidance clinic that decided to get

into the trauma game after an earthquake struc·- the San Fernando Valley in California in 1971. T he clinic announced that they were offering counselinf services for children who had been in the quake area.. Over the next few weeks they counseled more tha.;:;. 500 children in the quake area and got the attention of the national media, which generated headlines like "Quake proofing kids." Dr. Stephen Howard, direcro::- of clinical services, got nationwide attention when he declared in an interview with the New York Times tha:: the American Red Cross's attitude of "keeping a stiE upper lip" wouldn't work and that survivors needec to "talk about their issues" (Morris, 2011).

Return now to Rapid City, South Dakota. The local government's small number of overwhelmeG. mental health professionals and the federal gm·- ernment's lack of interest in the survivors' plighc prompted a call for help from a steering committee the local mayor organized that reached all the way ro the Denver, Colorado, office of the National Institute of Mental Health. The NIMH finally responded br sending psychiatric help to the beleaguered city. The problems of adequate mental health provision that were uncovered at Rapid City motivated U.S. senators from the state to become very active in funding these provisions for the Disaster Recovery Act.

In Wilkes-Barre a model program developed by local community mental health providers and the National Institute of Mental Health served as a blueprint for the creation of disaster mental healtl:: programs. Called Operation Outreach, one componen~ of this program was the training of outreach workers to go out and meet survivors as they tried to reassemble their lives and provide basic mental health services. Their initial attempts to provide those services were not accepted kindly by the survivors until the workers started giving them assistance in getting the basic necessities of living back in their lives. Then t he survivors started to take them into their confidence. Please note that this is a hard lesson to learn for zealous mental health practitioners who voluntee::- to go to a disaster. Like the workers at Wilkes-Barre, and Dr. Holly Branthoover whom you will get to mee~ later in the chapter, it is about moving boxes, procuring lice kits, and having your underarm deodorant fai..:. before you ever get to the counseling stage.

Finally, rescue workers in the Buffalo Creek dam failure in Logan County noticed many of the symp- toms in survivors that would later be formalize · into PTSD criteria. The resulting lawsuit against the mining company whose failed dam had caused the

--·

Buffalo Creek disaster brought a number of famous mental health experts into the courtroom. One of them was Robe, .. • ,...fton, a psychiatrist from Yale, who had done extensive study on Vietnam veterans and would later lay the foundation blocks for what would become PTSD from his work with them. He recognized some of the same pathology in the flood survivors and testified that everybody in Buffalo Creek was affected (Morris, 2011).

A group of people from all three of these disasters were gathered by the medical advisor to the Office of Emergency Preparedness (then the leader in disaster mitigation). There was general agreement that there was not a large outbreak of mental illness, but it was acknowledged that the emotional security of a large number of individuals had been compromised (Morris, 2011). Thus was born the Disaster Relief Act of 1974. This act then evolved into the Stafford Disaster Relief and Emergency Assistance Act of 1986, whose section 416 provided for enhanced mental health services to disaster survivors.

To really understand why mental health generally did not get front row status for a long time, you need to understand that the U.S. government's historical approach to disasters was piecemeal and spread over a variety of agencies . It wasn't until 1978 that the Federal Emergency Management Agency (FEMA) was authorized. It absorbed a variety of agencies that ranged from insurance to weather prediction to civil defense to dam and building safety to counterterrorism. It essentially became a catchall for everything that might create some kind of disaster in the United States. After 9/ 11, FEMA itself was absorbed into the Department of Homeland Security, becoming the Department of Emergency Preparedness and Response Directorate, which pretty much put FEMA in the back seat politically, financially, and prioritywise. After the debacle of hurricane Katrina, FEMA once again regained stand-alone status as a department. So it is not just mental health that has been given short shrift, but the overall coordination of natural and human-made disasters in the United States. So why has all this now changed?

Since 1974 there has been a huge change in that now psychological services and the people who provide them are seen as an integral part of disaster intervention by the federal government (Dodgen & Meed, 2010). The trauma business meandered along in the 1990s, but school shootings such as the Columbine and Sandy Hook public schools, the Virginia Tech massacre, and the Colorado movie shooting focused attention on

CHAPTER SEVENTEEN Disaster Response • 5 81

disaster in suburbia, the carnage of 9/11 put trauma back up in lights on the national marquee, and the horrific foul-ups by FEMA during hurricane Katrina sealed the notion that mental health would be an important part of any disaster in the 20th century in the United States.

In the aftermath of Katrina, the government poured $52 million for mental health support into Project Recovery in Mississippi, Project Rebound in Alabama, and Louisiana Spirit in Louisiana. That sum of money was second only to the $132 million that went in to mental health services after 9/ 11 (Morris, 2011).

The emerging concern is how very large interven- tion systems interact with one another to deal with large-scale crises and megacrises that may arise at the national, state, or community level and directly or indirectly affect neighborhoods, families, and ultimately the individual. Part of the problem is that crisis response systems have not been upgraded along with the times. Remember from Chapter 1 that large disaster relief systems in the United States that are designed to physically aid communities after catas- trophes are about 100 years old (Echterling & Wylie, 1999). The field of individual crisis intervention as it is applied in a scientific and systematic manner is about 60 years old (Lindemann, 1944). Systematic and comprehensive intervention by the U.S. government is about 30 years old (Federal Emergency Management Agency, n.d .). The addition of psychological crisis intervention systems and their incorporation into those large macrosystems are about 35 years old-if we are very generous in our time estimation.

While there has been a great deal of research since 9/ 11 on what kinds of mental health intervention and techniques work on individuals (Watson, Brymer, & Bonanno, 2011), there has been very little research in large-scale ergonomics. Cognitive and organizational ergonomics is the rather exotic scientific discipline concerned with understanding the interactions among humans and other elements of a system. It is the profession that applies theory, principles, data, and methods to product design in order to optimize human well-being and overall system performance- which also applies to coordinating, collaborating, and allocating resources after a disaster.

While system interfaces with individuals and ergonomics are pretty cerebral and exotic and not likely to be the topic of discussion over coffee at Starbucks or beer at a sports bar, understanding how those systems work, what effects they have in the fight against terrorism and in large-scale natural disasters,

582 • PART FOUR No Man's Land: Facing Disaster

and the mental health issues that go with them is critically important. In a compelling article on this subject, Nickerson (2011) points out that his literature search turned up very little on how ergonomics could help deal with the effects of terrorism when they occur. That research is compelling because, over and over, communication between human beings operating in different systems becomes problematic. Former members of the 9/ 11 Commission, meeting on the 10th anniversary of that act of terrorism, stated that there were still problems of communication among first responders (Callahan, 2011).

Further, there is little research on how these large systems work-or, in fact, whether they do work-in a palliative psychological manner with various subsystems or individuals (Dziegielewski & Powers, 2005; Litz & Gibson, 2006). Finally, even less is known about what effects vicarious traumatization has on large systems, or indeed what we should do about the effects that instantaneous real-time electronic media can have on various subsystems and the individual (Ursano & Friedman, 2006). How well systems com- municate with one another and understanding the effects of rapid changes in technological, geophysical, and societal forces on prevention, intervention, and postvention are key issues in the mitigation of a disaster (Aten et al. , 2011; Stokols et al. , 2009).

To the contrary, research into evidence-based post- trauma practices for individuals has exploded since 9/ 11 in the quest to find the best way to help people with mental health issues postdisaster (Watson, Brymer, & Bonanno, 2011). The acronym PTSD was known to few people in the first edition of this book in 1988-even our students! Now PTSD has become a household abbreviation for somebody who is trau- matized. Professional organizations have ramped up their focus on trauma. Division 56, Trauma Psychol- ogy, has been formed by the American Psychological Association and is one of its fastest growing divi- sions. The Council on Accreditation of Counseling and Related Educational Programs (CACREP), the accrediting body for counselors, has mandated crisis intervention as part of a required curriculum, as has the National Association of School Psychologists. Government, government-subsidized agencies, and professional organizations have published psychoedu- cational materials that range from mental health reac- tions after a disaster (National Center for PTSD, 2014) and providing schools with memorial guides to 9/11 (American School Counselor Association, 2011). Two centers for dissemination of information and research,

the National Center for PTSD and the National Child Traumatic Stress Network have come into existence in the last 10 years as a direct or indirect consequence of 9/ 11, Katrina, and Columbine High School.

Where the World Is The United States is not alone in its changed lmJ attitudes toward mental health provision after a natural disaster. Australia has been one of the leaders in the area because of the many natural disasters it has faced. Beverly Raphael, a professor of psychiatry in Australia, has been in the forefront of disaster research and practice with her landmark books The Anatomy of Bereavement (1984), When Disaster Strikes (1986), and Disaster Mental Health Response Handbook (2000), and dozens of research articles, chapters, and edited books on trauma and disaster.

Europe has established the European Network for Traumatic Stress (TENTS, 2011) in response to a need for consensus on what evidence-based outcomes work. TENTS has been funded by the European Union and has built Europe-wide networks of expertise in the psychosocial management of victims of natural and other disasters. It provides services, expertise. and support to areas of the Union that lack resources and availability of trained personnel (TENTS, n.d.) .

Internationally, the United Nations' Inter-Agency Standing Committee (IASC, 2007) has publishedJASC Guidelines on Mental Health and Psychosocial Input Support in Emergency Situations. Those guidelines are being used by countries as small and remote as Nepal to put into operation their disaster responses 0ordans et al., 2010).

International Terrorism and Human-Made Disasters The ecological, contextual model of cns1s in- tervention, based on ecosystem theory that has emerged on the international scene, is character- ized by continuously accelerating events in dynami- cally changing cultures and environments (Conyne et al. , 2003; James, Cogdal, & Gilliland, 2003; James & Gilli.land, 2003, pp. 341- 342; Myer & Moore, 2006: Norris ~-- 2006). Foremost among these events in the United States has been the September 11, 20 01. hijackings and terrorist attacks and destruction of the World Trade Center towers in New York City, the attack on the Pentagon, and the crashed airliner in Pennsylvania. These tragedies caused untold grief. loss of property, loss of life, economic damage, and a

change in the attitudes of most Americans regarding safety and security (Bass & Yep, 2002; Pyszczynski, Solomon, & Greenberg, 2002). The actions following 9/11 also set in motion other unprecedented events, such as the passage of the Homeland Security Act by the U.S. Congress and the invasions of Afghanistan and Iraq, and placed security in the United States at wartime levels. Practically every American had the feeling of having been individually attacked (Brainerd, 2002) and that we were, indeed, at war.

Add to 9/ 11 other terrifying events-the bombing of the Murrah Federal Building in Oklahoma City, the attacks on students in high schools from Littleton, Colorado, to Springfield, Oregon, to college students at Virginia Tech University and Northern Illinois University-and there is good reason for most Americans to think the United States is no longer a sanctuary but a battleground. Across the world, events such as the taking of hostages by Chechens and their resulting deaths in a rescue attempt in a Moscow theater and a southern Russian school, Palestinian suicide bombings in the streets of Israel, Muslim radicals' bombing of a nightclub and hotel in Bali and Jakarta and trains in Madrid, the Charlie Hebdo magazine attack in Paris, the assassination of armed services recruiters in Chattoonga, Tennessee, drug gang wars in Mexico that approach total war, embassies and nightclubs blown up in Africa and Asia by al Qaida, and the postwar chaos in Iraq and Afghanistan all send clear mes- sages that the world is an unsafe place and that terror may strike unannounced anywhere and at any time. As a result, the hypervigilance of being constantly on guard, the economic loss because of these attacks, and the social and financial expenses of guarding against them cause a variety of previously unknown stressors to appear that impact and crosscut entire nations, cultures, and ecosystems.

Disaster in the form of terrorism has its own special brand of traumatic wake for survivors and has the potential to have metastasizing effects across large systems (Huddy & Feldman, 2011; Morgan, Wisneski, & Skitka, 2011; Ursano & Friedman, 2006). This is true because of the unpredictability of the when, where, and to whom it will happen. Further, the seeming randomness creates fear and anxiety because there is no assurance it will not happen again, and where is anybody's guess. The use of insidious means such as poison gas, germ warfare, or nuclear arms causes horror and incredulity at their seemingly immoral use in the business of mass murder. Infor- mation is often inaccurate or highly controlled by the

CHAPTER SEVENTEEN Disaster Response • 5 8 3

government, which creates uncertainty and anxiety. Increased, constant hypervigilance creates constant and heightened anxiety, which causes both immedi- ate and long-term physical health problems.

Media coverage enhances the horror of gruesome death and injuries. Constant viewing of scenes of death and destruction increases trauma risk. Further compounding the trauma is the aftermath of the terrorist attack with ruinous financial loss and frus- tration and anxiety at the government's inability to act or bring the perpetrators to justice-particularly when they are outside the country's borders. Finally, there is the added difficulty of finding victim services and mental health professionals who have the know- how to deal with the unique issues that terrorist vic- tims bring with them (Dziegielewski & Sumner, 2005; Myers & Wee, 2005, pp. 247-248). Pastel and Ritchie (2006) aptly call these weapons of mass disruption be- cause of the profound psychological ripple effects they cause.

The Israelis are no strangers to terror. Practically all Israeli children carry cell phones so that they can immediately contact their parents and let them know they are safe after bombing or rocket attacks. It is somewhat chilling that one of the favorite children's costumes during the Israeli Purim holiday (somewhat equivalent to Halloween in the United States) among ultraorthodox Jews was a replica of the "Zaka" uni- form. Zaka is an ultraorthodox volunteer organiza- tion dedicated to ensuring proper burial according to Jewish rituals. In the immediate aftermath of a terror- ist attack, they search for body parts to bring as much of the body as possible to burial (Galai-Gat, 2004). After Galai-Gat delivered the paper just cited at the Annual Convening of Crisis Intervention Personnel, she related how amazed she was that people could come and go so freely from the downtown Chicago hotel where the convention was being held.' Thus in a changing world, the question arises, "As go the Is- raelis, shall the rest of the world go also, and does our mental health system go with it?"

Terrorism brings unique challenges to mental health professionals when weapons of mass destruction are used. The ratio of physical dead and wounded to psychologically afflicted is astounding. Obhu and associates (1997) found that in the Tokyo subway gas attack 11 people died but up to 9,000 people sought medical care because they thought they had been gassed. There is also the potential for organic men- tal disorders along with standard stress reactions given the type of weapon used. Medical isolation and

584 • PART FOUR No Man's Land: Facing Disaster

quarantine can create additional stress in individuals who may not be able to receive support from their social systems and in fact may be seen as lepers to be avoided (Flynn, 1998).

The worldview of individuals subjected to terrorist- generated disasters may be very different from others'. There is a good deal of evidence to indicate that these individuals experience PTSD, panic and anxiety disorders, and depression at a far greater and more intense rate than others who are subject to "natural" disasters .(U.S. Department of Justice, 2000). While there has been progress, with the counseling field becoming more trauma aware (Shallcross, 2011) and the Red Cross making concerted efforts to provide crisis intervention training to wider segments of first responders, there is as yet little unified training for the sheer number of mental health providers needed in any large-scale disaster or megadisaster. This issue is even more pressing with the lack of expertise to deal specifically with terrorist acts (Myers & Wee, 2005, p. 251; Roberts, 2005).

Lastly, the mental health infrastructure itself may be destroyed or disabled by human-made or natural disasters or simply be overwhelmed by the stagger- ing volume of people it will be expected to service. In her pictorial representation of early interventions with survivors of terrorist attacks, Galai-Gat (2004) showed a Gary Larson cartoon of a crisis center go- ing over a waterfall while on fire-a good analogy for the worldwide state of crisis intervention and what kinds of chaos ecosystemic crises can bring to local agencies, as witnessed by New Orleans mental health facilities attempting to get back into operation after being completely shut down by hurricane Katrina (Shraberg, 2006).

New Directions and New Visions Crisis intervention is no longer just a one-on- lmJ one proposition. We would like to introduce you to what we and some others (Cook, 2012; Collins & Collins, 2005; Gist & Lubin, 1999; Kilmer et al. , 2010; Myer & Moore, 2006; Stokols et al., 2009) believe will characterize more and more of what crisis intervention will become in the 21st century-ecosystemic crisis intervention in the wake of a large-scale crisis or megadisaster (James, Cogdal, & Gilliland, 2003). An ecosystemic crisis is one that reaches out and pervades at a minimum the community and perhaps whole regions or nations. It may be immediate and horrific, like 9/ 11, with a relatively small loss of life, but have

immense ramifications and spread shockwaves around the world. It may slowly and surely spread out across whole continents and have the potential fo r a tremendous loss of life, such as the African Ebola epidemic or bird flu. It may be human-made, occur dramatically, and then have long-lasting environmen- tal effects that span thousands of years and destroy the social and governing infrastructure of an entire region, such as the Chernobyl nuclear power planr explosion and contamination (Bromet, 1995). It may be malevolent terrorism, creating widespread fear and anger, such as 9/ 11. It may be a smorgasbord of natu- ral disasters such as the tsunami that struck Japan or hurricane Katrina that drastically altered the land- scape and the lives of those in the surrounding area.

In varying degrees, an ecosystemic crisis does all of the foregoing. An ecosystemic crisis not only creates victims who directly experience the traumatic event in widespread numbers, but also creates potential victims because of their vicarious experiencing of the event-even though they may be some geographical or psychological distance from the event itself (Chung et al. , 2003; North, 2004; Shallcross, 2011).

This is particularly problematic because often insurance or other mental health care providers do not recognize these groups of survivors as being in need of assistance (Galai-Gat, 2004). Therefore, the definition of an ecosystemic crisis used in this chapter is some- what different from the definition of crisis as it applies to individuals that is used in the rest of the book. An ecosystemic crisis is any disruptive or destructive event that occurs at a rate and magnitude beyond the ability of the normal social process to control it. Unless dedicated resources are brought to ease the crisis, the integrity of the social fabric is generally degraded in the course of the event such that it becomes very difficult if not impossible to sustain the way oflife as it was before the crisis occurred (Ren, 2000).

Although a number of theorists and researchers have examined wide-scale disasters and the collective experiences of the populations who experience them (Freedy & Hobfoll, 1995; Gist & Lubin, 1989; Hobfoll, 1988; Hobfoll & deVries, 1995; Kaplan, 1996), most of the literature focuses on a dissection of the indi- vidual's psychological responses (Kaniasty & Norris, 1999). Kaniasty and Norris (1999) propose that the individual's psychological response to disaster cannot be understood without considering the collective response that interacts with the political, cultural, environmental, and social realities of the ecosystem as it operated prior to and after the disaster.

Alternatively, on a very pragmatic and mundane level, the Federal Emergency Management Agency (FEMA) and its various departments spend a great deal of time and energy on providing education, information, and direct service in regard to opera- tional responses to disasters of all kinds (Federal Emergency Management Agency, n .d.). However, what FEMA-or anyone, for that matter- doesn't do is determine how this all goes together, and as you will see in a short while, that had ominous implications when hurricane Katrina came ashore. What one also does not find is a way of making sense out of how crisis intervention strategies interface with the community-wide stressors people experience after a disaster and the various agencies that respond to help them.

Although the impact of community-wide and na- tional traumatic events go back historically at least as far as Pompeii being buried by volcanic explosion nearly 2,000 years ago or the Black Plague killing mil- lions of Europeans in the Middle Ages, the knowledge of those catastrophes and their resulting impact were slow to be felt because news of the disaster traveled only by word of mouth. Likewise, help could come only as fast as responders could spread the word and bring together resources that might arrive in horse- drawn carts or be carried on one's back. Often help was simply unavailable, as there was no known way to mitigate the spread of disease.

Communities were isolated, and when a natu- ral or human-made disaster struck, it was typically felt only at the local level. Further, at the local level, the constituents were essentially of the same race, tribe, or clan, or other social identity and commonly held the same cultural, moral, and religious values. In short, until the 20th century, if Haiti suffered an earthquake, it was known and dealt with by the local community and perhaps the regional ruler. The prevailing philosophy was that people took care of themselves because they were the only ones affected by the traumatic event. In fact, if "strangers" had come to offer help, they probably would have been viewed with distrust and suspicion, given the insular cultural values of the time. The best that could be done proactively was to build cities that wouldn't be washed away by flood or blown away by winds, or to quarantine cities infected with disease. Historically, then, most crisis responses were by passive, preventive means that were meant to minimize the damage before it occurred. Little could be done after the fact to minimize the deaths, economic loss, or societal disintegration.

CHAPTER SEVENTEEN Disaster Response • 5 8 5

It should also be understood that there is a rather spirited debate today in world health circles as to whether there is in the Third World any need for a Western world mental health disaster mitigation plan as opposed to the need to obtain basic necessities for survival. PTSD is seen as a Western cultural artifact contrived to justify and propagate the medical mental health model (Summerfield, 2005). To the contrary, others do not see PTSD as a cultural artifact, but indeed a phenomenon that is cross-cultural in nature, and that to deny it would be a terrible professional error and subvert the prevention of suffering (deVries, 1998; Dyregrov et al., 2002).

With the advent of the industrial and informa- tion ages, active crisis intervention came to mean that a whole society could be rapidly mobilized and coordinated to reshape the total dynamics of a crisis by using the machines and the command/control/ communications/ intelligence systems that have evolved in the last two centuries (Ren, 2000). With the condensing of geographic and communication distances, a fundamental but essential trend is that a crisis can no longer be contained within an enclave. The interventionist must necessarily function within and become an integral part of an ecological system that is continually and often richly interwoven with environmental components in the immediate neigh- borhood, town, district, borough, city, county, parish, canton, state, province, country, continent, hemi- sphere, and ultimately the world.

This fundamental trend is a melding of systemic crisis intervention strategies that interact in the total environmental and multicultural context of a plu- ralistic and dynamically changing world. Yet this view is clearly not shared by everyone and may be seen by some as a pretext to impose Western medical practices on the rest of the world. Thus, in the early edition of the Sphere Project world health working paper on disaster response ("Humanitariai;i Charter," 1998), mental health was not even covered. Indeed the term psychosocial (having mental distress as a result of social upheaval) has been coined to take away the stigma that a person is mentally ill (Van Ommeren, Saxena, & Saraceno, 2005). Note what the Interna- tional Inter-Agency Standing Committee Mental Health and Psychosocial Support calls itself to make it more palatable to some parts of the international community (IASC, 2007). Indeed, most survivors of a catastrophe may only need social support, and "psychosocial support" is a lot more psychologically palatable than the designator of being "mentally ill."

586 • PART FOUR No Man's Land: Facing Disaster

You should thus understand that what is being proposed in this chapter is not universally loved and admired, or even thought to be necessary or right by a number of people.

To that end, this chapter deals with an emerging ecosystemic view of what crisis intervention is becom- ing as it operates in large systems and deals with me- tastasizing crises, large-scale crises, and megacrises. Metastasizing crises are those that start small but, if not contained both physically and psychologically, can quickly turn into large-scale crises (James, 2006). Large~scale crises are those that at a minimum affect whole communities or regions either directly or vicariously. Megacrises are defined as those that affect entire countries or the world, either directly or vicariously.

System Overview The ecological, contextual cns1s intervention approach that is described in this chapter reaches far beyond the relational interactions between and among the various members of the crisis client's family, or individuals in the client's workplace and immediate surroundings. Essentially, it is a dynamic, sociocultural, and multicultural view of all ecologi- cal influences that impinge upon the individual. It consists of five environmental systems, ranging from the fine-grained inputs of direct communications with social agents (individuals capable of interacting directly with crisis clients) to the broad-based inputs oflocal community agencies as well as the widespread influences of national imperatives and attitudes and ideologies of the cultures within which these systems operate (Santrock, 1999, pp. 42- 44). Cook (2012, p. 5) defines the term ecosystem as "The total sum of the interactive influences operating within an individu- al's life in varying degrees of proximity ranging from his or her biologically determined characteristics to the broader socio cultural context which structures human interactions." The approach is continually changing, emerging, evolving, and developing to ac- commodate the ecological and multicultural contexts within which it exists. It represents a paradigmatic shift: a newly emerging ecosystem that encompasses an interdependency among and within people at all different levels of the total environment. This is not some static amorphous entity. It is very much alive, and as one part is impacted, other parts react.

This ecosystemic view of crisis intervention is adapted from Uri Bronfenbrenner's (1986, 1995;

Bronfenbrenner & Morris, 1998; Santrock, 1999. pp. 41-46) ecosystemic theory of human develop- ment, and our own (James, Cogdal, & Gilliland, 2003: James & Gilliland, 2003, pp. 336- 337, 341- 342) and other psychotheorists' views (Cook, 2012; Conyne & Cook, 2003; Conyne et al. , 2003; Klotz, 2003) of eco- systems as they apply to psychotherapy in general and crisis in particular (Collins & Collins, 2005; Norris et al., 2006; Vernberg, 1999). In crisis intervention terms, not only is the individual in crisis affected bm also the client's total environment becomes the con- text that must be considered by crisis workers (Myer & Moore, 2006). Bronfenbrenner (1986, 1995) identified the five environmental components as the microsys- tem, mesosystem, exosystem, macrosystem, and chro- nosystem. (See Figure 17.1.)

Microsystem The microsystem is the setting in which the person in crisis lives. The microsystem setting's contexts may include the individual's family, friends, coworkers, peers, school, neighborhood, and usual haunts. It is within the microsystem that the individual in crisis experiences the most direct social interactions and communications with others. In the microsystem set- ting, whatever difficulties individuals experience tend to spill over into the family constellation and com- pound the difficulties caused by the disaster (Green & Solomon, 1995). In the traumatic wake of a disaster, many previous relationships, alliances, partnerships, bonds, and compacts in the microsystem, which were held together in the immediate aftermath as a means of mutual survival, crumble under the weight of com- pound stresses (Smith & Belgrave, 1995).

The crisis worker adhering to the ecological, contextual, multicultural approach views the person in crisis not as a passive recipient of experiences in those microsystemic settings but as an individual who actively participates in the construction of the settings (Santrock, 1999, p. 42). Reciprocally, the settings have a positive or negative effect on the indi- vidual and family and may ameliorate or exacerbate the crisis depending on the person's proximity, rela- tionship to, and perception and meaning of the event (Myer & Moore, 2006).

Mesosystem In Bronfenbrenner's (1995) developmental system, the mesosystem serves as the communications chan- nel, pathway, or interactive mechanism between components in the microsystem and the exosystem.

CHAPTER SEVENTEEN Disaster Response • 5 8 7

International macrosystem

Internet

/ National macrosystem World Culture International

media

U.N

\

NIMH

/

Interstate highways

I FEMA State/local emerg. serv.

TT Interoperability service

Dept. of Homeland Security \

GPS

Exosystem Local mental ~--.....__ health agencies

Primary mesosystem \

Local politics

Local media

Churches

Neighborhoods

Word of mouth

) Local phones

Police

State/national Red Cross

J State and

national agencies

International/ national politics National media

/ Wireless phones

Microsystem: Mesosystem: Exosystem:

Macrosystem:

Airlines and sh ipping

National professional organ izations

International professional organizations

The setting in which the ind ividual lives. The relationships, connections, and commun ication links between individuals and systems. The experiences in another social setting in which the individual does not have an active role; the exosystem does influence the individual's experiences in the immediate context. The national and regional systems, attitudes, and ideologies, behavior patterns, beliefs, and other products that are passed on from generation to generation and make up the fabric of the larger culture.

IUflmjiQI Adaptat ion of Bronfenbrenner's Ecosystemic Model for Crisis

The mesosystem is essentially the total communica-

tions network that allows all indiv iduals and groups

within each ecological system to exchange informa-

tion. It includes every form of communication-from

word of mouth to the most sophisticated electronic

technology- and is far more than cell phones and

television news announcements. In t erms of crisis and

crisis intervention, the mesosystem and its function

as the command-and-control structure of the total

system are critical.

588 • PART FOUR No Man's Land : Facing Disaster

The cns1s mesosystem is interspersed not only between the microsystem and exosystem (primary mesosystem) but between the exosystem and the macrosystem as well (super mesosystem). Both the primary and super mesosystems play critical roles in resolving ecosytemic crises. These two systems are extremely fluid and may expand very rapidly during a crisis. Think of a lava lamp where, as the oil heats up there are rapid and nonsymmetrical movements of the colored oil. This analogy carries over to a rapidly heati.ng and expanding crisis. (Whether this expan- sion alleviates or exacerbates the crisis depends a great deal on how and what is communicated by whom and under what circumstances.) One of the major failures in the aftermath of hurricane Katrina was the break- down of this system at both the primary and super levels. It should be understood that disaster mental health systems are complex mesosystems (networks of other systems) in and of themselves, and what makes them even more complex is that they will be imposed on to host micro- and exo-mental health systems that have their own agendas, vary in preparedness for a disaster, and may well suffer severe disruption them- selves due to the disaster (Norris et al., 2006).

Local emergency management agencies (LEMAs) expend a great deal of time and effort conducting tabletop and on-scene exercises to determine the most effective way of handling a crisis, dealing with logistics, and field-testing communication links (Freeman, 2003; Lane, 2003). These systems directly link crisis interventionists with emergency manage- ment agencies. Human services workers trained by NOVA, FEMA, the American Red Cross, and state and local mental health agencies are on call for emergen- cies, and when a disaster of a magnitude greater than what the local authorities can handle is encountered, these crisis teams are called up and go into action. In the United States, calling up the National Guard is a fair analogy to what happens when a call goes out for crisis workers. Hurricane Katrina is an excellent example of the need for both.

Primary Mesosystem. Communication in the primary crisis mesosystem means having translators to speak to victims whose native tongue is not the national language. It means having ham radio operators and trained weather spotters with two-way radios and crisis response teams and search-and-rescue teams with walkie-talkies to communicate with one another in wrecked buildings or in a blown-down forest . It means establishing clear links from emergency management agencies to media outlets. It means

creating integrated communication networks betwee emergency management agencies and a wide variety of supportive agencies that range from law enforcemem and fire departments to heavy equipment operators and mental health professionals.

A primary mesosystem is everything from sign language for a deaf person to the most sophisticated wireless computer satellite uplinks to state and federal emergency management agencies (EMAs (Freeman, 2003; Lane, 2003). It maintains con- nections and communications within and amon6 workplaces, schools, churches, families, peer groups. and local social, medical, and governmental services (Bronfenbrenner, 1995; Freeman, 2003; James & Gilliland, 2003, pp. 341-342; Lane, 2003; Santrock. 1999; Stewart-Sickening & Murai, 2012).

For crisis intervention agencies, fast, effective. clear communication is at the center of everything they do. Communication redundancy is critical because if one system fails, another can be substi- tuted. For example, during an electrical storm, the emergency management director of Nassau Count}", Florida (Jacksonville area), was in her car and attempt- ing to communicate with a member of her staff about storm damage. But she quickly found that commu- nication was impossible because of electrical interfer- ence. Despite all of the sophisticated equipment that the county EMA had, the only thing that worked was leaving messages on each other's voice mail (Freeman, 2003). It is not accidental that Jerry Lane, the former emergency manager of the city of Sycamore, Illinois, is a licensed advanced-class amateur radio operator (Lane, 2003). One of the more aggravating problems of hurricane Katrina was that various local agencies used different radio frequencies and could not com- municate with one another, nor could they commu- nicate with the super mesosystem. Thus a recurring theme throughout disaster intervention is that com- munication is vital to the ability to respond in a disas- ter (Rebman, Carrico, & English, 2008).

Super Mesosystem. Interlinking the macrosystem with all interior systems is the super mesosystem. The su- per mesosystem that connects the exosystem and the macrosystem serves many of the same coordinating functions, but on a national level. The super mesosys- tem is composed of information systems that range from the postal service, to national commercial radio and television corporations, to the Internet and its websites, e-mail, instant messaging, and chat rooms to satellite communication and global positioning sys- tems. Federal agencies such as FEMA, and its parent,

the Bureau of Homeland Security, are linked with other governmental agencies such as the Bureau ofJustice and private agencies such as the Red Cross and National Organization of Victims Assistance, National Oceanic and Atmospheric Administration weather satellites, the U.S. Weather Service storm prediction centers, super- computers at national agencies that model and predict disaster scenarios and relief efforts, and the National Emergency Broadcast systems for the public.

National agency and federal department interlinks and downlinks to state EMAs and agencies are all part of the super mesosystem for crisis intervention that operates in the United States. It has major command- and-control centers that can be linked to state commu- nication and control centers, which in turn are linked to local emergency operations centers. These national organizations and agencies have complete mobile command, control, and communications centers that can be rapidly moved on tractor trailers by highway, rail, or ship, or flown into any disaster site. This system was so devastated during hurricane Katrina that the base of operations for repairing the levees and pumping systems in New Orleans was situated in the U.S. Army Corps of Engineers office in Memphis, Tennessee, more than 400 miles up the Mississippi River!

Therefore, the mesosystem is of primary concern to crisis interventionists and the crisis intervention process because it coordinates and drives the dynamic linkages among all components (people, groups, con- textual connections, ecological resources). The crisis interventionist- in the role of consultant, collabo- rator, coordinator, and communicator- is a key re- source person operating within the mesosystem.

The advent of smartphones with multiple applica- tions has enhanced the potential of both the primary and super mesosystems in a variety of ways that were unimaginable as little as 5 years ago. Aten and asso- ciates (2011) have detailed a number of applications made possible by this new technology:

1. Texting takes far less bandwidth than talking. When other phone systems are plugged up, text messages are likely to get through. Many universi- ties now have text warning systems that can get to any student who has a cell phone on.

2. Smartphone users with weather and news apps can access outside information when they might not otherwise have access to current conditions that affect the crisis.

3. Social networking sites such as MySpace, Face- book, Twitter, Flickr, and Linkedin allow people to stay in synchronous contact with other net

CHAPTER SEVENTEEN Disaster Response • 589

users. Clearly these sites can be used for organiz- ing activities of large groups of people, as wit- nessed by the recent revolutions in Egypt and Libya which used these devices to organize large demonstrations and avoid police dragnets. These sites would seem to have the same applicability in organizing people during disasters.

4. Global positioning systems (GPS) have proliferated both as hardwired applications in automobiles and trucks and in portable systems such as smartphones. These have tremendous applicability in a disaster for directing traffic, giving directions, providing alter- nate routes, and locating people who don't know where they are. Onstar is a satellite communication, GPS, and emergency notification communications system hardwired into new General Motors (GM) ve- hicles. GM has teamed with the American Red Cross to provide information on shelters, medical services, safe routes, food sources, and other services. Aten and associates (2011) reported that Onstar's usage rate went up 30% during hurricane Gustave, which is a pretty good indication of how much its subscrib- ers relied on it during what they considered to be an emergency ("GM's Onstar," 2008).

5. When super mesosystems use systems like Onstar, a great many people can access these systems in a hurry, and they don't need an electrical transmission line to do it. The Centers for Disease Control have picked up on this technology and made podcasts that provide "what to do and what to know" information about disease epidemics, safety tips, and other health-related information that can be used by people in disaster areas with no electricity who might otherwise be cut off from critical health information (CDC, n.d.).

The point of all th is new technology is that for many people in the primary mesosystem, using it daily is standard practice. Thus super mesosystems like those operated by the federal government or interpational charitable organizations can use it not only with their own workers when standard communication links are down, but also with a large number of primary system users who are not mystified by the techljlology and can then spread the information by word of mouth. If these new devices and systems are put to use wisely, they may do much to push the communication problems that have plagued relief efforts into the dustbin of history.

Exosystem The exosystem exposes the crisis client or clients to expe- riences in a wider social setting than those encountered

590 • PART FOUR No Man's Land: Facing Disaster

in the microsystem context (Bronfenbrenner, 1986, 1995). The exosystem reaches much farther out into the community and may even include state or regional en- tities. Legal and social welfare services, local mass me- dia, and all governmental agencies and programs that are in a position to impact the individual and to assist persons, families, or groups who are in crisis are part of the exosystem. Crisis workers who live in other parts of the state or province may be called in to help. Typically, in the United States, each local EMA has backup per- sonnel.who are in place or on standby support if a crisis arises that temporarily exceeds local capacity to handle the situation.

How effective the exosystem and macrosystem are in providing services depends in large part on how well information passes back and forth through the primary and super mesosystems and how well resources are allocated, delivered, and used based on that information. The FEMA on-site, one-stop-shopping for all related disaster assistance to individuals is an excellent super mesosystem example of direct com- munication between victims in the microsystem and national providers in the macrosystem.

Macrosystem The macrosystem includes the national government and all its agencies, and national charitable, religious, service, professional, and benevolent organizations. It encompasses the national rail, air, marine, and highway transportation modalities, and food, fuel, and energy transmission systems. The macrosystem encompasses the total culture in which people live (Bronfenbrenner, 1995). Total culture refers to the behavior patterns, traditions, beliefs, mores, historical artifacts, legal constructs, and all other traits and pursuits that are endemic to a group of people and that are passed on from generation to generation (Santrock, 1999, p. 44) . The macrosystem has importance in crisis interven- tion for two reasons. First and foremost, when a disas- ter exceeds the normal coping capacity of the disaster impact area, the macrosystem is most likely the place from which help and resources will flow. Second, if the crisis is of a national magnitude such as 9/ 11, it will be important to do a triage assessment of the national psyche to determine what if any intervention needs to occur with the entire ecosystem.

Disasters do not have to be large in geographic scope or have large numbers of fatalities to be consid- ered macrosystemic. The killing rampage ofSeung-hui Cho at Virginia Tech in April 2007 was an isolated in- cident. Although 32 people were killed, that number

pales in comparison to the number of dead on 9/11 in 2001 or the almost daily casualty rate in the Afghan War or the weekly death tolls on U.S. highways. By all objective measures, the Virginia Tech killings were a small disaster. Yet the fact that the tragedy occurred on a quiet college campus, in a place where one's children are supposed to be safe, upset the nation's sense of con- trol much as the Columbine High School and Sandy Hook shootings did. The Virginia Tech tragedy quickly turned into a metastasizing crisis that carried far be- yond Blacksburg, Virginia. While landline telephone connections jammed up, text messaging, which takes far less bandwidth, did not. Facebook and other social networks were relaying news of the tragedy as it took place and identified danger zones the students needed to stay out of and get away from (Aten et al., 2011).

Most particularly, parents who had sent their chil- dren off to college became very concerned about their children's health and well-being, no matter what u n i- versity or college they attended and no matter what part of the country it was in. Those parents immedi- ately began sending a deluge of phones calls, letters, and e-mails to universities across the country (a na- tional macrosystem), demanding to know what safety measures were in place to protect their children from psychotic gunmen and other potential predators.

Perhaps even more important, the constituency of the universities, students and professors, are highly capable of communicating across the super mesosys- tem via e-mail, blogs, cell phones, and text messages. That rapidly expanding super mesosystem put the in- formation, conjecture, hypotheses, and rumors abour the massacre at Virginia Tech out into the interna- tional macrosystem within hours of the shootings. As an example, the dark, violent, and macabre plays that Seung-hui Cho is alleged to have written as a student at Virginia Tech were published in the blogosphere 24 hours after the shootings occurred.

Chronosystem The Individual. The chronosystem is identified by Bron- fenbrenner (1995) as the patterning of environmental events and transactions over the life span as well as the social and historical circumstances that influence the individual, family, peers, coworkers, and others. The es- sence of the chronosystem is the dynamic influence that time has on events, and time, with its movement, is an absolutely critical variable in regard to disasters. The cri- sis chronosystem starts with the birth of the traumatic event and not the birth of the person. Although the crisis chronosystem starts with the event, if possible the crisis

interventionist needs to backtrack over the personal developmental chronosystem of the individual to deter- mine what, if any, precursors may have contributed to the incident's impact and what antecedent events may cause it to be exacerbated.

In crisis intervention, understanding the part the chronosystem plays in exacerbating or ameliorating the crisis is particularly important. There are two types of disaster trauma-individual and collective (Erikson, 1976). Individual trauma hammers the individual

CHAPTER SEVENTEEN Disaster Response • 5 9 1

psyche and breaks through the person's defense so forcefully and suddenly that reaction is impossible. Collective trauma does the same thing, only it does it across the microsystem (the community) to the ex- tent that the social bonds that connect people are torn apart and the community is rent asunder. The chrono- system is important for both individual and collective traumatic responses and can be marked in phases that are generally linear and progressive in nature (see Figure 17.2). Following are brief descriptions of those phases.

Time Individual/systemic

traumatic onset of a crisis event

Event occurrence

First hours

Impact

Emergency/acute heroic phase

Inventory phase Shock, denial, hysteria,

anger, grief (peritraumatic symptoms)

Acute stress disorder

Chronic posttraumatic stress disorder

Delayed onset posttraumatic stress disorder

Anniversary of cr isis; regression to event

Transcrisis-complicated grief, delayed PTSD, chronic drug use, anniversaries , etc.

First days

First month

3 months

6 months

1 year

More than a year

otdimiflj Pat hological Chro nosys tem of a Crisis Event

Honeymoon phase

Avoidance phase

Adaptation phase

Disill usionment phase

Pathogenic to salutogenic shift

Restabil ization/reconstruction

592 • PART FOUR No Man's Land : Facing Disaster

Impact phase. The first few minutes and hours during and immediately after the crisis are critically important. While fear and shock are common, most people behave adaptively and take action to protect themselves and their loved ones. Time may become disoriented and slowed down, with disbelief and denial at what has happened. However, while a good deal of collective chaos may ensue, people react mainly in proactive ways (Myers & Wee, 2005, p. 20). Maslow's hierarchy of needs comes into operation, particularly when th·e crisis is a disaster that leaves people without food, shelter, or clothing. As the crisis plays out in the traumatic wake of the next few days, the resolution of problems ranging from having a roof over one's head to communicating or being physically reunited with one's family becomes critical.

Emergency/ acute heroic/ rescue phase. Immediately after impact, people spring into action to save others and to save property and regain control of the situation and environment. During this heroic or rescue stage (Myers & Wee, 2005, pp. 20- 21; NIMH, 2002; Pennebaker & Harber, 1993) individuals are generally highly energized physically and emotionally, have great morale, cognitively perseverate on the event, and gain relief by talking about their anxieties surrounding the crisis and their responses to it. While individuals are highly energized, problem solving and priority setting are often compromised by the sheer magnitude of the disaster, which many times translates into lots of activity and low efficiency. Seeking or finding out that family members are safe and can be reunited is critical.

Inventory/ recovery phase. At some point between the impact and the heroic stage an inventory and initial attempts at recovery phase occur. People conduct an appraisal of the situation and start to plan what they are going to do (NIMH, 2002). They engage in information seeking in regard to finding loved ones, determining whether they are safe or injured, and finding out how well their homes and places of employment have fared (Myers & Wee, 2005, p. 21). Typically there is frustration with the inability to find loved ones or anger at authorities for not letting the survivors back into their neighborhoods to find out about their homes.

Honeymoon phase. There is a collective "we are in this together" attitude. This may last anywhere from 1 week to up to 3 months postimpact. The community pulls together. There is optimism about recovery, and

the belief that there will be full restitution of financial loss is high. There is a great deal of media coverage anci high-level political attention. Public outpouring in the form of physical and financial donations give the community a sense of hope for rebuilding, and there is a strong sense of having shared a horrific experience but having prevailed over the worst of it (Farberow & Frederick, 1978).

At any time from 2 weeks to 2 years, depending on the severity and scope of the event, individuals wi[ experience reintegration and return to a pre-evem level of functioning or better, or they may not.

Avoidance phase. As individuals work their way through the next few weeks, the kinds of physical an psychological support systems that are provided affect whether acute stress disorder will arise and whether it will eventually turn into posttraumatic stress disorder. As time passes, an avoidance phase generally emerges (Pennebaker & Harber, 1993). People stop talkin. about the event, but the images and thoughts about ii: continue to dominate cognitive functioning.

Adaptation phase. Whether the pathology of the even continues and the individual enters the adaptatior. phase (Pennebaker & Harber, 1993) depends a grea.:: deal on the resiliency of the individual and the crisis worker's ability to institute a salutogenic model (Antonovsky, 1980, 1991) that emphasizes health anc wellness over sickness and pathology. The salutogenic concept affirms what we historically know abou~ people and crisis. Stress is ever present, and severe stress is going to occur, but people are resiliem . recover, and can thrive and grow from it. If people can come to grips with the financial, emotional, anC. environmental problems they will invariably face, anC. come to see that no matter what they do things wi..L. never quite be the same as they were before but the~· can move forward, they will have adapted and mm·e on. However, for many adaptation will be difficul: because of the disillusionment that sets in.

Disillusionment phase. Disillusionment may begi;:: several days or weeks after impact and may last fo- years, depending on how individuals adjust to the~ new environment. Disillusionment occurs because the media and politicians go home, bureaucratic rec tape slows recovery, insurance money doesn't pay ou: as much as expected, and multiple other problems arise that say that recovery will be slow if at all. Fatigue finally sets in, and the individual is emotionally anc

physically exhausted from extended psychological and physical stress. A variety of public health problems may arise from poor living and sanitary conditions, environmental pathogens, and communicable diseases. Stress-related health symptoms, ranging from high blood pressure to exacerbation of preexisting health problems, may occur. Disaster relief workers ironically refer to this period as the second disaster. Psychological problems may range from PTSD to panic and anxiety disorders to depression and suicidal ideation (Myers & Wee, 2005, pp. 23).

Anniversary phase. As time moves forward into the next year, the anniversary of the occurrence may become significant (Cohen et al., 2006). After a year or more has passed since the incident, a transcrisis state may be reached, depending on whether the individual has resolved the trauma or not. For some victims, the need to talk about and seek help validating their experience will go on and on, much to the dismay of others. This continuing need for catharsis and rumination about the crisis may be met with disapproval and outright anger by others in the victim's support system who seek to distance themselves from it (Smith & Belgrave, 1995). The result is often a perception by the victim of secondary victimization.

Pathogenic to salutogenic shift. Around the time of the first anniversary of the traumatic event, a benchmark is usually reached. If individuals have put the traumatic event into past context, mourned their losses, and started to rebuild their lives, then they have made a salutogenic shift in their lives (a shift that is healthful, wholesome, promoting psychological growth) (Antonovsky, 1980). They have met the challenge the traumatic event posed for them and are able to move on with their lives. In contrast, if individuals have remained mired in the traumatic event long past the acute stage, then they may be said to have made a pathogenic (diseased, unwholesome, psychologically debilitating) shift that may become residual and chronic, bringing on a host of physical and psychological maladies. A continuing and contentious issue in the field of trauma therapy is how individuals attain and retain a salutogenic state and if they do or do not need assistance in doing so (Stuhmiller & Dunning, 2000). Antonovsky (1991) has demonstrated that the stronger a person's sense of coherence (the extent to which the stress is deemed manageable, coherent, and meaningful), the more likely he or she is able to cope with life's stressors.

CHAPTER SEVENTEEN Disaster Response • 5 9 3

If that model is adopted, then much of the role and function of the crisis worker ceases to exist, because in a salutogenic model stress is universal, humans have adapted to it, and they do not necessarily crumble under traumatic stress (Stuhmiller & Dunning, 2000).

Restabilization/reconstruction phase. As time passes, deci- sions have to be made as to whether to rebuild one's life in the same environment or move on to a different place. Rebuilding is not just putting a new house up after an earthquake. It is also about rebuilding and restabilizing one's emotional and social self. Even though there are setbacks, with denied loans, divorce papers, homes that are a total loss, friendships that have been lost, or friends who have died in the disaster, somehow over the months and perhaps years, stabilization and new constructs replace the old.

Therefore, as time moves forward, the survivor needs to engage in a process that is much like Schnei- der's (1984) transformational model of grief. Moni- toring and following up on this transformational process to the client's final acceptance and putting the disaster in perspective may require tracking the client for a year or more. Richard Tedeschi and Lawrence Calhoun have been hard at work on the concept of posttraumatic growth (Calhoun & Tede- schi, 2008; Taku et al., 2015; Tedeschi & Calhoun, 2009, 2010, 2012; Triplett et al., 2012). These two re- searchers have developed different inventories-Post Traumatic Growth Inventory (Taku et al., 2008), Post Traumatic Growth Inventory for Children (Kilmer et al., 2009), Short Form of the Traumatic Growth In- ventory (Cann et al. , 2010), and The Event Related Rumination Inventory (Cann et al., 2011)-to assess people's ability to discover new possibilities such as better ways of relating to others, new personal strengths, positive spiritual changes, and stronger ap- preciation of life in the wake of a crisis (DeAngelis, 2011). One might say they are putting the empirical test to the Chinese Kanja characters indicating both crisis and opportunity. ·

The Society. When we move from the individual to the society at large (the micro-, exo-, or macro- system), the chronosystem also plays an important part in what is going to happen systemically. In the immediate hours and days of the aftermath of the crisis, all of the resources, agencies, and personnel needed to bring control and equilibrium back to the community are brought to bear, and time be- comes acutely important. During this heroic stage

594 • PART FOUR No Man's Land: Facing Disaster

(Raphael, 2000), the system responds with unself- ishness, self-sacrifice, and heroism in its attempts to rescue people and provide shelter and emergency assistance. Indeed, if there is forewarning, such as the landfall of a hurricane, timelines will extend backward to precede the occurrence.

As an example, the Nassau County Florida Emer- gency Management Department has a nine-stage sequence that extends from an awareness stage, which starts 72 hours before the hurricane's pro- jected landfall, to a reconstruction stage, which may be continuous and ongoing for weeks or months af- ter the hurricane is over (Nassau County Emergency Management Department, n .d.). During the imme- diate aftermath, a psychological honeymoon stage (Raphael, 2000) occurs in which there is a great deal of attention by the media, massive intervention by disaster relief agencies, and the notion that things will be set right and services quickly restored. There is an overall "We're all in the same boat, and every- body is equal" attitude.

After all of the emergency crews have finished get- ting power and phone lines back on, the wonderful outside assistance and resource support have gone home, and the media have moved on to the next disas- ter, the long-term degrading effects of the disaster are still there and consuming additional resources. When physical facilities-such as churches, schools, parks, and community centers-are gone, activities and in- terpersonal contacts that were taken for granted may be lost. State and federal bureaucracies and insurance companies seem to have miles and miles of red tape and may deny requests for compensation and sup- port for reconstruction of basic infrastructure. Both for individuals and communities, this phase has of- ten been called the "second disaster" (Myers & Wee, 2005, p. 29).

Losing access to community gathering places has symbolic, social, spiritual, and psychological mean- ing and may have long-term toxic effects on the community. Rebuilding these structures and reestab- lishing social links that were severely fractured take a great deal of time and effort (Kaniasty & Norris, 1999). At this point, a disillusionment stage may emerge (Raphael, 2000). There is a sense of frustra- tion, hopelessness, and abandonment that things will never be the same. Widespread posttraumatic stress and depressive symptoms are likely to appear if con- tinuous and long-term mental health assistance is not available. Thus, a very real question arises as to the "when" of provision of services. It is not nearly as

glamorous 6 months after a disaster strikes to appea: on the scene "ready to help," but it may be as criticall:· important to provide mental health services in the long term as it is in the short term.

Community resilience has become a key compo- nent in federal emergency plans. Whether a comm l.!· nity rebirths or dies after a disaster has a lot to do wiu. how well it plans for disaster by building communir:· resilience through both individual preparedness an · establishing a supportive context within that com- munity (Plough et al., 2013). That supportive con- text particularly speaks to providing social justice for vulnerable populations that typically experience short shrift in the provision of goods and services in the aftermath of a disaster (Baker & Cormier, 2015: DeAngelis, 2014; Royiscar, 2013; Roysicar et al. , 2013 ,.

The chronosystem, then, represents the develop- ment of events in individuals' lives and larger socia: systems over time, and crisis interventionists need to be aware of how important time and timing are in re- sponding to crises. The phrases "Time changes every- thing" and "Time is of the essence" appear to captu re the flavor of the chronosystem (James & Gilliland. 2003, p. 342).

Defining Principles of a Crisis Intervention Ecosystem Coming to grips with complex ecosystem service de- livery issues is daunting, to say the least. However. Conyne and Cook (2003) and Norris and her associ- ates (2006) have generated the following principles for doing so.

1. Systems must be interdisciplinary. No single dis- cipline or "ology" has a corner on this market. Emergency management agencies and crisis in- tervention systems must rely on a broad spectrum of people, ranging from sanitation workers and electrical linemen to civil and logistical engineers to medical emergency staff and communication workers to law enforcement and fire and rescue personnel to sociologists and psychologists co bankers and economists to ministers and social workers. Further, all of the people in these skills, crafts, trades, and professions must work in an integrated manner. The competent crisis worker integrates seamlessly into this smorgasbord of "ologies"; the pretentiousness sometimes associ- ated with a college degree and the egotism of a par- ticular profession have no place in an ecosystemic

crisis. Ecosytemic crisis intervention is the most egalitarian of all mental health endeavors, and lay- person volunteers may be just as effective as psy- chiatrists. Anyone with an inflated ego will soon

. be humbled in a large crisis. 2. The system must be multitheoretical. If we look at only

the psychological component of wide-scale crises, no single psychological theory is presently ad- equate to deal with the complex swirl of human dynamics that comes out of a crisis. It should be stated absolutely and unequivocally that nobody has a theoretical corner on this market. That in- cludes proselytizers for any of the "alphabet" tech- niques such as CISD, EMDR, TFT or, alternatively, those who would rail against them. It especially includes the authors of this book! When dealing with large-scale crises or megacrises, psychologi- cal theory must at the very least harmonize with logistics, medical, communications, economic, and political theory. To further complicate mat- ters, it is not just which psychological theories and techniques are used, but also when and how those services are delivered.

3. Individuals are part of the ecosystem. Like it or not, unless we can somehow find a place in the desert or mountains to become hermits, we are part of the total ecosystem of the world. Our biological makeup, interpersonal relationships, physical envi- ronment, and sociological context are all becoming more tightly interwoven into the total ecosystem of the world.

4. Multiple contexts must be considered. Micro-, meso-, exo-, and macrosystems are all components of the total ecological system that impact the individual when a megacrisis occurs. To deny that these sys- tems are vectors and forces that impinge on the individual is to have a very parochial view of what this business is about and is to be doomed to fail.

5. Time is of the essence. If we believe any of the PTSD research about the deleterious effects the passage of time has on the individual if nothing is done to alleviate the possible effects of the trauma, we need to understand that what occurs in the chro- nosystem is critical. The availability of adequate physical and psychological resources to deal with a crisis in a timely manner is paramount.

6. Meaning is important. What sense we make of the crisis from a broad systemic view is as important as what sense we make of it individually and has much to do with how quickly and effectively it is resolved for both individuals and society.

CHAPTER SEVENTEEN Disaster Response • 5 9 5

7. Parsimonious interventions are needed. Concordance and coordination within various systems are needed if large amounts of precious time and energy are not to be wasted. At the federal level, sufficient funding and information resources must be generated and disseminated. At the state level, preparedness plans should address multiple levels of the response across relevant jurisdictions, which includes clear plans on how the state agencies will communicate with the public and providers. Opti- mal utilization of resources is critical, and collab- orative relationships and understanding between agencies need to be formed in advance. Interven- tion in large-scale crises is extremely expensive in terms of person power and material resources. One of the major balancing acts of local EMAs is to have just enough resources available to bring maximum effort to bear at just the right time to experience maximum effect.

8. The process is cooperative, collaborative, and consulta- tive. Just as no single discipline holds sway in a large-scale crisis or megacrisis, cooperation, col- laboration, and consultation within, among, and between systems and individuals are paramount. The provision of mental health services is impor- tant, but so are getting communication and power systems back on and determining where there is available shelter and whether buildings are safe.

9. There is a full range of targeted interventions aimed at individuals, institutions, communities, on up to the national level, depending on how widespread the crisis is, and they are ongoing in response to longer-term needs. Each involved system component, from the individual to the nation, needs to be triaged. Based on that assessment, target-specific interven- tions need to be made. How things will wind up after a disaster is not just determined in the days after it, but in the months after it. The infrastruc- ture and community as client is as important long range as are individuals.

10. The service characteristics of credibility, acceptability, accessibility, proactivity, continuance, and confidentiality should be adopted as "cast in stone" goals for service delivery in disaster-stricken areas. Norris and her associates (2006) found adherence to these characteristics to be one of the most impressive of her findings of the 9/ 11 response in New York City. Meeting this gold standard of service delivery most likely means that the whole disaster mesosystem is integrated with host systems and running well. To do that effectively requires a

596 • PART FOUR No Man's Land: Facing Disaster

variety of organizations and individuals who operate with a high level of cooperation to make that system work.

Overarching all of the foregoing points are pla~­ ning, more planning, practicing, critiquing, evaluat- ing, and yet more planning. The necessity for vertical and horizontal links in the ecosystem of disaster plan- ning cannot be overemphasized. The result of not hav- ing such links became clearly evident after hurricane Katrina. One of the critical components to planning is making sure that disaster mental health planning and activities do not take a backseat to security and safety concerns; people who can make clear decisions must be in place and have the authority to make those decisions (Flynn, 2003). That issue became abundantly clear in the aftermath of Katrina, with local and state leaders bickering about plans that should have been carved in stone long before the hurricane made land- fall (Flynn, 2003; Gheytanchi et al. , 2007).

National Crisis Response Teams Perhaps the most important outreach approach l!iJI has been taken by national agencies in on-site delivery of mental health services at major disasters and the coordination of these services with other relief efforts. Because of past criticism ofhow both charitable and fed- eral agencies have handled major disasters, those agen- cies have done a great deal of work to better coordinate their efforts in providing comprehensive disaster relief that cuts across the survivors' total environment (Bass & Yep, 2002; Pyszczynski, Solomon, & Greenberg, 2002; Smith, 2002). Mental health support does little good when people don't have a roof over their heads because it has been blown away in a hurricane. However, it also does little good for survivors to obtain housing but be so traumatized and depressed from the disaster that they cannot begin to regain control over their lives. From plane crashes to university campus shootings, to floods, to post office shootings, to forest fires, to train wrecks, to building bombings, to earthquakes, to school shootings, and to 9/11, some of the most potent and appropriate examples of the ecological nature of crisis intervention have occurred in the United States in the last 10 years, as has a large mobilization, t raining, and response effort to provide emergency mental health services to victims and survivors of any type of imaginable disaster.

An enormous number of mental health workers from throughout the country, working under the auspices of the American Red Cross, NOVA, FEMA, and state and local EMAs, and supported by the major

professional mental health organizations in the Unic, States, have contributed monumental services to dY thousands of clients affected by those disasters (Bass - Yep, 2002; Gladding, 2002; Hayes, 2002; Juhnk, 2002; McCarthy, 2002; Modrak, 1992; Morrisse:· 1995; Pyszczynski, Solomon, & Greenberg, 2002 Riethmayer, 2002a, 2002b; Smith, 2002; Sullivan, 2002. Underwood & Clark, 2002). Among the comments o: hundreds, perhaps thousands, of mental health work- ers over dozens of major crises, the following is perhaps both descriptive and representative:

In that capacity, I was an escort who walked with families from the front of the building to the bac · - and talked with them about what they were fee1- ing, what they had felt , or what they anticiparec doing in regard to the emotions that would be coming. I also accompanied families to Grounc Zero so they could see for themselves the horror and finality of the event. The view from the site helped many individuals begin the process of grieving in depth, as they realized in a stark anc: striking way that those they had loved and cher- ished in so many ways were indeed dead and wou lc not be coming back to be with them. (Gladding. 2002, p. 7)

Development of Crisis Response Teams (CRTs). T he Oklahoma City federal building bombing, the shoot- ings at Columbine High School and Sandy Hook Elementary School, and the 9/11 attacks struck a nerve in the United States. The massive amounts o[ media coverage of those traumatic experiences and the disaster relief that followed in their wake brought graphic attention to how disasters are handled, in- cluding the work of immediate follow-up rapid re- sponse teams. These teams did not just spring up full grown at the time of those disasters. Rather, through- out the late 1980s and 1990s, rapid response teams were developed to handle numerous tragedies and disasters, including hurricanes (Shelby & Tredinnick. 1995), serial murders (Wakelee-Lync~, 1990), plane crashes (Modrak, 1992; Shafer, 1989a), bank robberies and hijackings (Brom & Kleber, 1989), campus shoot- ings (Guerra, 1999; Guerra & Schmitt, 1999; Sleek. 1998), and train explosions and post office shootings (National Organization for Victim Assistance, n .d.).

National Organization for Victim Assistance (NOVA) CRTs. The rapid crisis response team movement re- ceived impetus and support on a national level with

the establishment of the National Crisis Response Project by the National Organization for Victim As- sistance (NOVA) in the late 1980s (Young, 1991). Originally established to help victims of crime, NOVA, a private, not-for-profit organization, has branched out to offer help to victims of all kinds of disasters through the National Crisis Response Proj- ect. It has state and local affiliates throughout the United States. The project set up national crisis re- sponse teams (NCRTs) to assist communities follow- ing community-wide crises or disasters. One of the first major organized national responses of an NCRT for the specific purpose of providing mental health assistance was on August 20, 1986, when an Edmond, Oklahoma, postal worker shot and killed 14 cowork- ers and himself.

The main objective of an NCRT in dealing with a lo- cal community disaster is to form local crisis response teams that are in a position to deal with the commu- nity's grief reactions, stress effects, and posttraumatic stress disorder resulting from the disaster. According to Young (1991), the "project is based on the premise that disasters can cause individual and community-wide crisis reactions and that immediate intervention can provide communities with tools that are useful in miti- gating long-term distress" (pp. 83-84).

NCRTs are dispatched at the request of leaders in the affected community. "When a disaster occurs, NOVA is placed in contact with the community in one of two ways: either the community calls NOVA, or NOVA, on hearing of the tragedy, calls the commu- nity and offers assistance" (Young, 1991, p. 95). Three types of disaster service are available: (1) providing written material giving details on how to deal with the aftermath of disaster; (2) providing telephone consultation to leading caregivers in the area af- fected; and (3) sending in a trained team of volunteer crisis workers to assist the community.

The Red Cross. The American Red Cross, like its Red Cross and Red Crescent counterparts around the world, is tasked with dealing with all kinds of disas- ters. Founded by Clara Barton, the American Red Cross has been in business for about 120 years. It is a private organization that has close ties with local, state, and federal governments. It helped the federal government start the Federal Emergency Manage- ment Agency. It is a major contributor to crisis in- tervention in the wake of large-scale disasters and megadisasters through its training of mental health professionals as members of rapid response teams

CHAPTER SEVENTEEN Disaster Response • 5 9 7

(Red Cross, 2015). Professional organizations in counseling, psychology, and social work are closely linked with and provide candidates for its mental health training program.

Federal Emergency Management Agency (FEMA) and the National Institute of Mental Health (NIMH). FEMA was born in 1979 as the result of complaints about federal agencies' slowness, bureaucratic red tape, in- efficiency, ineptitude, and duplication of effort in responding to a disaster. Several different agencies were merged into FEMA, and it is now housed in the Department of Homeland Security. FEMA has numer- ous responsibilities. Among them are education about all kinds of disaster preparedness and coordination between federal, state, and local emergency manage- ment agencies in regard to preparedness, training, and disaster mitigation. It provides disaster assistance that ranges from debris removal and rescue efforts to di- saster loans for rebuilding and on-site mental health crisis response teams. Its Emergency Management Institute at Emmitsburg, Maryland, is a virtual univer- sity of emergency preparedness courses. Courses range from training community emergency response teams (CERTS), made up of ordinary local citizen volunteers who provide support to first responders to aid in rescue efforts, to colloquiums with state mental health service providers on the latest techniques for providing men- tal health services after a large-scale disaster (Federal Emergency Management Agency, 2015).

Sometimes more than one agency of the federal government coordinates the work of crisis response teams. Several instances of events during modern times that triggered such a coordinated effort were the earthquakes in both the Los Angeles and San Francisco areas; hurricanes Hugo, Andrew, Floyd, and Katrina that brought devastation and flooding to large parts of the southeastern United States; the nu- clear accident at Three Mile Island; and the J..,ove Ca- nal contamination. The response teams were sent in by the National Institute of Mental Health (NIMH) and sponsored and funded by FEMA. In all such na- tional disasters, FEMA and NIMH provide the widely affected areas with instruction, consultation, and ex- pertise in developing local and regional support sys- tems to cope with the enormous aftermath of these disasters (Shafer, 1989b).

Professional Organizations. Professional organiza- tions, such as the American Psychiatric Association, the American Psychological Association, the American

598 • PART FOUR No Man's Land: Facing Disaster

Counseling Association, and the National Association of Social Workers, provide volunteers for the Red Cross and NOVA CRTs. These organizations also provide a variety of publications for both professionals and lay- persons that can be obtained on their websites or or- dered from them. Their conferences and conventions provide formats for discussion and dissemination of the theory and practice of crisis intervention.

The American School Counseling Association and the National Association of School Psychologists are involved in providing crisis intervention services to schoolchildren and adolescents in the face of a large- scale disaster. As an example, on April 19, 1995, im- mediately after the Oklahoma City federal building bombing, an American Counseling Association team of Oklahoma school counselors and an art teacher wrote and illustrated The Terrible, Scary Explosion. This book, modeled after one written for children after hurricane Hugo in South Carolina, was in the hands of Oklahoma City schoolchildren by April 25, with local school counselors serving as facilitators. The purpose of the book was to help children of all ages process the whole incident and provide a tool to help adults help children (Morrissey, 1995).

The National Association of School Psychologists has national emergency assistance teams (NEATs), which are tied in with NOVA. The mission of NEAT is to develop policies and procedures, disseminate in- formation, provide consultation, and facilitate the training of school-based crisis teams in response to significant emergencies affecting children and ado- lescents. These NEAT teams go to the scene of school disasters and provide support for local agencies. They are composed of nationally certified school psychol- ogists who have expertise in crisis prevention, inter- vention, and postvention. The intention of the NEAT team is to help save lives, reduce trauma and injury, facilitate the psychological well-being of students and staff, and allow schools to return to regular ac- tivities as soon as possible (Zenere, 1998).

Constructing an Outreach Team. Depending on the nature of the crisis and the ecological setting, out- reach teams generally have a diverse occupational range: from psychiatric nurses, paramedics, emer- gency workers, and psychiatrists to social workers, vol- unteers, rehabilitation counselors, police officers, and psychologists. These outreach teams are character- ized by their multidisciplinary team approach, strong social and community networks, user participation in policy and service delivery, and egalitarianism in

the workplace (Gulati & Guest, 1990). Alise Barde:: a private practice licensed professional counselor, c~­ scribes her experience as a volunteer worker follow~:~ hurricane Katrina. Based in Gulfport, Mississipp, she slept in a large Navy Seabee storage facility\\_;_:.. 600 other volunteers. She slept two feet from a retiree. nurse on one side and a Vietnam veteran on the othe::- both of whom she had just met for the first time in he:- life (Kennedy, 2007).

Integrative-collaborative teams have a distinctiw operational setup and are characteristic of many geo- graphical areas where financial and human resources are not sufficient to form freestanding, specialized cri- sis units. They are not an ad hoc group collected afte:- a crisis, but rather are trained prior to the crisis. Eaci:: member has different skills that, combined, allow the team to respond to a variety of crisis situations. T he;· operate much as a volunteer fire department does. Members typically have primary jobs in other seL- tings, but when a crisis call comes in on a hotline, th~· immediately leave their regular job, form a crisis team. and go to the crisis site. They are identifiable within the community as the crisis response team and are a cost-efficient and effective way to provide generic crisis intervention (Silver & Goldstein, 1992).

Vertically and Horizontally Integrated Local Emergency Management Systems Overarching all local agencies involved in crisis after a disaster are the local emergency management agen- cies. They are the offspring of the old Civil Defense system of the cold war. The examples that follow refer to Florida, where each local agency is directly linked to one of seven regional areas, and Illinois, where there are eight regions linked to the state emergency man- agement agency. In turn, the state agency is linked to FEMA (Freeman, 2003; Lane, 2003).

Role of Local EMA Directors. Jerry Lane and Nancy Freeman are two public servants whose lives have been anything but simple. They both have run local emergency management agencies.

Jerry was executive director for the Dekalb County, Illinois, Community Mental Health Board and direc- tor of the Sycamore, Illinois, Emergency Managemern Agency. Sycamore is a small town in northern Illi- nois, located in rolling farmland about 60 miles west of Chicago. It is not famous or notorious for much of anything. However, it does have grain elevator and agricultural chemical warehouse fires, tornadoes, straight-line windstorms, blizzards, and flooding.

But does it really need an emergency management system and a local manager? Listen to Greg Brown, former director of EMT services in White County, Illinois, and chemical mixing and applications supervisor for Brown Feed and Chemical in Carmi, Illinois. "If you want to talk about the potential for terrorism or accidental disaster, talk about what we have in this warehouse. We easily have enough agricultural chemicals, if used with malice or han- dled incorrectly, to kill everybody in this town twice over and have some left to spare. You'd better have somebody around who knows what to do with them, and that would apply to about every town in the coun- try that has an agricultural base" (G. Brown, personal communication, December 15, 2004).

For Jerry Lane, living in a small town that may need his skills is the greatest reward of the job. His agency's problems were those of most beginning crisis agencies: inadequate funding, little respect, and a whole lot of politics. Many emergency management jobs were filled by patronage seekers, which may satisfy the needs of a political party but will probably leave a lot to be desired when the crisis starts-as evidenced at the national level with hurricane Katrina. Listen to the comment of a county commissioner in White County, Illinois, about the volunteer EMT program that was asking for an increase in funds from the county board: "Why, they could train a monkey to do that job! Why do they need to be paid any more?" We certainly hope that commis- sioner doesn't have a heart attack "way out there on Possum Road" because we doubt whether a chimpan- zee could make the drive in an ambulance and keep him alive long enough until a life flight arrived, piloted by-we would guess- a baboon.

Although you may consider the commissioner's comment outrageous and patently stupid, this is not an atypical response to any new upstart agency that deals in crisis. Until it becomes politically necessary, little government funding is forthcoming to support crisis intervention programs. Certainly 9/ 11 and hur- ricane Katrina put a new perspective on the need for local emergency management agencies and competent people to run them.

Nancy Freeman is a retired deputy director of the Nassau County, Florida, Emergency Management Agency. Nassau County is next to Jacksonville, Flor- ida. Nancy got into the emergency management busi- ness doing research analysis for hazard mitigation while she was a graduate assistant at the University of North Florida. While doing research for various coun- ties in north Florida, she learned enough about the

CHAPTER SEVENTEEN Disaster Response • 5 9 9

business of emergency management that she applied for a job with one of the counties and got it! Besides being adjacent to a large urban population-with all of its potential hazards for disaster-Nassau County is situated on the shore of the Atlantic Ocean, with all of the hurricane risks attendant to that locale. To add a little more to the hazardous, potential-for-di- saster mix, the county also has military facilities with nuclear capabilities. Suffice it to say that the Nassau County EMA is very, very interested in hurricanes and their potential effects under a variety of conditions.

Nancy's world is defined by the term networking and, as is true for most emergency managers, it is a double-edged sword. On the one hand, Nancy sees networking with a variety of very committed pro- fessionals as one of the most rewarding parts of her job. On the other hand, when egos, turf guarding, and politics get involved, it can be one of her major headaches.

These managers are a new breed of technocrat that is being placed in charge of coordinating a wel- ter of activities, agencies, and logistical problems in regard to managing every conceivable emergency you might imagine and then some. If you'd like a job like this, you had better be good with acronyms and know what they stand for. Want to be able to do a HHVA (hospital hazard vulnerability analysis) or get a RACES (radio amateur civil emergency system) up and running? Curious to know what the difference between cold, warm, and hot zones are, or whether you need a Level A protection suit when you venture into one of them? Does that sound like an interesting job? Think you'd like to do that?

Background and Training. What are the qualifica- tions? you may ask. What university do I need to attend to major in that "stuff"? The answer to that question now is, "About any place in the world!" Spe- cifically in regard to mental health crisis interven- tion, the University of South Dakota had established the first doctoral program with a specialty track in clinical/disaster psychology. Now, if you go to www .chds.us/?partners/institutions, which is the website for the Center for Homeland Defense and Security (2015), you will find 477 programs that range across associate, bachelor's, master's, doctorate, and certifi- cation programs in just about any type of emergency management program with any type of focus you can imagine. You should understand that the content of these degrees varies quite a bit because as of yet there is no clear consensus on what all that "stuff" should be.

600 • PART FOUR No Man's Land: Facing Disaster

If you sought to earn an interdisciplinary bachelor's degree with a major in emergency management from Western Carolina University, for example, your courses could range from International Terrorism to Crisis Communications to the Politics of Budgeting (Western Carolina University Emergency Manage- ment Institute, 2015).

However, as Nancy Freeman (2003) says, "My bachelor's degree and graduate work is in the human- ities, with an emphasis in interior design, history, and historital preservation, and you wouldn't think that would be anything like what you'd need for this job, but I learned about architecture in that program, and I can read a building plan and know what 'load bear- ings under initial impact' means, and that is critically important when we are designing evacuation and safety plans. I also know how to do research and that is critically important in this job."

Jerry Lane holds a master's degree in community mental health. Jerry sort of wandered into this business by being an amateur radio operator and weather spot- ter. As Jerry says, "I'm kind of a rare breed. Most emer- gency managers don't have a mental health background. They tend to be retired military and have a pretty good handle on how to handle logistics prob1ems, which is indeed important in this job" (Lane, 2003).

Both of these directors have taken many courses through the Federal Emergency Management Asso- ciation's Emergency Management Institute, which has a campus in Emmitsburg, Maryland, and various correspondence and Internet courses. Besides criti- cal incident stress debriefing and PTSD training, you might also be required to take Preparedness Planning in a Nuclear Crisis, Mortuary Services in Emergency Management, Hazardous Materials Basic Awareness, and Executive Analysis of Fire Service Organization and Emergency Management. If you are getting the idea that you had better be a Jack or Jill of all trades and a master of many, you are right!

There is a national certification process and an international association of emergency managers. In Florida, emergency managers must be certified through a combination of course work, training, and work experience. They must also take 150 hours of education courses every 4 years to retain their cer- tification. There is continuous ongoing training in management tools resources, new technology, and communications. There are two annual conferences managers are expected to attend, one of which cov- ers general emergency preparedness. Lots of training

exercises are developed at the national and state le,·- els and then are brought down to the local level to be used in training exercises (Freeman, 2003). Still inter- ested in this job?

What Do Emergency Managers Do? Certainly, di- sasters don't happen every day. Does that mean tha;: emergency managers sit around playing pinochle drinking coffee, eating doughnuts, pitching horse- shoes, and polishing the fire engine, waiting for something to happen? Local EMAs are in the bus:- ness of preparing for, preventing, intervening in, anc: mitigating the effects of any and all kinds of disas- ters . To do that takes a great deal of planning anc: coordinating. Direct your attention to the matrix o: city and county agencies and the support functions they engage in as primary or secondary supports ic a disaster (see Figure 17.3). While you might think of roads, bridges, potable water, and sewage disposal as being critical, the last thing you might think of woul · be animal issues. But if you had severe flooding after a hurricane, animals-both alive and dead-would be a very real problem.

Planning for Disasters. There are two types of disas- ters, those that have prior warning time and those that do not. As a result, local EMAs have various di- saster plans that are implemented in stages. Although there might be very little warning in the case of a tor- nado or a chemical spill from a derailed train, hur- ricanes and forest fires generally do have lead time for preparation. Nassau County has a very complex and lengthy hurricane plan that is divided into 10 stages. A brief description of those stages follows to give you an idea of just how involved this business is (Nassau County Emergency Management Department, 2003 .. For each stage, a particular action is noted and the re- sponsible section is designated to implement it. Those sections are emergency operation center (EOC) com- mand, planning, logistics, operations, administra- tion, recovery task force, and elected policy makers.

Awareness stage. 72-60 hours Estimated Land Fa1 (ELF) of hurricane. Activate emergency command. center. Establish liaison with the National Weather Service, state department of emergency managemenL surrounding counties, media, utility services, law enforcement, and fire agencies. Conduct vulnerability analysis. Activate alert phone system. Prepare primary evacuation routes. Notify all gas and diesel wholesalers

CH APT ER SEVENTEEN Di saster Respon se • 601

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All local media s Amateur Radio Emera. Serv. s s s Acme County Medical Center s s s s Goodwil l Industries Center s s Midville City Public Works Deot. s s s s s s Midville City Fire Deoartment s s s s s s Midville City Police Deoartment s s s s Midvi lle City Plannina Department s s Civil Air Patrol s s s Contracted Medical Examiner s s State Deot. of Law Enforcement p s State Hiqhway Patrol s p State National Guard Forces s s State Power and Liaht Dept. s s State Public Uti lities Dept. p s Animal emeraency care centers s s Home Health Care Aaencies p s Req ional Electrical Authority s s s s Medical SuoPIY Comoanies s s Acme County Buildinq Dept. s s s s Acme County Cattleman's Assoc. s s Acme County Clerk of Court s s Acme County Coord inator s Acme County Council on Aa ina s s s s s Acme County Emergency Mgmt. s p s s s s s s p s s Acme County Enaineerinq Services s s s s Acme County Extension Aaency s s s s p s Acme County Facilities Maintenance s s s s Acme County Fi re/Rescue s p s s p p s Acme County Geoq. Info. Systems s s s Acme County Health Deot. s s p s Acme County Humane Society s p Acme County Jai l s s Acme County Library System s Acme County Planning Dept. s s s Acme County Risk Management p p s Acme County Road & Bridge Dept. s p s s s s Acme County School Board p s p s s s Acme County Sheriff's Office s p s s s s s s s s p s · Acme County Solid Waste Dept. s s s s Acme County Veterinary Society s s Acme County Volunteer Center s s s Regional American Red Cross p s s s s State Parks & Recreational Services s s Pri vate businesses s s Salvation Army s s s s Mental health centers s s Volunteer oraanizations s s

WdimlfJI Midvil le City/Acme County Emergency Support Funct ion Matrix SO URCE: Adapted from Nassau County, Flor ida, Emergency Management Department (Freeman, 2003).

602 • PART FOUR No Man's Land : Facing Disaster

to restock retail outlets within 12- 24 hours. Test EOC communications equipment.

Standby stage. 60-48 hours ELF. Activate emergency broadcast system. Notify amateur radio group to go on standby. Use local media and National Weather Service bulletins to advise boat owners, home owners, drawbridge operators, and motel and hotel managers, and detail causeway and bridge closings and evacuation routes. Coordinate establishment of emergency worker shelters. Secure EMS ambulances, transport vehicles, oil spill trailers, and heavy equipment.

Decision stage. 48-45 ELF. Activate traffic control plan and emergency transport plan. Declare state of emergency and activate county emergency plan. Recommend/ order evacuation. Designate nonessential businesses to close. Coordinate decision-making actions and link all municipalities, law enforcement agencies, fire districts, utility companies, hospitals, and medical care facilities with State Division of Emergency Management and the National Hurricane Center.

Preparation stage. 45- 36 ELF. Begin implementing evacuation plan for "at risk" populations such as mobile homes, people with special needs, tourists, campers, people without transportation, and low- lying areas. Activate all EOC communication systems. Announce public closings. Implement 24-hour operation of fleet management garage and fueling resources. Activate emergency transportation plan. Prepare shelters for opening.

Evacuation stage. 36-4 ELF. Issue evacuation orders. Identify areas at risk. Announce shelter openings and transportation pickup points. Request National Weather Service to broadcast information on road closures. Activate/ coordinate shutdown of electric power services. Maintain communications with public shelters, emergency worker family shelters, special care centers, emergency transportation, area hospitals, animal emergency care facilities, power, water, sewage, utilities, fire districts, law enforcement, and public works. Begin preplanning poststorm activities.

Storm/ emergency stage. Monitor storm/ emergency characteristics. Continue preplanning poststorm act- ivities. Continue communications with other agencies.

Immediate emergency stage. Commence local emergency response activities. Determine long-term human

service needs, including mental health care counselin&. Determine information and referral services. Assess temporary housing needs. Distribute resources: foo water, clothing, and cleanup kits. Activate recover:· task force and review damage reports. Recommenc implementation of appropriate moratoriums anc: adoption of emergency resolutions and ordinances. Determine if curfew is needed. Activate Damage Assessment Teams. Monitor public health conditions.

Evaluation stage. Determine if primary threat still exiscs. Conduct/ coordinate initial impact assessment effort. Reaffirm and/ or reestablish communications with ah shelters, hospitals, towns, state emergency operations. law enforcement, public works, fire districts, anC: surrounding counties. Enact emergency resolutions. Determine initial mutual aid requirements anci request assistance from state EOC. Discuss emergency ordinances to be enacted. Issue news media releases. Establish times for briefings/ planning meetings. Report accidents to date and update status. Assess damage to areas with existing or potential hazardous materials. Summarize current operational activities underway. Discuss current strategy. Review human resource needs. Determine additional resources needed. Implement rest and rotation policies for emergency workers. Assess logistics of transportation routes opened, distribution sites, feeding procedures, and available sleeping facilities.

Reconstruction stage. Perform long-term act1vmes or projects focused on improving or strengthening community's economy. Complete restoration of services. Dispose of debris and allocate resources to cleanup chores. Focus on community recovery planning, building and construction issues, and environmental/ ecological issues. Continue/ complete human services delivery assistance of information and referral, resource distribution, health care deliver}', mental health care counseling, and transportation assistance. Complete activities for presidential disaster declaration. Perform hazard mitigation projects to reduce community's susceptibility and vulnerability to hurricanes. Repair, replace, modify, or relocate public facilities in hazard-prone areas.

Restoration stage. Perform assessment of community needs and economic damage. Address the following restoration issues: economic and job base assessment community recovery planning, building and construction issues, public information and citizen

outreach, and environmental issues and ecological concerns. Provide health care delivery for both pre- and postdisaster needs, including home health-care management and case referral. Put mental health care counseling into operation. Determine victims' counseling needs by triage assessment. Determine training needs for mental health professions on disaster-related issues. Place mental health professions/ CISD team members on community assessment teams. Determine where counseling services will operate. Determine transportation needs to public feeding sites, shelters, and disaster service sites. Reestablish and implement public transportation service. Chore service needs assessment for cleanup. Determine needs and coordinate with volunteer groups for debris cleanup, interior home cleanup, window repair, etc. Coordinate with FEMA to set up Disaster Field Office and Disaster Application Centers. Assist in establishing temporary housing sites. Establish a federal public assistance office to coordinate all disaster relief efforts to clients. Participate in interagency hazard mitigation team and hazard mitigation survey activities. Complete after- evacuation report and county incident report. Critique the management of the storm emergency.

Throughout the unfolding stages of the disaster, constant needs assessment should occur. A community mental health needs assessment formula (Flynn, 2003, p. 23) that constantly updates the dead, hospitalized, nonhospitalized injured, homes destroyed, homes with major and minor damage, unemployed due to job loss, and other losses will give a good indication of the potential numbers of people in need of crisis counsel- ing services. The same community-wide assessment should continuously occur in regard to mental health (Katz, 2011). Nancy Freeman was asked when she would know that the crisis is over. She stated, tongue in cheek, that she'd know because no one had called and everyone had found his or her dog and Aunt Nellie. In reality, the immediate crisis is considered passed when everyone's safety is assured from any effects of the di- saster, public works are back in operation, and services are returning to normal. That's when the EOC can get a doughnut and some sleep!

The foregoing plan for hurricanes can be adapted to any kind of disaster, whether natural or human- made. While timelines may be very compressed or in some instances operations may start at the emergency stage, the format is replicable with just about any kind of community-wide crisis. Although local EMAs have very little preparation time for other types of disas- ters, they do not stand idly by waiting for something

CHAPTER SEVENTEEN Disaster Response • 6 0 3

to happen. Continuous interagency tabletop exer- cises give them practice in responding to a variety of potential disasters. Assessment of particularly vital and vulnerable public sites, ranging from water treat- ment plants to nursing homes, is made to determine what needs and weak points there may be. Jerry Lane spends a fair amount of time working with individual agencies to develop their own internal disaster plans to fit with the overall one that the local EMA has.

Mental Health Components of Local EMAs

Any local mental health clinic should have IDB a prototype disaster response plan (Lane, 2003). While each community will have variations due to its own particular regional and state systems of men- tal health delivery, geographic locale, and popula- tion differences, they should generally follow along with what Hartsough (1982) has outlined for mental health agencies' typical response to a disaster.

The following points are abstracted from Hartsough (1982) and Lane (2003). First of all, the centers must have a plan that assumes that they may be victims themselves and have breakdowns in com- munications; loss of or inability to find staff; loss of equipment, supplies, and records; inability of staff to cope with loss; and problems recognizing their functional limits. The mental health center must be prepared to provide services in two situations- a lo- calized but traumatic event and a large-scale disas- ter. A localized event can be responded to without affecting operations to any great degree. A disaster will most likely disrupt operations to some degree, while drastically increasing the demand for services. A clear chain of command with redundancy features is mandatory. There should be an assessment of population groups in the area with regard to high- risk groups such as children, non-English-speaking, elderly, and low socioeconomic groups. Interagency cooperative agreements should be made. 'A specific mental health liaison person should be named to the local EOC.

Predisaster training encompasses development of outreach programs that target "normal people acting normally in an abnormal situation." Training spe- cifically targets practitioners who have not had for- mal training in outreach or who historically perform poorly when they have to rely on their formal train- ing. Consideration should be given to sending local clinicians to Red Cross training. Drills and tabletop exercises should be developed and conducted in coor- dination with the local EOC.

604 • PART FOUR No Man's Land: Facing Disaster

Personnel. Volunteers who would function as reserve crisis counselors should be recruited and trained in crisis intervention skills. Specified workers should be selected for multidisciplinary crisis response teams. A chief of operations should be nominated and will be the individual actually running the disaster response. There should also be an emergency preparedness coordinator who will be responsible for planning and preparation prior to a disaster and will function as a consultant to the chief of operations during an actual emergency. This person will be the liaison to the local EOC.

An outside clinical consultant should be retained to assess the physical and mental condition of the staff A command-and-control and communications center should be established and staffed by a team leader and other staff necessary for it to function ef- fectively. A historian should keep an ongoing journal of activities that occur as a result of the disaster. The decisions, events, problems, and information should include details, names and addresses, times, and is- sues that can later be used for debriefings, psychologi- cal autopsies, system improvements, grant requests, or reimbursement.

A personnel liaison will assist the chief of oper- ations in assessing, making, and tracking staff and volunteer assignments. A media/ information liaison will provide information to the media and local gov- ernment, develop press releases, and distribute gen- eral information regarding service delivery. Staff may be made available to the local EOC to provide psycho- logical support.

Transdisaster (0-14 Days). The mental health unit needs to initiate immediate mental health services when the disaster occurs; restore services to clients served during normal times; act as the disaster mental health advisor to the local government; provide out- reach programs and coordinate resources for the de- livery of disaster mental health services from the Red Cross, NOVA, FEMA, and other religious and philan- thropic organizations; coordinate the responses of any contractors for services with particular emphasis on evacuation of residential facilities; target specific areas, such as evacuation centers, emergency relief centers, and FEMA "one-stop" service centers; provide support services for disaster workers; and assist with mental health emergencies in hospitals with victims requiring medical or psychiatric care.

Postdisaster (15-365 Days). Evaluate and assess the need for postdisaster services; implement prepared

immediate services grant and prepare regular sen-ici'S grant if a presidential disaster is declared; establi-- linkages with American Red Cross mental he<L.-- workers to hand off clients requiring longer-re= care; monitor for long-term psychological effec-.s. educate the public regarding disaster-related psyche-- logical phenomena; evaluate program response, bo~ short and long term; perform psychological aurnps-- on total crisis response and debrief workers.

In the foregoing sections of this chapter you ha•-c read about the overall composition of disaster pla.:::.- ning and infrastructure. In an ideal world, even in;:_ world of disasters, all of this runs smoothly. WhLc 9/ 11 certainly had its share of chaos and confusio;::. (Halpern & Tramontin, 2007, pp. 171-197; Kau l =- Welzant, 2005; Norris et al., 2006), order came oi.:: of that maelstrom fairly quickly, and everyboC.;- thought they had learned a lot oflessons. Then alon~ came hurricane Katrina and everything got turneC. upside down.

What Happened with Katrina? · In any disaster there is invariably an attempt to fix blame. If blame can be fixed, then people may star: to believe that the impossible, out-of-control, insane. unbelievable, chaotic, and unfathomable event ca.::: be contained, made sense of as to the reasons it oc- curred, and a sense of control regained as to what wen~ wrong and how it can be made right the next time. l;:;. that sense hurricane Katrina is no different from mU:.- titudes of other natural disasters that have hit other countries. Indeed, in comparison to typhoons am: earthquakes that have plagued Asia and the Middle East, it is a relatively small event, and certainly so in regard to loss oflife. Yet the recriminations from hur- ricane Katrina are unending and rub raw nerves from the standpoints of socioeconomic, racial, political, and even interstate rivalries. While it is expected, rightly or wrongly, that there will be disasters in countries like Bangladesh, it "cannot happen" in the United States. We pride ourselves on controlling our destiny through science and industry, up to and including controlling nature. After Katrina, apparently not!

This is not an exposition about who's to blame or what's to blame. The emerging facts suggest that there is plenty of blame to pass around and share. However, what Anahita Gheytanchi and her associates (2007) have compiled is worth reporting as a way oflooking at how the various systems within a disaster ecosystem operate or in the case of hurricane Katrina ... don't! Gheytanchi and her associates report 12 key failures of response.

1. Lack of efficient communication. The sine qua non of disaster mitigation is communication. Both within and between the primary and super me- sosystems, communication failed. At least four separate command structures were operating in Katrina's aftermath: two command structures in FEMA and two military command structures. That's at least two too many and resulted in crossed communications, duplicated or incomplete ef- forts, and generally clouded decision making.

2. Poor coordination plans. Coordination is about mov- ing assets to where they are most needed. The in- ability to coordinate relief efforts ranged from not utilizing one of the finest hospital ships in the world, the U.S.S. Bataan, which sat idly offshore, to an inability ofFEMA to find buses and drivers and move people out of the Superdome, to hundreds of trucks filled with ice sitting idly in Memphis freight yards with no place to go, to thousands of house trailers sitting in Arkansas when they were desperately needed in Mississippi and Louisiana.

3. Ambiguous authority relationships. The Department of Homeland Security remained on a "pull" basis, which means that the state had to request federal assets, rather than a "push" basis, which means that assets would be immediately made available to the state. The National Response Plan Cata- strophic Incident Annex (NPR-CIA) should have been invoked prior to landfall, but in fact was never invoked. The prevarication and waffling by Loui- siana state and local governments on instituting mandatory evacuation because of the cost, even though they were getting intense pressure from federal authorities to do so, caused severe prob- lems that culminated in the Superdome fiasco.

4. Who's in charge? Factious political fights plagued relief efforts. The shifting of blame from the mayor of New Orleans to the governor of Louisi- ana to the president of the United States settled nothing. Lessons from previous hurricanes about coordination among federal, state, and local gov- ernments have not been learned or at least not been put into practice. Laws that govern the use of the armed forces in the continental United States also severely hamstring efforts to quickly deploy military personnel and need to be changed.

S. Counterterrorism versus all-hazards response. Money, staff, and other assets have been drained our of FEMA and moved to Homeland Security efforts to combat terrorism. A natural disaster the size of hurricane Katrina dwarfs any terrorist attack up

CHAPTER SEVENTEEN Disaster Response • 605

to a nuclear detonation or release of the plague. Yet Homeland Security funded disaster prepared- ness for terrorism as opposed to natural disaster at a 7-to-1 ratio pre-Katrina.

6. Ambiguous training standards and lack of preparation. Across the board, training and experience with disasters were lacking. While the aforementioned FEMA training to become a certified LEMA man- ager sounds good, the reality is that the training requirements to become an emergency manager and become certified were cumbersome and dif- ficult to complete. Standards for accreditation of response agencies were also vague and not tied to any performance-based evidence.

7. Where is the "learning" in lessons learned? A multia- gency hurricane exercise that very closely resem- bled Katrina was completed prior to the storm. Outcomes closely paralleled what actually hap- pened. Yet failure oflocal and state governments to follow up and take advantage of the exercise doomed it to collect dust on the shelf. This is not the first instance of failure to heed learning from the past. Putting into practice all of the proce- dures necessary to stave off a disaster like Katrina is difficult, costly, and time consuming; it de- mands expertise and interagency cooperation at the local level and vertical integration with state and federal agencies. Tackling the logistical and tactical problems involved in implementing those procedures takes a backseat when the dan- ger is not imminent.

8. Performance assessment was not integrated into the process. In an evidence-based world, continuous performance assessment should be built into disaster relief efforts, but that is not the case. Performance evaluation is especially lacking in mental health provision. An assessment device that provides benchmarks and rubrics to gauge how relief is proceeding and how well it is go'ing is sorely needed so that best practices models may be generated. There was discussion about that after 9/ 11, but it still hadn't happened 7 years later. To this day there still is no clear way of systematically evaluating the services rendered (Watson, Brymer, & Bonanno, 2011).

9. The geography of poverty. Are race and socioeco- nomic status response factors? While race became a factor because the majority of the poor in New Orleans were black, the fact is that disaster plans as they are currently formulated put the poor, the elderly, the sick, and other disenfranchised

604 • PART FOUR No Man's Land: Facing Disaster

Personnel. Volunteers who would function as reserve crisis counselors should be recruited and trained in crisis intervention skills . Specified workers should be selected for multidisciplinary crisis response teams. A chief of operations should be nominated and will be the individual actually running the disaster response. There should also be an emergency preparedness coordinator who will be responsible for planning and preparation prior to a disaster and will function as a consultant to the chief of operations during an actual emergency. This p5rson will be the liaison to the local EOC.

An outside clinical consultant should be retained to assess the physical and mental condition of the staff A command-and-control and communications center should be established and staffed by a team leader and other staff necessary for it to function ef- fectively. A historian should keep an ongoing journal of activities that occur as a result of the disaster. The decisions, events, problems, and information should include details, names and addresses, times, and is- sues that can later be used for debriefings, psychologi- cal autopsies, system improvements, grant requests, or reimbursement.

A personnel liaison will assist the chief of oper- ations in assessing, making, and tracking staff and volunteer assignments. A media/ information liaison will provide information to the media and local gov- ernment, develop press releases, and distribute gen- eral information regarding service delivery. Staff may be made available to the local EOC to provide psycho- logical support.

Transdisaster (0-14 Days). The mental health unit needs to initiate immediate mental health services when the disaster occurs; restore services to clients served during normal times; act as the disaster mental health advisor to the local government; provide out- reach programs and coordinate resources for the de- livery of disaster mental health services from the Red Cross, NOVA, FEMA, and other religious and philan- thropic organizations; coordinate the responses of any contractors for services with particular emphasis on evacuation of residential facilities; target specific areas, such as evacuation centers, emergency relief centers, and FEMA "one-stop" service centers; provide support services for disaster workers; and assist with mental health emergencies in hospitals with victims requiring medical or psychiatric care.

Postdisaster (15-365 Days). Evaluate and assess the need for postdisaster services; implement prepared

immediate services grant and prepare regular services grant if a presidential disaster is declared; establish linkages with American Red Cross mental heald: workers to hand off clients requiring longer-term care; monitor for long-term psychological effects: educate the public regarding disaster-related psycho- logical phenomena; evaluate program response, borh short and long term; perform psychological autops;· on total crisis response and debrief workers.

In the foregoing sections of this chapter you haYe read about the overall composition of disaster plan- ning and infrastructure. In an ideal world, even in a world of disasters, all of this runs smoothly. While 9/ 11 certainly had its share of chaos and confusior. (Halpern & Tramontin, 2007, pp. 171-197; Kaul & Welzant, 2005; Norris et al., 2006), order came ou- of that maelstrom fairly quickly, and everybody thought they had learned a lot oflessons. Then along came hurricane Katrina and everything got turne · upside down.

What Happened with Katrina? In any disaster there is invariably an attempt to fix blame. If blame can be fixed, then people may star: to believe that the impossible, out-of-control, insane. unbelievable, chaotic, and unfathomable event ca,"1 be contained, made sense of as to the reasons it oc- curred, and a sense of control regained as to what wem wrong and how it can be made right the next time. In that sense hurricane Katrina is no different from mul- titudes of other natural disasters that have hit othe:- countries. Indeed, in comparison to typhoons an ' earthquakes that have plagued Asia and the Middle East, it is a relatively small event, and certainly so in regard to loss oflife. Yet the recriminations from hur- ricane Katrina are unending and rub raw nerves from the standpoints of socioeconomic, racial, political, and. even interstate rivalries . While it is expected, rightly o;- wrongly, that there will be disasters in countries like Bangladesh, it "cannot happen" in the United States. We pride ourselves on controlling our destiny through science and industry, up to and including controlling nature. After Katrina, apparently not!

This is not an exposition about who's to blame or what's to blame. The emerging facts suggest that there is plenty of blame to pass around and share. However. what Anahita Gheytanchi and her associates (2007) have compiled is worth reporting as a way oflooking at how the various systems within a disaster ecosystem operate. or in the case of hurricane Katrina .. . don't! Gheytanch! and her associates report 12 key failures of response.

1. Lack of efficient communication. The sine qua non of disaster mitigation is communication. Both within and between the primary and super me- sosystems, communication failed. At least four separate command structures were operating in Katrina's aftermath: two command structures in FEMA and two military command structures. That's at least two too many and resulted in crossed communications, duplicated or incomplete ef- forts, and generally clouded decision making.

2. Poor coordination plans. Coordination is about mov- ing assets to where they are most needed. The in- ability to coordinate relief efforts ranged from not utilizing one of the finest hospital ships in the world, the U.S.S. Bataan, which sat idly offshore, to an inability ofFEMA to find buses and drivers and move people out of the Superdome, to hundreds of trucks filled with ice sitting idly in Memphis freight yards with no place to go, to thousands of house trailers sitting in Arkansas when they were desperately needed in Mississippi and Louisiana.

3. Ambiguous authority relationships. The Department of Homeland Security remained on a "pull" basis, which means that the state had to request federal assets, rather than a "push" basis, which means that assets would be immediately made available to the state. The National Response Plan Cata- strophic Incident Annex (NPR-CIA) should have been invoked prior to landfall, but in fact was never invoked. The prevarication and waffling by Loui- siana state and local governments on instituting mandatory evacuation because of the cost, even though they were getting intense pressure from federal authorities to do so, caused severe prob- lems that culminated in the Superdome fiasco.

4. Who's in charge? Factious political fights plagued relief efforts. The shifting of blame from the mayor of New Orleans to the governor of Louisi- ana to the president of the United States settled nothing. Lessons from previous hurricanes about coordination among federal, state, and local gov- ernments have not been learned or at least not been put into practice. Laws that govern the use of the armed forces in the continental United States also severely hamstring efforts to quickly deploy military personnel and need to be changed.

5. Counterterrorism versus all-hazards response. Money, staff, and other assets have been drained out of FEMA and moved to Homeland Security efforts to combat terrorism. A natural disaster the size of hurricane Katrina dwarfs any terrorist attack up

CHAPTER SEVENTEEN Disaster Response • 605

to a nuclear detonation or release of the plague. Yet Homeland Security funded disaster prepared- ness for terrorism as opposed to natural disaster at a 7-to-1 ratio pre-Katrina.

6. Ambiguous training standards and lack of preparation. Across the board, training and experience with disasters were lacking. While the aforementioned FEMA training to become a certified LEMA man- ager sounds good, the reality is that the training requirements to become an emergency manager and become certified were cumbersome and dif- ficult to complete. Standards for accreditation of response agencies were also vague and not tied to any performance-based evidence.

7. Where is the "learning" in lessons learned? A multia- gency hurricane exercise that very closely resem- bled Katrina was completed prior to the storm. Outcomes closely paralleled what actually hap- pened. Yet failure oflocal and state governments to follow up and take advantage of the exercise doomed it to collect dust on the shelf. This is not the first instance of failure to heed learning from the past. Putting into practice all of the proce- dures necessary to stave off a disaster like Katrina is difficult, costly, and time consuming; it de- mands expertise and interagency cooperation at the local level and vertical integration with state and federal agencies. Tackling the logistical and tactical problems involved in implementing those procedures takes a backseat when the dan- ger is not imminent.

8. Performance assessment was not integrated into the process. In an evidence-based world, continuous performance assessment should be built into disaster relief efforts, but that is not the case. Performance evaluation is especially lacking in mental health provision. An assessment device that provides benchmarks and rubrics to gauge how relief is proceeding and how well it is _going is sorely needed so that best practices models may be generated. There was discussion about that after 9/11, but it still hadn't happened 7 years later. To this day there still is no clear way of systematically evaluating the services rendered (Watson, Brymer, & Bonanno, 2011).

9. The geography of poverty. Are race and socioeco- nomic status response factors? While race became a factor because the majority of the poor in New Orleans were black, the fact is that disaster plans as they are currently formulated put the poor, the elderly, the sick, and other disenfranchised

606 • PART FOUR No Man's Land: Facing Disaster

individuals who are not financially or physically able to evacuate, relocate, or rebuild at extreme risk without regard to race, creed, color, national origin, religion, sexual preference, or any other distinctive human quality.

10. Rumor and chaos. Urban legend and rumor, the bane of any disaster, ran rampant in New Orleans. No clearly designated official spokesperson appeared, giving clear, unconflicted, factual messages that could be believed. Exaggeration by elected offi- cials of armed violence was given airtime by the media, and these rumors then turned into "facts" and took on a life of their own. At its best rumor served to warn people and put them on their guard. At its worst it turned into a self-fulfilling prophecy that slowed rescue efforts. Concrete, fac- tual, up-to-the-minute information by an official spokesperson with both face and content validity was essentially absent. Above all else, an ironclad rule in any disaster is that one highly valid, knowl- edgeable spokesperson gives facts out in a timely manner and dispels rumors as they arise.

11. Personal and community preparedness. There was clearly a sharp divide between what happened in Louisiana and Mississippi in regard to recovery efforts. Both states suffered an equal amount of catastrophic devastation along their coast. How- ever, for whatever reasons, and there are many variables to be examined, Mississippi was more resilient. Whether the majority of its people had better resources and support systems is a differ- ent question from whether they were prepared. However, that question needs to be examined carefully, for both physical and psychological dif- ferences and perhaps even cultural differences that were demonstrated and heavily influenced long-term outcomes in the two states.

12. Disaster mental health and the role of mental health professionals. What actually works for reducing mental health problems in people afflicted with a disaster like Katrina is still not clear, and a great deal of research needs to be done to find out what evidence-based practices do work. Critical incident stress debriefing (CISD), which has been used and most certainly abused as a panacea, appears not to be the ultimate answer. Further, attributions that label survivors as suffering from a mental illness don' t work very well either. The preferred operating mode now is the use of psychological first aid and social support (Watson, Brymer, & Bonanno, 2011). Self-efficacy models

that foster self-reliance, coping, and problem- solving skills, focus on individual needs, seek m extinguish PTSD at early onset, and concentrate on functional recovery rather than looking for pathology seem to hold promise (Ruzek, 2006).

Psychological First Aid and Psychosocial Support as Applied to Disaster Survivors As detailed in Chapter 1, the National Institute of Mental Health (2002) defines psychological first aici (PFA) as establishing safety of the client, reducin,:: stress-related symptoms, providing rest and physic<L recuperation, and linking clients to critical resources and social support systems. Psychological first aid has now been adapted and modified from its initial use b;· Raphael (1977) into a first-order, evidence-based ap- proach to working with survivors of mass disasters (Brymer et al., 2006; Hobfoll et al. , 2007). It may be taught to paraprofessionals and nonprofessionals. For example, it is one of the training modules (CERT. 2011) that volunteer CERT workers get as part of their search and rescue work training.

Psychological first aid as it is applied in a disaster is designed to reduce distress, generate short- and long- term adaptive functioning, and link survivors wit!:: additional services (Watson, Brymer, & Bonanno. 2011). The Field Operations Guide for Psychological Fin-; Aid developed by the National Child Traumatic Stress Network and the National Center for PTSD (NCTS' - NCPTSD, 2006) is considered state-of-the art in tha: regard (Webber, Mascari, & Runte, 2010). Deliver;· of PFA includes a number of core actions (NCTS. - NCPTSD, 2006): make initial respectful contact b;- a warm engaging presence; gather and provide in- formation in regard to supports needed to deal witl: immediate physical and safety concerns; provide an direct people in regard to practical assistance needec:: provide for their safety and comfort both from a phys- ical and psychological standpoint by linking thee: with social services; teach them basic coping skills if requested; and get information and help that wil. connect them to social supports, such as reunitin~ them with family and other social groups with wh ic!:: they are involved.

The job ofCFA workers is not to attempt to engage in therapy or elicit details of the tragedy; rather, it is to reduce acute psychological distress by their sup- portive and compassionate presence through basic active listening and responding skills (Everly & Flyna . 2005). Initiating contact involves the notion of "jus~

being there" or "compassionate loitering" (Webber, Mascari, & Runte, 2010), which emphasizes careful observation, a nonintrusive presence, and caring, re- spectful contact. One example is the crisis workers who were available in the dining halls of Virginia Tech residence facilities and classrooms immediately after the shootings there. Volunteers had handouts on normal reactions to tragedies, self-care tips about trauma, and resource lists. Workers were instructed to engage and support students who seemed to be struggling by a respectful, nonintrusive introduction as a way to offer their support. They wore purple arm- bands to identify their presence. They reported that students initially would not speak to them, but as time went by and students started coming to terms with their grief, they would stop by and thank them for being there (Lawson, Bodenhorn, & Welfare, 2010).

Even doing the foregoing may not be necessary as most people are pretty resilient after a disaster (Hobfoll et al. , 2007). As indicated in Chapter 2, Culturally Effective Helping in Crisis, insistence on participating in "psychotherapy" may be met with anger and extreme resistance. In support of the con- cept of voluntary participation, Bonanno, Westphal, and Mancini (2011) found that a one-size-fits-all intervention might hold no advantage over, and could even undermine, the self-efficacy and resiliency of sur- vivors . For many others, PFA may be both necessary and sufficient. Finally, for some few others, PFA may be necessary but not sufficient.

When More Than PFA Is Needed It was first thought that severity of exposure to the event and severity of postevent stress and adversity would be the greatest factors indicating the need for more in-depth intervention for serious and chronic psychological problems (Norris, 2006). However, since 9/ 11 it is clear that degree of exposure or prox- imity to the attacks does not explain all of the persons presenting with severe psychological problems after a disaster. An individual waving an American flag for hours and hours over an interstate highway 1,000 miles from the impact sites, and refusing to come down for safety, is one example among literally thou- sands of individuals across the country who "lost it" after 9/ 11 and needed something more than PFA. In other words, vicarious traumatization through expo- sure to merely seeing or hearing about disaster events could instigate maladaptive psychological respond- ing. As a consequence, Watson, Brymer, and Bonanno (2011) have compiled a laundry list from their own

CHAPTER SEVENTEEN Disaster Response • 6 0 7

and a number of other researchers that total 22 risk factors for adults and 13 for children. We believe it doesn't make a lot of sense to try to go through that list and winnow out significant variables. What we do believe in is knowing how to use the Triage Assess- ment Form in this book. People scoring 20 or more are going to need something more than PFA for sure; they are going to need someone to monitor them closely until they regain some precrisis equilibrium and most likely should not be turned loose on their own. People in the high 20s, who are potentially lethal to themselves or others either by intended commission of unsafe acts or unintended omissions of activities needed to keep them safe, should not be turned loose. People in the high teens will most likely profit from PFA and a good deal of on-site psychosocial support so that they don't escalate into the 20s. People in the low teens are probably ideal candidates for PFA. Any- body in the single digits on the TAF probably needs to counsel us!

The Current State of Affairs The problem with this latter approach, however, is twofold. First, it assumes that a large enough number of practitioners have the necessary crisis intervention skills to do this. If mental health practitioners are not available, then paraprofessionals or laypersons like those who operate in Community Emergency Response Teams (CERTs) and are taught psycho- logical first aid as part of their training may be ini- tial providers of psychological support. That may be stretching it a bit. With all due respect to CERT vol- unteers, we spend a lot of time teaching these "first aid" techniques to graduate students. They are not easy to implement, particularly when faced with a person in crisis, and we wonder if the estimated learn- ing time of 1 hour and 15 minutes (including video) will be sufficient (CERT, 2011).

You will soon hear from a licensed pro(essional counselor who was deployed in Louisiana post- Katrina. This counselor has extensive training and practice in crisis intervention. She is still the excep- tion rather than the rule. Given her background and training, she struggled and reevaluated her therapeu- tic worldview as she went through her tour of duty. Her story is not much different from that of many oth- ers who were there with her. While the American Red Cross crisis counseling training program has trained thousands of practitioners, that resource was clearly not enough for hurricane Katrina. The Red Cross and government agencies were forced to suspend their

608 • PART FOUR No Man's Land: Facing Disaster

standards and bring in any licensed counselor, psy- chologist, social worker, psychiatric nurse, or psychia- trist they could get their hands on.

FEMA's crisis counseling assistance and train- ing program (CCA-TP) is available to state mental health authorities once an area has been declared a disaster area by the president. That is a lot like clos- ing the barn door after the horse has escaped. Way too many things are happening to stop and say, "OK, we now have a large, metastasizing disaster on our hands; let's do some training! " This training oc- curred · in Memphis approximately a month after Katrina. To say it was mostly useless is being kind. We believe that training should come prior to any catastrophic event and follow-up refresher courses should go with it. After a congressional inquiry into this program's problems in south Florida, a critical review of it was instigated and a number of worth- while recommendations were made to tighten it and beef it up-particularly in regard to coordination ac- tivities (Department of Homeland Security, 2008). None of those recommendations, however, made clear whether a municipality can actually get train- ing prior to a disaster.

Young and his associates (Young, 2006; Young et al., 2006) have developed a comprehensive predisas- ter training program that holds much promise. It has a conceptual framework that differentiates natural and human-caused disaster and examines effects on both individuals and communities. It has both prac- titioner and administrative training components and specific modules on high-risk client populations and interfaces with other organizations. This fine pro- gram is time consuming, most likely expensive, and requires trainers who have expertise in both disaster mental health practice and administration. Those are difficult commodities to find.

Consistent and comprehensive training for mental health providers in crisis intervention as they matricu- late through professional training programs has been piecemeal at best (Coke-Weatherly, 2005), as clearly de- scribed by Roberts (2005). That appears to be chang- ing to some extent. The Council for Accreditation of Counseling and Related Educational Programs and the National Association of School Psychologists both require the teaching of crisis intervention in their ac- crediting criteria. While that may now be seen as nec- essary, it remains to be seen whether what is taught will be sufficient. Other professional accreditation agencies appear to make the provision of crisis inter- vention training voluntary.

Most certainly, Katrina was a megacrisis that had metastasizing effects far beyond its geographic landfall and a physical scope that had never before been expe- rienced, with disenfranchised people shipped all over the United States. The terrorist attack on 9/ 11 probably had the widest range of vicarious psychological effects ever experienced in the United States, with the possi- ble exception of the Japanese attack on Pearl Harbor. A number of national committees issuing from both 9/11 and Katrina have made numerous recommendations in regard to the provision of crisis services to individu- als following these human-made and natural disasters. These recommendations have been summarized by Watson, Brymer, and Bonanno (2011) in their article on postdisaster psychological intervention since 9/ 11.

1. Be proactive ahead of time with pragmatic, flex- ible plans that match appropriate services to each phase of the recovery period.

2. Promote a sense of safety, connectedness, calm, hope, and efficacy.

3. Participate in groups with stakeholders to coordi- nate and learn from others, minimize duplication, and mend gaps in service.

4. Be culturally sensitive and consider human rights. 5. Be willing to undergo evaluation and open to

scrutiny of practices. 6. Stay up to date on evidence-based practices. 7. Maximize participation by local populations and

find and use local resources and capabilities. 8. Integrate activities and programs into larger systems

to reduce stand-alone services, reach more people, and be more sustainable over time and space.

9. Use a stepped approach that focuses early efforts on practical help and pragmatic support, with psychological first aid for a generally resilient population.

10. Use triage assessment and focused care for those with specialized needs who require increased lev- els of intervention.

11. Provide technological assistance, consultation, and training to local providers.

12. Conduct needs assessment of the community with ongoing monitoring of services and program evaluation.

13. Support community-based cultural rituals, memorial services, and spiritual healing practices.

Priscilla Dass-Brailsford's book Crisis and Disas- ter Counseling: Lessons Learned From Hurricane Katrina and Other Disasters (2010) examines many of these

recommendations, and the lack of their in-depth im- plementation. The book places particular emphasis on cultural variables (Boyd, Quevillon, & Engdahl, 2010; Boyd-Franklin, 2010; Dass-Brailsford, 2010) that affected mitigation efforts post-Katrina. How the worker interacts in the first few minutes and hours of contact will most likely determine how ef- fective intervention is and can profoundly affect the recovery course of survivors (Miller, 2010). You should understand that this is why we included a chapter on multiculturalism in this book-not just to be politi- cally correct, but because this is one of the most im- portant variables in disaster crisis intervention.

You should also understand that, as yet, we believe the foregoing 13 principles are neither well known nor practiced regularly by a sufficient number of folks in this business to handle a megadisaster or a pandemic. That is particularly true of pandemics, in which the needs will be exponentially greater than in local megadisasters like Katrina (Webber & Mascari, 2010).

Crisis intervention is not the major occupational definition of most of the people who are called to a mass disaster, nor are you going to find it named in the Dictionary of Occupational Titles. Until that hap- pens, there are likely to be, both on an individual and systemic basis, problems from people attempting to ply this trade who don't know what they are doing or, worse yet, think they do but don't. Frankly, the mere fact that you are reading this book most likely makes you more knowledgeable about crisis inter- vention than a lot of other professionals who hold Ph.D.s in the helping services fields . The recent birth of Division 56 (Trauma Psychology) of the American Psychological Association and the requirements of counseling and school psychology accrediting agen- cies for the provision of crisis intervention are a start, along with the American Red Cross's view to expand its psychological intervention curriculum and con- duct outreach to more constituencies. Evidence-based treatment practices are starting to be published, but the real-time chaos of disasters makes it hard to do much other than do ex post facto studies. We agree with Silverman, Allen, and Ortiz (2010) that with all due respect to PFA, which appears to have replaced CISD as the treatment de jour, we would like to see a whole lot more outcome studies on its effectiveness, particularly in regard to whom it is applied to, by what kinds of people, and under what kinds of conditions. Please forgive us for being flinty-eyed about panaceas, but 40 years in this business have seen a lot of cure-alls come and go.

CHAPTER SEVENTEEN Disaster Response • 609

The People of Disasters: Responders and Survivors

Crisis Workers at the Disaster Crisis workers have a wide range of duties after a Im disaster. Foremost is simply being available for survivors to talk with, listening to their experiences, empathiz- ing, and processing with them as they attempt to make sense of it. These activities fall mostly within provision of psychosocial support services and psychological first aid. Workers may help survivors locate significant oth- ers, help relatives with identification of victims, or help make arrangements for the deceased. They may provide information on the affective, behavioral, cognitive, in- terpersonal, and physiological responses to traumatic events (Friedman, Ritchie, & Watson, 2006).

Crisis workers may help relatives through the grieving process, promote social support systems for survivors, and devise a plan of action to mobilize the survivors' resources. They may make appropriate re- ferrals and provide follow-up services. They may also provide debriefing to other emergency service work- ers (Walker, 1990), prepare food, find clothing, wash dishes, move rubble, help people find lost puppies, talk about -how a family who has just lost everything is going to get their 17-year-old into the private col- lege they had planned sending her to but now have no money to do so, administer first aid, help people figure out insurance and FEMA claim procedures, help determine what to do with a grandmother whose nursing home is now full of black mold, conflict- resolve angry feelings between tired, hot, smelly in- habitants of a disaster shelter, and do a thousand other things that lend physical and psychological sup- port-all while dining on military MREs, contracting head lice, going without a bath for a very long time, getting bitten by fire ants, and seeing a dermatolo- gist for an unknown skin condition after their tour of duty. Following are some reflections by' Dr. Holly Branthoover (personal communication, October 18, 2006) on her experience post-Katrina.

Thoughts of a Mental Health Worker on Katrina One Year Later Dr. Holly Branthoover, Licensed Professional Counselor and Associate Professor of Counseling, Indiana University of Pennsylvania

I was recruited by the National Board for Certified Counselors via e-mail on Sunday, September 4, 2005,

610 • PART FOUR No Man's Land: Facing Disaster

to respond to hurricane Katrina for the Red Cross. I filled out the application packet immediately, faxed it back, and expected to hear from them in a few weeks. The Red Cross contacted me 2 days later, on Tuesday, September 6, asking, "When can you leave?" I garnered permission from the university, prepared coverage for my classes, and flew out on Saturday, September 10. Preparation for the trip included a Red Cross phone orientation and faxed material provid- ing me instructions.

I flew into Baton Rouge, Louisiana, and completed my "in processing" with the Red Cross. I slept in a staff shelter in Baton Rouge that evening and received my assignment the next morning. I was assigned as a part of a team of three mental health workers-a team leader who was a licensed clinical social worker and another team member who was also a licensed profes- sional counselor. We drove to Covington, Louisiana, to the regional Red Cross headquarters for the east- ern region of Louisiana. At Covington, we were given our field assignment-to live and work with evacuees at Pearl River High School in Pearl River, Louisiana (275 residents), and to also service three other shelters: Riverside Elementary (25 residents), 6th Ward Elemen- tary (36 residents), and Abita Springs Middle School (35 residents). We also added 5th Ward Elementary (50 residents) when we got to the field.

I stayed in Louisiana for 2 weeks, leaving on Saturday, September 24. However, my departure was very stressful as hurricane Rita arrived on Friday, September 23, closing the Baton Rouge airport and necessitating a drive to Jackson, Mississippi, to catch a flight. Here are some of the points I feel are impor- tant if you decide to do disaster mental health work:

In addition to my initial mental health team of three, we received another mental health team mem- ber and heavily utilized some local mental health peo- ple who had volunteered. The local people were very important in that they were a potential constant in people's lives, whereas we could only be available for a short time. So we had them handle people or fami- lies that were potentially staying in the area. It worked very well. I believe this use of local resources is para- mount to a successful operation on this scale.

Another thing that I feel very strongly about af- ter my experience is that roving teams may work for medical personnel, but they do not work for mental health. You must join the system. My team lived in the shelter. We ate from the ERV [emergency response vehicle]. We showered (or didn't, in some cases) in the same showers as the residents. Although we certainly

did not share their experience of loss, we did share their experience of the frustration of living in a shel- ter, and I believe it helped them develop a rapporr with us that facilitated assistance.

When we first got to Pearl River High School, we were assigned a counseling room in which to see peo- ple. How many people came to that room? Not one! People in crisis do not present for counseling; they are not looking for self-actualization. We had to be out there, in the shelter, sitting with them, talking to them, listening to their stories. As previously men- tioned, our team was covering several other shelters, not just Pearl River High School. Our team leader made a wise decision that we needed to provide a con- stant presence there, as well, so the same people trav- eled to the same shelters on a daily basis.

One of the things that crisis textbooks talk abom is that crisis responders should have the quality of flexibility-I never realized the importance of this un- til my experience in Louisiana. I had no idea where I was going when I boarded the plane to Louisiana. I had to call a phone number when I landed to get more information. Talk about an adventure! After I reached my assignment in Pearl River, communica- tion was terrible. Even 2 weeks after the storm, cell phone service, landline phone service, TV, Internet, electricity, and so on were all unreliable or nonex- istent. Information was carried by courier in some instances, and by the time a directive reached us, it could be wrong or changed.

Misinformation was rampant. We spent some time on rumor control. We actually traveled by car to sites that we "heard" were providing services-like water, cleaning kits, food, blue roofs (tarpaulins to cover damaged roofs), and so on. We tried to confirm what information was factual and pass that to our residents. Who would want to use the last of their gas to drive to a site for assistance and find there is no assistance available? We also acted as a liaison with FEMA representatives in the area, getting accurate in- formation and facilitating services. Much of our time was spent in linking clients to assistance-more social work than counseling.

Medical services are also a part of what the Red Cross provides during a disaster. The mental health staff worked closely to assist the medical staff. Some people were in crisis because of their injuries (e.g., a woman with a severe vaginal infection from being in the floodwater who thought she was dying). Some were in crisis because they could not get their medi- cation (everything from life-sustaining medication

to methadone). We detoxed half a dozen people from their methadone in the shelter. Lack of medication was a big issue. Since we, as a team, had a car, we tried to barter and borrow supplies and medication when we came into contact with staff at other locations or on trips to regional headquarters . Things like hand sanitizer and lice kits were quite a commodity.

Working with the children in the shelters was an- other important activity that we engaged in. One of the members of my team was the head of a day care center in New York, so she was very invested in set- ting up children's programs. Again, we did very little counseling here. Our team member set up children's activities three times per day at Pearl River. Activities included arts and crafts, games, movies, and the like. This served two positive purposes, providing struc- ture to the children's day (the shelter is a boring place) and giving parents a break. We had to put boundar- ies on the parent break because some took advan- tage. For example, we had to make a rule that parents could not leave the shelter while children's activities were going on (so they could be available if there was a problem). Although it varied by developmental level, children began to express their feelings about the hurricane and their current life situation via the art- work and games.

When we first arrived, and periodically through- out, we worked with disaster relief services staff a great deal. Staff were stressed and burned out. At some of the smaller shelters, we were the only profes- sional mental health service providers that the disas- ter relief staff had seen since the hurricane. At one shelter, several medically needy residents had died, and staff needed to talk about and process this experi- ence. They were angry at the lack of supplies and com- munication- so much food was available that it was sometimes thrown away, but there was a great lack of medical supplies. At times, staff members got into arguments, and we would mediate. Sometimes, staff was just stressed and needed to talk. Our team leader consulted often with the shelter manager, assisting in administrative decisions about shelter services. I be- lieve this was a strength of our shelter manager-get- ting mental health input on shelter operation. In one instance, I was asked to talk with a staff member who had violated Red Cross policy and was going to be re- lieved of her duties and sent home early.

In the shelter, we had National Guard protection for only the first 2 days. From then on, we had 24- hour protection from local law enforcement-parish sheriffs, with at least two on duty at all times. We

CHAPTER SEVENTEEN Disaster Response • 611

worked closely with the sheriffs-assisting with resi- dent arguments, and so on. There were two cocaine arrests at the shelter, with those residents being taken to jail. We had two domestic violence incidents-we worked with security to come up with a safety plan for all residents (this meant moving the two offend- ing husbands to a different shelter). I spoke person- ally with a least two people who were suicidal, and we worked with security to observe them since there were no inpatient mental health facilities available.

Another incident that was particularly scary hap- pened two nights before I left. When hurricane Rita was coming, a mandatory evacuation of New Orleans resulted in our shelter numbers swelling to close to 500 people. Many were Hispanic workers from con- struction crews who spoke little or no English. A local person and a worker got into a fight in the cafeteria, and a gun was pulled. Although security directly dealt with the gun issue, we assisted with crowd control and calming everyone down afterward-including staff!

Some of my philosophies of crisis intervention were challenged as a result of this experience. The goal of crisis intervention is to return clients to their precrisis state of functioning. In this case, the major- ity of the clients in the shelter had a precrisis state of functioning that was dysfunctional! By 2 weeks poststorm, most of the residents left in shelters were people who had little before the storm in the way of resources-both personal and financial. People with family support systems or money were already gone. The majority of our residents had supported them- selves via public assistance or SSI disability. Many were involved with community mental health, child protective services, and the legal system. Several were inmates from the county jail who had been released as the storm approached. Drug abuse, child abuse, and domestic violence were prevalent. Given the demo- graphics, it was hard to tell when crisis intervention should end! I also found it important to help people problem-solve within the context of their culture. One man felt trapped about making a decision to go back to work. He did not want to leave his wife alone at the shelter, as he felt it was his duty to protect her. His wife had been called back to work, too. However, he did not want her working while he was not (who would watch their stuff?), and his duty as a man was to provide. I had to work within these values-not my own.

My last two thoughts are related to actually being a part of a team response. Just because you are "mental health" doesn't mean that you are not part of the en- tire shelter team. Pitch in! I did kitchen work, carried

612 • PART FOUR No Man's Land: Facing Disaster

and moved things, and cleaned. Each night, after resi- dents went to bed (curfew at 10 P.M.), the whole shelter was disinfected. I helped with this every nighr. Work- ing alongside someone can give a great opportunity for them to share their feelings or vent. It also allowed us to be part of the staff- not separate. This said, I do not minimize the benefit of doing mental health things for staff The second week I was there, a local pizza place opened. The mental health team orga- nized a pizza party for staff for after residents went to bed. It turned out to be a great stress reliever.

Last, all of the things I have talked about are oc- curring while you are living the experience of a disas- ter and trying to help people at the same time. I slept on a cot, showered only once the first week, and tried to avoid getting lice (which I did, luckily, because the thought alone freaked me out!). In our travels, we saw the horrific devastation in Slidell, Louisiana, which borders Pearl River and was where the eye of the hurri- cane passed through. We also traveled, on our day off, into New Orleans, again witnessing the loss and dev- astation of the storm. During our trip to the city, we got free pizzas from Dominos (they were passing them out) and water. We drove around the city to different National Guard troops, firemen, and EMS compa- nies, passing out pizza and water, and spent time just talking to them-something they were grateful for when they found out we were "mental health." It was scary to be in a city that looked like a ghost town, pa- trolled by military personnel with M16s. We got to see the Superdome and the Convention Center. I believe it was important to have this R&R even though we were still, in a way, doing our mental health job. There were several times in the 2 weeks when I got really stressed out (like when I asked for lice kits at headquarters and was told we couldn't have lice at our shelter-because they hadn't gotten a report of it!). So it is important to find a way to take care of yourself- phone calls home, camaraderie with other staff, watching a DVD (after the power is back on!), and so on. You can't help oth- ers if you are a stressed-out, burned-out mess! Source: Used with permission from Dr. Holly Branthoover, Associate Professor of Counseling, Indiana University of Pennsylvania

Now switch to Memphis, Tennessee, 450 miles away.

Lessons I Learned from Katrina Dr. Richard James, Licensed Professional Counselor; Psychologist, National Board Certified School Counselor; Department of Counseling, Educational Psychology and Research, University of Memphis

When Katrina hit the Gulf Coast, little did men- tal health providers in Memphis, Tennessee, realize

that they also would be in the eye of the hurricane. As the magnitude of the disaster started to become clearer and the flow of evacuees moved away from the coast, one thing became very clear in a hurry. \{'e were not prepared for the onslaught of people with wide-ranging mental and medical problems that were about to descend on us. Compounding the problems those medically and mentally fragile people brough[ into our community were 13,000 homeless individ- uals who were essentially living out of their cars or motels for the first 2 weeks post-Katrina. As it became clearer that these people were not going back home immediately, a variety of crisis situations arose.

Three anecdotes will give you a pretty good idea of how ill prepared the city of Memphis and Shelby County, Tennessee, were to deal with a major disaster as far as provision of mental health service was con- cerned. This is probably more ominous when consid- ering that the scene of the actual disaster was more than 400 miles away from us .

On September 3, 2006, I was helping my daughter and her fiance load my truck with gasoline, lantern and cooking fuel, lanterns, cooking equipment, fire- arms, meals ready to eat, sleeping bags, and other sup- plies as they prepared to go back to see what was left of their home in Long Beach, Mississippi, after hur- ricane Katrina sent a 5-foot wall of water through iL At 10:00 A.M. I received a phone call from a harried Shelby County Red Cross director of medical services who had located me by word of mouth and was told I might be able to help since "I knew everything about crisis intervention." He asked ifI could provide assis- tance to the crew of the American Queen sternwheeler passenger liner that was docked in Memphis with a crew of 250 very agitated individuals. The boat and crew all shipped out of New Orleans, and they had no word of their families or homes because they had been on the Mississippi River since Katrina hit. The problem was that no one could find this 400-foot- long boat-in Memphis, not even the police. Finally, the riverboat was located at 5 P.M. I got another coun- selor and headed for the boat. Now the problem was that the boat was set to sail at 6 P.M., passengers were filing on board, and dinner was being served, so no one could come to talk to us. That was the start of what came to be a deluge that we were ill prepared to handle and caused us to reevaluate every facet of our disaster preparedness and mental health provision system in Memphis.

The bishop of the Memphis Catholic diocese had witnessed Katrina firsthand from a hotel room as he

saw his car go floating away in Bay St. Louis, Mis- sissippi. He immediately flung open the doors of all the Catholic schools in Memphis and welcomed any and all families from the coast to enroll their chil- dren tuition free in the Memphis Catholic school system. Many of these children came from very poor families with extreme deficits in their educational backgrounds. A lot of these kids were the toughest of the tough to teach and found their way into new Catholic inner-city Jubilee schools, which operate on very tight budgets with little support staff. Since I was "the guy who knew all about crisis" and was also a school counselor educator, I was asked to put a work- shop together for the private schools in Memphis on dealing with traumatized children. On September 10, together with Dr. Jo Epstein, a National Certified School Counselor and an elementary school coun- selor with the city of Memphis, I delivered a workshop at the University of Memphis that was attended by 31 counselors and teachers from 19 private schools. After we finished delivering a 3-hour workshop on trauma and what they might expect to see in their school buildings, I looked out over the room and saw that many of those faces looked like deer caught in the headlights of an oncoming truck! I immediately knew that I would need help in dealing not only with evacuees but also with teachers and counselors, who would be suffering from secondary traumatization from attempting to deal with those children. For the next 6 months, these teachers and counselors met with me for supervision as they valiantly attempted to deal with these high-risk children and stave off com- passion fatigue and burnout.

It quickly became apparent that we didn't have enough mental health professionals to deal with the people coming into our city with a host of medical and mental issues. We also did not have anyone in charge of handling these people. The coordinator of the local crime victims' assistance center, a licensed clinical so- cial worker, and another LCSW at one of the local men- tal health clinics stepped into the breach and started to make order out of what was rapidly turning into a classic example of chaos theory at work (see Chapter 1, Approaching Crisis Intervention). Picture your author sitting in a reception center talking with a methadone maintenance heroin addict from New Orleans.

Addict: Hey, man, they won't give me any methadone, say I got to have a prescription. IfI don't get some methadone pretty damn quick, I'll go rob a liquor store and get the real deal!

CHAPTER SEVENTEEN Disaster Response • 613

By the middle of September we had approximately 13,000 expatriates from New Orleans and the Gulf Coast in our city. All thoughts about licensing and certifying mental health workers for disaster work went right out the window with Katrina. The fac- ulty at our university mobilized 200 students in the counseling, school psychology, and social work de- partments, and with faculty supervisors they started working in the shelters. These students and faculty served up to 2 months in this capacity until some semblance of order could be restored.

The bottom line was that we too were not prepared for this megadisaster. The outcome of this disaster was the establishment of a planning committee for the Greater Memphis Area Emergency Preparedness for Mental Health. That committee's composition ranges from mental health personnel from hospitals, community agencies, and human services provision organizations to religious leaders, school system per- sonnel, city and county officials, the police, fire, and EMT departments, charitable organizations, home- land security, medical facilities , and universities. This is certainly a work in progress. Will we be better pre- pared than we were for Katrina? That's a good ques- tion! Where\ler you are in this country, or any other country for that matter, you might ask yourself the same question. The ripple effects of a disaster this large flow far out from the epicenter. Disasters that affect such a great number of people need all of the professions mentioned above if successful crisis inter- vention is going to occur, as you will soon see.

Case Study of the Benefield Family Now meet the Benefield family, who are about to expe- rience the crisis of their lives. The Benefields typify, in an encapsulated way, how the ecosystemic crisis inter- vention model should (note the emphasis on "should") operate when a large-scale disaster afflicts a family.

Tuesday, April 21, 14:00 Hours Military Time (2:00 P.M. CDT)

An F-4 tornado has hit Midville, Tennessee, a town with a population of approximately 40,000 in the south-central United States. The storm cut across the town and left a path of destruction about one-quar- ter to one-half mile wide for a distance of more than 5 miles. It effectively cut a path through the industrial park, damaging numerous buildings but particularly wreaking havoc on the automotive plant, which

614 • PART FOUR No Man's Land: Facing Disaster

employed more than 1,000 people. The plant is close to a total loss. The storm continued through several residential areas and a housing development, hop- scotched, and then hit the main elementary school of Midville and reduced it to rubble. All 600 students were inside the building at the time, under cover in the hallways.

The water plant received a direct hit from the storm and can no longer keep water pressure up or produce potable drinking water. The power grid has been disrupted by downed power lines and wrecked substations, and the city is currently with- out power. Both cellular and landline telephone systems are inoperable because of downed towers and lines. The local hospital has received minor damage but is still in operation. Local fire, police, and emergency services have emerged largely un- scathed and are close to fully operational. There has been a significant loss oflife in addition to in- juries that appear to be in the hundreds.

Now meet the Benefield family: Travis Benefield, age 33, a machinist at the local automobile plant; Sara Lee Benefield, age 32, a dental assistant; Jason Benefield, age 13, an eighth-grader at Midville Mid- dle School; Lou Ann Benefield, age 11, a sixth-grader at Midville Middle School; Shawn Benefield, age 6, a first-grader at Midville Elementary School; and Loretta Benefield, age 54, the mother of Travis.

April 21, 14:15 Hours Military Time (2:15 P.M., 15 minutes after the tornado)

Travis Benefield is emerging from the rubble of the automobile plant. He has no major injuries, just mi- nor cuts and bruises from falling and flying debris. While frantically helping dig others out, he is also attempting to reach his wife on his cell phone, but that is not working. Sara Lee Benefield is currently upside down in her van in a water-filled ditch. She is there because she heard the tornado siren and, instead of taking cover in the dentist's office where she worked, became hysterical and was on her way to school to pick up her children. She is semicon- scious, bleeding, and clearly in need of rescue and medical assistance.

Jason Benefield is currently looking for his sister, Lou Ann, in the melee that is now Midville Middle School. No one was hurt in either the middle school or the high school, and neither school was signifi- cantly damaged. Everyone in both the middle and high schools had been protected in the hallways; how- ever, chaos now reigns as teachers attempt to control

panic-stricken students who heard the tornado go over and can now see the destructive path it has made. Lou Ann is likewise attempting to find her brother Jason. She is also hysterical because she has seen thac the tornado essentially destroyed the elementary school that her brother Shawn attends. Shawn is cur- rently missing, probably buried somewhere under the rubble of the elementary school. Loretta, the grand- mother who resides with the family, is currently lying in a field, dead from a broken neck and back, about one-quarter mile from where the family lived in a manufactured home that has been blown away and no longer exists.

April 21, 14:25 Hours, Emergency Command Center

LEM director, Thaddeus Washington: (on short-wave radio to all ham operators and state police emergency and state emergency broadcast systems) It appears we have had a major tornado disaster here involving most of Midville. We currently have no power or cellular or landline telephone communication. It appears that there is a large path of destruction through- out the city, and there is also a very high casu- alty rate as we had less than 15 minutes' warning time. We have ruptured gas lines and water lines and have no ability to pump water. We have at least two fires. We are requesting immediate as- sistance from the region IV and state emergency management network. We are making a damage assessment now. Instructions will follow in about 30 minutes.

As the reports from police cars and ham radio op- erators start to come into the center, the director has to make several quick decisions about the magnitude of the disaster. From the initial reports he decides to alert the regional and state emergency management coordinators. He also needs a better assessment of what is going on in the community. He therefore asks for a state police helicopter and instructs his emer- gency preparedness manager to get airborne and con- duct an assessment.

April 21, 14:35 Hours, Midville Middle School, School Crisis Response Team Meeting in Cafeteria

Linda Gidcome, Assistant Superintendent, Crisis Response Coordinator: It appears that we have a major cri- sis involving not only the elementary school but the whole town. The police are over at the elemen- tary school, but we have many children trapped in there. Undoubtedly there are casualties in that building. Jackson Little, the elementary school

counselor and our crisis intervention coordina- tor, is not yet accounted for. Until he is found, Jim Constansis, the high school vocational coordina- tor, is his backup and in charge of intervention. We also have some other missing people, so, Jim, I want you to get backups for them. I am going to turn the meeting over to Jim.

Jim Constansis, Crisis Intervention Coordinator: We also have to deal with our children here and in the high school to be sure they are safe. We need to get everybody back in their rooms and run the roll. Right now we don't have any good informa- tion about where "safe" is. As such, we are going to hold all middle and secondary school students in their respective buildings. It appears that right now there is no way into the school from outside due to debris on the roads. I want to get backups for all the missing members of the team. Our first priority is to run the rolls and see who is miss- ing. So we need to take the TO GO boxes' primary hard copy and send three teams (Red, Blue, Green) over to the elementary school, while the Orange Team stays here and the Purple Team stays at the high school to start receiving kids. We will bring K through third grades here and fourth and fifth grades to the high school. Red has Kand 1, Blue has 2 and 3, and Green has 4 and 5. They are going to need medical assistance over there, so I want the Orange Team to pull all of our available medi- cal supplies out of the sports facility storage and set up a dispensary in the cafeteria.

Luda Sarapokin, our school nurse, will be run- ning that. We're going to get on the radio and let OEC know what our condition is just as soon as the building engineer can get the generator hooked up to it and running. All of you pick up your two- way radios. Things are going to get pretty hectic, so remember your radio manners and protocol. We have done this in an exercise; the only difference was that the middle school was the target. We can do this. Let's go to work!

The Incident Command System has been in place for 2 years in the Midville School District. It has a clear incident command system (Thomae, 2002) that has been activated on the tornado's departure. Its first and primary job is to account for all the chil- dren. Any parents who could somehow manage to get to the school would be taken to a waiting area be- fore any children would be released. The parents have been informed of this plan and know what to expect and what to do.

CHAPTER SEVENTEEN Disaster Response • 615

April 21, 15:05 Hours, above Midville in a helicopter

Saria Wickeramasaka, Emergency Preparedness Coor- dinator: (in a state police helicopter above Midville, on the radio speaking to the LEM director) The Pack- ard engine plant is completely ruined; the total building is involved. I can see human move- ment, but there are undoubtedly people trapped in the plant. I do not see any evidence of fire. We will need heavy equipment including cranes and hoists . We will need EMTs and rescue equipment and units. The Hi Power petroleum bulk plant got hit and there is leakage from their storage tanks. It appears both gasoline and fuel oil are being discharged, although the berms seem to be containing the fuel at present. We will need a containment and cleanup crew there along with fire equipment and spillage trucks. I see no evi- dence of fire. The elementary school has received a direct hit. The middle of the building has sustained a great deal of damage and the east wing has collapsed. I can see movement, and it appears the school CRTs are working at the el- ementary school. There are undoubtedly many casualties.

The roads to the school are currently impass- able. We will need heavy equipment including teams with chain saws to get in there. I would recommend this as our first priority. We do have two house fires, one on Appleton at Branch and one on Sycamore past Hoover. The one on Syca- more is in danger of involving an apartment com- plex. It should be fought immediately. The street is blocked from the north, but trucks can come in from the east side and through the apartment complex.

The waterworks is a total loss with the pump- ing station and filter house completely wrecked. You can probably assume that the available water supply is what is currently in the two north and south standpipes, which appear to have sustained no damage. The sanitary works is operational. The path of the tornado is pretty steady from south- west to northeast approximately one-quarter to one-half mile wide running from state highway 37 to just south ofI-69 for a stretch of about 5 miles. There are some skips, but it has pretty much gone through Midville from the industrial park on the southwest side of town through the west side of town. Before it went back up in the air, it got the mobile home park on Breezemore Road. There are mobile homes blown apart and on top of one

616 • PART FOUR No Man's Land: Facing Disaster

another. I can see human movement here also, but there are going to be lots of casualties here as well.

I estimate about 200 homes destroyed or heav- ily damaged and 600 more with some damage. We need to notify Midville Central and St. Andrew's hospitals that they need to go to Code Red [highest emergency status]. We are going to need Tennessee Valley Power to do the same, as it appears we have a complete power outage across the city. Midville Power and Light will not be able to handle this out- agB alone.

As this assessment comes into the emergency op- erations center (EOC), information is relayed through the regional EOC coordinator and transmitted to the state EOC. As the magnitude of the disaster un- folds , the governor is notified and mobilizes National Guard units. Word goes out to FEMA, the Red Cross, and the Salvation Army, and these groups begin mo- bilizing human resources to go to Midville. Within 1 hour and 10 minutes, a massive mobilization effort is underway. Food, drinking water, medicine, medical supplies, emergency medical personnel in the form of EMTs and fire departments, rescue teams, and heavy equipment all move toward Midville.

As Lane (2003) indicates, if roads are impassable and it is possible, someone with the EOC needs to get airborne and conduct a visual assessment of the ex- tent of the damage and relay information to the cen- ter about what and who are going to be needed where and under how high a priority.

April 21, 15:21 Hours, Command Center

As the LEMA director sends out mobilization orders, a number of workers you will soon meet swing into action. In these first few hours and days they will be administering what is generally construed to be psychological first aid as they attempt to gain con- trol over the chaotic scenes and traumatized individ- uals who are survivors of the disaster. As they enter the setting, they will be sensitive to the culture and diversity of the populations they are servicing. They will also be aware of and looking for at-risk popula- tions. They are, first and foremost, interested in the immediate physical safety of survivors . To that end, they will attempt to provide a sense of predictability, control, comfort, and safety to survivors by providing straightforward and easily understood information about disaster response activities and services. They will attempt to protect survivors from additional traumatic experiences and trauma reminders while they go about their work. Major tasks will be reuniting

children with their caregivers, stabilizing emotion- ally overwhelmed survivors, and providing suppon for acutely bereaved persons (National Center for PTSD, n.d.a.).

To accomplish the foregoing tasks, the workers will engage in a great deal of information gathering in regard to current needs and concerns about the following:

1. Nature and severity of experiences during the disaster

2. Death of a family member or close friend 3. Concerns about immediate postdisaster circum-

stances and ongoing threat 4. Separations from or concern about the safety of

loved ones 5. Physical illness and need for medications 6. Losses incurred as a result of the disaster (home,

school, pets, personal property, etc.) 7. Extreme feelings of guilt or shame 8. Thoughts about causing harm to self or others 9. Lack of adequate supportive social network

10. Prior alcohol or drug use 11. Prior exposure to trauma or loss 12. Prior psychological problems (National Center

for PTSD, n.d.a.)

When the workers have the foregoing informa- tion, they will identify and clarify the most im- mediate needs of the survivor, discuss an action plan with the person, and then act to address the identified needs. Integral to this process is provid- ing information on traumatic stress and coping mechanisms to help alleviate the stress and linking the individual with the disaster relief services they will need (National Center for PTSD, n.d.c.). Follow these crisis workers now as they put the foregoing points into action.

April 21, 15:51 Hours, Midville Elementary School

Jack Tankersly, School CRT Blue Team member at Midville Elementary: (helping a dazed boy with some cuts and blood on him out of the rubble of the east hallway of Midville Elementary School) I'm Mr. Tankersly from the middle school. How are you doing?

Shawn: Iah guess Ah'm OK, Iah dunno .... Whaaar happened?

Jack: There was a tornado, but you are going to be all right. If you can walk OK, we are going to take you to the middle school and get you checked out. Can you do that?

Shawn: Yeah, I guess. I jest got some little cuts on my arms. There's some other kids hurt bad back in the hallway, though. Jamie's eyes were shut and he wasn't talkin' even when I shook him. He was hurt real bad, maybe even dead or somethin'.

Jack: Yes, I know, and we will get them out. So don't worry about that. Right now let's focus on you. Can you give me your name and tell me who your teacher is?

Shawn: Shawn Benefield. Ah'm in Mrs. Cruz's first- grade class.

Jack: (checks over the two-way radio with the documenta- tion leader on the student in the central elementary To Go box) Good. You have a brother and a sister in the middle school, Jason and Lou Ann, right?

Shawn: Yes.

Jack: I am going to have someone take you up to the middle school and get those cuts cleaned up and check you out. I'll let them know you are coming, so your sister and brother will know you are OK.

One of the critical components in any disaster in a school is keeping track of and accounting for chil- dren. Nowhere is the concept of the school as in loco parentis (in place of the parent) more important. Portable, centralized, and redundant To Go boxes (Thomae, 2002) are critical to such an endeavor; they hold classroom lists, student names, addresses, tele- phone numbers, medical issues, release forms , and parent and guardian names . Moving a school full of injured, confused, and terrified students is an un- dertaking that must be done carefully and precisely so that no student is lost or unaccounted for. While there is a school Critical Incident Stress Manage- ment Team to deal with students' psychological con- cerns, it is separate and distinct from the incident command system and will not come into operation until the physical safety of the students is assured. Particularly important staff members on this team are bus drivers, secretaries, and custodians who have knowledge of children and building facilities that educators do not (Allen & Sheen, 2005). Reuniting missing children with parents is a critical compo- nent and one of the highest priorities in any disaster (National Center for PTSD, n.d.a.). As an example, one of the Herculean efforts accomplished by the National Center for Missing and Exploited Children after hurricane Katrina was reuniting all 5,192 chil- dren reported missing with their families (Missing Children, 2006).

CHAPTER SEVENTEEN Disaster Response • 617

April 21, 15:30 Hours, BOC Command Center

Thaddeus Washington: (addressing command center staff) We have a Class One disaster. We are going to be overwhelmed with dead, wounded, and people needing shelter, food, water, clothing, and mental health assistance. We are setting a shelter up at the National Guard Armory. We are going to set up a morgue at the Seabrook Packing Plant. The high school and the middle school are going to be re- ception and clearing centers, so we can get people sorted out and families reunited.

We may have to turn them into shelters too. As soon as we get that done, we will probably set up for the Red Cross and FEMA teams here at the Civic Center. Our first priority is to get the kids out of the elementary school. Preliminary reports indicate that there are a number trapped in the building.

We need to get the roads opened so we can get heavy equipment in there. The EMAs from Sawyer, Plainfield, and Cumberland are sending fire and rescue units. The state EOC has been notified and informed the governor, who is going to call for a presidential disaster order. We need to get the road opened, so get all of Howell Paving and Construc- tion and the State Highway department equipment on the road and heading in that direction, and get three of our CERT teams to help them clear trees, so let them know we have to have chain saws. Saria landed and says we will need at least one and pos- sibly two tracked cranes.

Our second priority will be the Packard plant. I want Cassius Mendoza, the construction superin- tendent for Norton Metal Frame Buildings, to go out there and tell us what we need. We also need to get people out there to help organize them- although Joel Pickard, the plant superintendent, and I have gone over their emergency plan and they seem to be functioning pretty well given the way the whole thing came down. Get the rtst of the CERT teams spread out along the line from state route 37 up to I-69. Be sure we get one team up to the mobile home park on Breezemore. We need to get the water system back on line. It appears most of our staff at the waterworks, including Joe Mul- vidge, the chief engineer, and Hack Townsend, the superintendent, have been injured. I have asked staff from the Sawyer water system to come and give us an assessment. Until further notice we will ration water and put a boil order out because we are bound to lose pressure on the system. I have a

618 • PART FOUR No Man's Land: Facing Disaster

feeling that this is going to be really bad. I hope our practices have paid off Dr. Benjamin, we are going to need to get your mental health team as- sembled. I am afraid there is going to be work for them. OK, everybody, you know your jobs, let's go to work!

April 21, 15:35 Hours

Dr. Yolanda Benjamin, Executive Director of Hatchie County Mental Health Center and mental health liai- son to the Midville BOC: (speaking to Ester Carey, her secretary, at the mental health center on an emergency band radio) How many staff have we got that are at the center? OK, good! They know what to do. We are going to need counselors at the National Guard Armory and out at Seabrook Packing. We are also going to need to send counselors out to both hospitals to work with the chaplains out there. As soon as they open the road to the schools, I'll go out there and see what kind of assistance they need there. There are going to be Red Cross counselors coming in, but right now we are it.

Both Washington and Benjamin are going to have to balance between being responders and coordina- tors. For the present, they are in the responding busi- ness, but as more outside assistance arrives, their job will change to consulting and coordination with the external support systems that are going to flood into the area (Lane, 2003). It is critically important that integration of mental health services with other di- saster responders occurs and that it is recognized as a critical component to overall relief efforts, as exem- plified by Mr. Washington and his immediate referral to Dr. Benjamin and her mental health teams (0rner et al., 2006).

April 21, 17:12 Hours

Juanita Sanchez, leader of Community Emergency Re- sponse Team (CERT) 10: (Looking for survivors, she clambers down a steep ravine into a muddy creek bottom where Sara Lee Benefield's SUV is upside down. Sara is barely conscious and keeps rambling incoherently about needing to get her kids.) (speaking into her two-way ra- dio) Jake, notify the medical OEC that CERT 10 has a woman pinned in her car at the bottom of Rutledge Creek at the Brunner Street Bridge. We are going to need medical assistance, a wrecker, and an extraction team. (speaking to Sara Lee) Can you hear me? I want you to talk to me. OK? We are getting help here for you. Can you tell me your

name? Mine is Juanita. I am on a CERT team. I found you down here where the tornado blew you and your car. We are going to get you out of here.

Sara Lee: I .. . need mah children ... Shawn and . . . I cain't remember ... (eyes roll back)

Juanita: OK, I understand that is what you need ro do. Now you stay with me. Stay awake! We will help you with that. Do you hurt anywhere?

Sara Lee: (slow, measured, and staggered speech in a low voice) Mah . . . legs . . . are .. . numb and mah chest hurts. Iah cain't move. Iah need to git mah kids. Where ... are . .. mah ... kids? Iah need ... some . .. hep!

Juanita: There are people at the school right now tak- ing care of all of the kids . Good! Great! You are talking to me! Stay awake! (radios information back to the team) I am not going to leave you. My name is Juanita Sanchez. Can you say my name?

Sara Lee: Juanita ... Juanita Ramras.

Juanita: Close enough! (Starts to conduct a head-to-toe basic medical assessment. Covers Sara and keeps her talking to postpone shock and unconsciousness.)

CERT volunteer teams are common everyday citi- zens who have undergone FEMA training as a rapid and immediate reaction force to help save lives. The FEMA training teaches volunteers skills needed to as- sist before, during, and after a disaster, such as fire suppression, diagnosing and dealing with the three major killers of injured-airway obstruction, bleed- ing, and shock-first aid, light search-and-rescue op- erations, disaster psychology and team organization, and disaster simulation exercises (Federal Emergency Management Agency, 2015). Juanita is a volunteer who has gone through CERT training. Her occupa- tion is a bookkeeper at a local auto dealership.

April 21, 18:23 Hours

Allie Tran Nyguen, CERT Team 4 member: (in a field 300 yards northeast of the Breezemore Mobile Home Park, speaking into his two-way radio) I have a female, ap- proximately age 50, who is unresponsive and who has no pulse, lying about 150 yards north of Breezemore Road. We need to get her ID'ed. She has no identification on her. Can we get her trans- ported? We will need a four-wheel drive.

Carl Hanratty, Team 4 leader: I'll send Sheila, Jon, and Jerry over there with the 4 X 6 ATV. EOC is setting up a morgue at the Seabrook Packing Plant. We'll get her out of the field and then they can pick her up.

Write down her description and the details of where she was found and we'll attach that to her bag.

April 21, 19:02 Hours, Midville Civic Center

Travis Benefield: (at the Civic Center; stunned, irate, and half hysterical, speaking rapidly and loudly to Kate McClain, mental health counselor) I NEED SUM BY-GOD HEP HERE AND RITE NOW! I cain't git to mah house. Iah heared that everything in the Breezemore Park has done blowed away. Mah momma was at our home there sleepin'. I don't know where mah wife is, there weren't no one at the dentist's office 'cause it was all beat up from the twister. Iah heared that everybody at the el- ementary school done got kilt, and Iah got kids there, but they won't let me near there neither. Iah walked and hitched a ride into here 'cause Iah ain't got no vehicle 'cause part of the Packard plant is on top of it. And Iah cain't find mah dad-burned tools nowheres.

Kate: (de-escalating Travis) I see how upset you are. I am Kate McClain. I do not know your name.

Travis: Ah'm Travis Benefield. Iah work out to the Packard plant and mah wife's Sara Lee and she works at Doc Collard's office. She's his dental as- sistant, and Iah got three kids out to the schools- Shawn, Lee Ann, and Jason, and then there's mah momma, Loretta, and Iah been out at the Pack- ard plant pullin' folks outta there, and there's a lotta people bad hurt, and Iah lost all mah durn tools, and Jim Houston, the other millsetter, is dead under a stamping machine, and ... I'm ahm ABOUT TO GO NUTS AND AH NEED SOME DAD GUM HEP! (rapid, panting breathing, eyes rap- idly moving back and forth, fists clinched pounding hand in fist, rapid, random pacing verging on hysteria)

Kate: (Gently interrupting his continuous, escalating, out-of control verbiage, she starts with enough command in her voice to get Travis's attention, then rapidly diminishes her voice level.) TRAVIS! T-R-A-V-I-S. IF I AM TO HELP YOU, I NEED YOUR FULL ATTENTION. (Travis gives a startled look, but slows down and attends to the worker.) Thank you, Travis. I want you to take a deep breath and just listen to me for a moment. Good. Just take a deep breath. Again, I understand all the confusion. It is a mess, but we will get it straightened out. I hear how concerned you are about all your family and how terrifying that is not knowing any- thing. I need you to get grounded here so I can be of the most help. To do that I need for you to have your

CHAPTER SEVENTEEN Disaster Response • 619

wits about you. OK! So humor me here a moment. Tell me where you are right now, tell me what time it is on that clock behind me, and tell me what they're doing over there in the corner?

Travis: Ah, well, we'uns are here into the com-mun-it- ee center and it's ah well ... I think that thar clock has done stopped. Them ladies is settin' up what looks like some sammiches 'n' sodas 'n' water and what-not.

Kate: Excellent. I just wanted to get your feet planted back on the ground here so we can make some headway. OK?

Travis: (rather sheepishly) Yes'um, I do indeed have my wits about me now. I do apologize for my un- seemly behavior thar.

Kate: Thank you. You have every right to be upset. That is normal. But we will get this squared away. I am a counselor here, and I am going to help you. Right now I need you to help me, though. How about let's go over here and sit down and let me get Jo dell Brown over here. She is one of the coor- dinators, and we will see what we can start to find out, and get you reunited with your family. I bet you haven't had anything to eat or drink since the tornado hit. I need you to be calm and collected, so we can get the information we need, so do you suppose you could sit here and maybe eat a sand- wich and have a soda and tell me andJodell what we need to know to help you?

Travis: Well, OK. Ah'm jest so scared, though. It were purely awful out there to the plant, and Iah cain't find out nu thin'. Iah done pulled people out of there as much as Iah could until they done got there with the heavy equipment, then Iah didn't want to leave but Iah had to find out about mah family.

Kate: So you did what you could out there. It is certainly understandable that you want to find out about your family and get them together. Not knowing is really the worst part, but here is Jodell, and she is go- ing to get the information she needs from you, and then we will be able to tell you something. And that's really what you want to know, isn't it? Let me go get you a sandwich and a soda and just tellJodell.

In the preliminary stage of a crisis, mental health counselors need to understand that they can best help by providing very practical support (0rner et al., 2006). A central information area will be a trip into Bedlam with people attempting to reunite with families. Getting order and direction is a first priority. This is not a time to

62 0 • PART FOUR No Man's Land: Facing Disaster

attempt to do "counseling." Help is what is needed, and the mental health crisis worker can best do that by calm- ing and defusing people who are very distraught, angry, grief stricken, and in shock.

Kate is helpful in de-escalating and defusing a very distraught individual who has been severely trauma- tized and is now terrified that his family has fared even worse. She uses two standard techniques with excitable and distraught clients. First is entrainment (literally synchronization of the organism [Travis]to an external rhythm [hers] here slowing Travis down by use of verbal calming techniques) and then grounding (a reality ori- entation technique that helps keep someone in the pres- ent and helps reorient a person to the here-and-now and in reality) (Webber, Mascari, & Runte, 2010). She raises her voice in a command level manner, but not quite as loud as the client's; she then tails off her decibel level and speaks more slowly. This tactic catches the client's atten- tion, but then hopefully models for him to tone down and slow down. She uses simple calming techniques of introducing herself and asking for his name. She then asks him to take a deep breath to slow him down. She does a quick reality orientation that refocuses him into his present environment. She then offers him food and drink and a place to sit. All of these are basic calming and grounding techniques that are simple but effective. Her negative interrogative question is generally a very bad counseling technique because it implies agreement, but in this case Kate specifically uses it to get agreement and further stabilize and get Travis under control.

April 21, 19:22 Hours, Civic Center Reception and Clearing Area

JodellBrown, clearing coordinator: (Kate McClain, mental health crisis worker, is also present.) Mr. Benefield, here is what I have. All of your children are safe. Shawn had some minor cuts and bruises, but he has re- ceived medical attention for those and is fine. They are all at the middle school. They are getting sup- per served to them. We will relay to them that you are safe also. Your wife is in the hospital. She was pinned in her car, but they got her out. She had to have one leg operated on because it was fractured. She has two fractured ribs, but she is OK and in stable condition. She already knows the children are safe, and we are now relaying to her that you are safe. From what we now know, I am sorry to tell you that there are no homes left standing in Breezemore Park. There were many people who were killed and there were many injured out there, and presently it is off limits as they sort through

the debris looking for survivors. We have no one identified as Loretta Benefield at any hospital. As of now we are listing her as missing. We will have transportation here to take you to the children. If you do not have any friends ' or relatives' home you can go to, then we can take you to the National Guard Armory for tonight. There will be a FEMA field office set up tomorrow, and there will be all of the major insurance carriers here in mobile di- saster units by tomorrow morning. As soon as we have any word about your mother, we will let you know. Now Kate will go with you and get you om to the children. Do you have any questions for me?

Travis: (Dazed, taking in all of that information, hesi- tates and thinks. The crisis worker waits patiently.) Well, no, I don't rightly guess. I guess mah sister over to Crowley could take we'uns in, but I don't know how to git word to her. I guess fer tonight we'uns just best go to the Armory. Ah'm sick to death about not knowing about momma. But I do thank you for findin' out all the rest. I 'preciate it most kindly, ma'am.

]odell: You are welcome, Mr. Benefield. If you will give me her phone number and address, we will try to get in touch with her. Just so I can be sure that you have gotten all that, could you sort of summarize it so I'm sure that I haven't left anything out or have been unclear?

The crisis worker very carefully and specifically goes through the items she needs to cover. She then asks Travis to recapitulate what she has said so that they all have a clear understanding of what has been covered and what is going to happen. Kate will see that Travis and his children are reunited and will hand him off to another crisis worker at the shelter. This is basic psychological first aid that is designed to slow things down, get some control back in the situ- ation, provide support and reassurance, and improve short-term functioning (Halpern & Tramontin, 2007, pp. 203-218).

April 22, 08:35 Hours, National Guard Armory Disaster Shelter

Ollie Naifeh, MSW, Red Cross disaster counselor from Memphis: Mr. Benefield, hello, I am Oliver Naifeh, a Red Cross counselor from Memphis. You can call me Ollie. I just got your name as one of my people. How did your night go?

Travis: Well, not real well, sir. Iah didn't sleep much, but the kids did. Iah'd like to git over to see

Sara Lee. And Iah'd shore like to find out about momma.

Ollie: We have contacted your sister, and she is on her way over here now. The whole city has been declared a disaster area, so it is going to take her some time to get here. I do not have any good news to tell you about your mother, Travis. She was not among the survivors. I am sorry to tell you that a woman answering the description you gave us was found in a field about 300 yards from your home, and she was deceased when she was found. She is at a temporary morgue. This is a terrible task, but we need you to go down there and see if the person is your mother. There will be another counselor there. His name is Jeffrey Chung. He knows you are coming, and he will be there to help you if indeed it is your mother. I will stay with you until your sister comes, and we will talk about what you will need to do about housing and insurance and any other assistance you may need. There will be counselors at the FEMA One Stop to help you with any ques- tions you may have or assistance you may need.

April 22, 09:42 Hours, Seabrook Packing Plant Temporary Morgue

Travis Benefield and Jeffrey Chung, Licensed Profes- sional Counselor from Hatchie County Community Mental Health Center and grief specialist, look on as a medical assistant gently unzips a body bag.

Travis: (recoils in shock, then gently touches his mother's cheek) Oh Lordy, momma! You have done gotten yourself kilt dead. I told you and done told you to go to the shelter if'n a twister was comin', but you didn't never pay no mind to me. Oh, dear God! Mah momma is dead! (starts sobbing)

Jeffrey: (nods to the attendant and gently turns Travis away) I am terribly sorry for your loss. Come on, let's go outside and sit down and talk.

Travis: (crying) Did she ... do you ... know ... ah ... suffer much?

Jeffrey: The field report said she was dead when they found her, and the autopsy shows she died of a broken neck, so I would say no. (The counselor waits patiently while Travis weeps.)

Travis: (head in his hands) Iah jest ... it is jest too much. Iah don't know ... cain't think. Too much.

Jeffrey: (Uses STOP technique. Slowly and easily puts his hand on Travis's shoulder and gently guides him out of

CHAPTER SEVENTEEN Disaster Response • 621

morgue and over to a chair, where he sits down with him. After a while of letting Travis sob quietly, he be- gins speaking very gently and slowly while making eye contact.) It is overwhelming, and that's why I am here. I would be happy to get the paperwork to- gether and move your mother to a funeral home if you would like. Or we can keep her here for a while and give you some time to decide what kind of arrangements you would like to make. Oliver Naifeh is your counselor, so he will work with me. Given all you have gone through, it is understandable that you feel overwhelmed. Anyone would. It is a common response to an awful, abnormal situation. You may feel guilty about not doing enough to get your mom to go to a shelter, but that was her choice. (sits patiently and gently touches Travis's forearm while he silently sobs) Do you have a minister or anybody else I could call?

Travis: Oh ... OK. If'n you could do that. Our family has always done gone to Kittinger's Funeral Home. Iah guess you could call them up. Iah hadn't even thought about church. We'uns go to the First Baptist Church. Pretty near every Sunday. Reverend Dehl is the minister, but I 'spect he is right busy about now. I guess he'd like to know 'bout Loretta 'cause she sang in the choir and was a pretty staunch member. If'n you could take care of it, Ah'd 'preciate it most greatly. Seems like Iah cain't take care of mah family what's alive right now hardly a'tall, let 'lone what's done and gone.

The morgue counselor does three things. First he implements the STOP technique, which for a morgue counselor is standard operating procedure given the further trauma people will experience when they identify loved ones. STOP is an acronym for Sit, Think, Observe, Plan (Webber, Mascari, & Runte, 2010). The counselor slowly moves the cli- ent away from his mother and guides him over to a chair where they sit down. He gauges that it will be okay to put his hand on Travis's shoulder given what he has observed about the cultural norms of the area in times of grief. He observes that indeed Travis will need basic assistance and starts to plan out what he will need to help him with. Being in charge of a morgue at a disaster site takes a great deal of compassion and sensitivity, and the STOP system is a sort of default way of slowing things down and gently moving the bereaved in helping them get mobilized.

622 • PART FOUR No Man's Land: Facing Disaster

Second, he offers to provide very specific help with details concerning Travis's mother's death. Jeffrey's triage rating of Travis is in the low 20s. He sees a per- son who is cognitively overwhelmed and behaviorally and emotionally exhausted, has narrowly escaped death as has the rest of his family, and now has to identify his mother's body. As a result,Jeffrey needs to gently but firmly provide support and direction. How access to the dead is provided to loved ones and the interaction that occurs while this is happening are often critical to the survivors' ability to integrate the traumatic event and avoid further psychological in- jury (Shalev et al. , 1998).

Finally, the worker suggests help from his church. Faith-based organizations play huge roles in disaster relief (Phillips & Jenkins, 2010). The worker is fairly sure that, given the culture of the area, Travis's church and minister can and will provide a great deal of sup- port to him. Thus, he asks ifhe can contact his church.

The morgue counselor is further aware of the stages of survivor grief (see Chapter 12, Personal Loss: Bereavement and Grief) and empathically re- sponds to Travis's shock, sadness, anxiety, and guilt without judging Travis's ability to "handle" all of it. Further, Jeffrey does not judge what Travis has or has not done, nor does he offer meaningless platitudes about Travis's losses. The scenario is played out over and over with other families in the immediate after- math of a disaster. Local crisis workers work closely with Red Cross, NOVA, and FEMA crisis workers to provide an integrated, efficient, and seamless opera- tion. While these crisis workers will provide immedi- ate mental health assistance, it will be most often in terms of support. This support provides for both the family's survival needs and emotional needs.

April 24, 11:00 Hours, Hatchie County Mental Health Center

Sara Lee Benefield: Well, we'uns are in a fine fix right now. We are both out of work and livin' with Tra- vis's sister, and we still have funeral arrangements to make fer Loretta. It's like we don't know where to start. We did have some home insurance, but Iah don't think it will be near enough. There isn't a thing left of our home, so we'uns have to start all over again. About what we've got is the clothes on our backs and $437.12 in the bank. Travis hasn't even got his tools, which he cain't seem to quit worryin' about all along with the other stuff

Ollie Naifeh, social worker: OK, I am going to drive you over to the Civic Center, and we will go to

the Disaster Recovery Center. I am going to in- troduce you to some people I know in the Red Cross and the Salvation Army. They can help with immediate assistance for food and shelter and maybe even tools. We can go to the FEMA One Stop and see about getting you a home loan to get you back on your feet and a roof over your heads. They will send an inspector out there re- ally quickly and get the ball rolling, and they will work with your insurance company. They will also work with you on what is called disas- ter unemployment compensation. It is not quite your paycheck, but it will help out a good bit. Jeffrey has gotten your mother taken care of, and we can talk about funeral arrangements for your mother, Travis. I am guessing that money may be a problem?

Travis: Well no, momma had one of them universal burial policies, although I don't have no idea where it is, and she had about $5,000 put back. Reverend Dehl said he would be proud to preach momma's funeral as soon as we let him know, and there was Wednesday night services, and everybody done gave us their condolences and said what a fine per- son Loretta was and not to worry over much, that they would help take care of things.

The crisis counselor does very little mental health counseling at this juncture. He is far more concerned with just getting the basic survival needs of this family met (Ruzek, 2006). There will be time enough for the other later on. As soon as external crisis workers help the community regain control after the immediate af. tershock of the crisis, they will leave and turn their cli- ents back over to the local mental health unit.

April 25, 18:00 Hours, High School Gymnasium

Eva Jane Walters, Superintendent, Midville Public School District: (speaking to about 500 parents) Thank you for being here under the tough circumstances you are facing. I know many of you have lost your homes or have your home heavily damaged. I know this because I have been sleeping with many of you at the National Guard Armory as my own home is heavily damaged. We are now 4 days post-tornado. It is Friday. It is time to get your children back to learning. I also know we are going to have school Monday morning, and that includes all the elemen- tary school students. We have been working this week to make those arrangements happen. At the end of my talk there will be a number of teachers

in the cafeteria with homerooms, children's names, and new attendance centers for them. St. Benedict's Catholic Church and Midville First Baptist have graciously opened their doors to us, and we are go- ing to hold classes there. That will be in walking or carpooling distance, and we will have buses at the shelters for those children still housed there. Some of your children will have different teachers because their teachers are dead or injured. We are going to have school counselors trained in crisis intervention from Saline, Wahatchie, and Forked Deer counties' schools here working with our counselors, school psychologists, and school social workers from the Tennessee River Special Education District will be here as well, and teachers to deal with any emo- tional issues children have. We are composing a se- ries of classroom guidance meetings, which should go a long way towards helping us identify and work through problems that children are having. We are going to work very closely with you in this regard, and we want you to work very closely with us. We know this community does not lack for courage and mental toughness, and we know you and your children are tough minded and resilient, but there is toughness and there is smartness and we want to be smart about taking care of your children's aca- demic, social, and emotional needs because we know if those other needs are taken care of we get better academic results, and in the end that is what we are about, the best academic success we can get. Midville schools have long been outstanding and part of the glue that holds this city together and gives it pride. We are not stepping back from that one inch, but to do that we are going to need all of the cooperation this community can bring to bear on getting these schools up and running. If you have any questions, I will be happy to take them now or talk with you or individually later on.

I also want to say something about our loss, not only of a building but of teachers and students who made it into the viable academic community it was and will be again. We are now planning with the PTA a commemorative memorial service in the Civic Center that will take place before school is out at the end of May. We understand that many of you are dealing with your own personal grief and loss right now and we want to give you time to work through that. We want to be supportive of you in any way we can because we know it is important to you and your children. The Hatchie Mental Health Center and grief counselors will be available if you

CHAPTER SEVENTEEN Disaster Response • 623

or your children have need of them. You can call the Hatchie clinic or call us at the high school counsel- or's number. All the calls will be kept confidential. Thank you for coming. If you have questions now, there are teachers who will bring you a microphone so everybody can hear. I have the rest of the schools' administrative staff here, so ifI don't have the an- swer one of them probably will. When we are done here, we'll exit towards the cafeteria where you can pick up your child's school, room, and teacher as- signment. We will have e-mail as power becomes available again but are not sure when that will hap- pen. So we've resurrected some old mimeograph machines and you grandparents will recognize the purple bulletins. Welcome back to the 1950s, but we'll get information to you, rest assured. This is not going to be easy, but with your help we will get the Golden Eagles back up and running.

The superintendent does five things that are critical when a school suffers a calamitous event. First, the "whole child" is the focus. Academic, so- cial, and emotional components are all targeted. Second, she is intent on moving the school and the community as quickly as possible back to day- to-day living and a sense of "normalcy." Third, she seeks to develop a strong sense of community with the families whose children attend the school. Fourth, she has the school function as a valid and reliable source of information by telling parents specifically what is happening and keeping a com- munication line open to them so that they know there is a centralized and trusted source of infor- mation that they can go to when the rumor mill gets going (Kilmer, Gil-Rivas, & MacDonald, 2010).

The superintendent also does something else that is critical in the face of a disaster in which children's lives are lost. Students' ability to work through the grieving process is in part a social phenomenon that is anchored in their peer group when friends are lost (Worden, 2002). Therefore, school needs to get started again to serve as the place where they come together to grieve friends' loss. Providing not only counselors to deal with adjustment problems but grief counsel- ors who can work with the whole family to help them come to terms with their loss is not an easy sale at times. However, providing the common ground of the school as a brokerage for such deeply personal issues can go a good way toward easing the stigma of hav- ing to seek help with one's loss. Even if parents have not lost a relative, many people will have lost houses, places of employment, or social gathering places such

624 • PART FOUR No Man's Land: Facing Disaster

as churches, clubs, and organizations that play inte- gral parts in their lives, fracturing both their micro- and to a large extent their exosystem supports. We are fully aware that a school system should not get into the funeral business (see Chapter 13, Crises in Schools). However, when faced with a large-magnitude disaster that affects the whole community, the school system certainly needs to provide a process for students to grieve and move on. It also needs to take part in me- morial exercises that are inclusive of all students and parents as a way of acknowledging the loss, allowing expression of feelings , and effecting reengagement with school (Kerr, 2009, pp. 130- 132). You may won- der why we included this piece about schools here and not in the school chapter. It is important to under- stand how critical a school is in the fabric of a commu- nity and its recovery in disaster (Kilmer, Gil-Rivas, & MacDonald, 2010). To not have one example of the part the school plays in disaster mitigation is to leave out a critical part indeed of the exosystem of a community.

April 30, 16:00 Hours, Hatchie County Mental Health Center

Kate McClain, licensed professional mental health coun- selor: How are things going? I spoke with Ollie be- fore he left, and he said things were moving along. How do you feel about that?

Sara Lee: Well, we have done got the loan approved, and the insurance company has been real good about things. We have got us temporary hous- ing assistance and have a place over in Crowley. The kids want to stay here with their friends , so we'uns are gonna bring them over here every day. Mah dentist office is gonna open up next week. But we don't know when or if the Pack- ard plant will reopen, so Travis is gonna be on unemployment.

Travis: Maybe y'all could talk to Shawn some. He is wakin' up at night screamin'. Iah don't think he is near over the school fallin' in and his best friend gittin' kilt. It was tough buryin' momma, but we got that done, and the church really hept.

Sara Lee: And maybe you could talk to Travis here too about him feelin' so durn guilty about leaving the plant to come look fer us. And Iah don't suppose it would hurt for me to talk some too, seein' as how I feel so stupid about runnin' off like a chicken with mah head cut off and makin' things even worse, durn fool that Iah am.

Kate: OK, I will be glad to do that. I think you are making progress and showing me that you h ave some strong fiber, that you are moving forward rapidly to getting things back to some kind of normalcy. Maybe your minister has told you . but there is going to be a community-wide meet- ing put on by NOVA. It's called "Y'all come" fo r all those who were in the tornado or affected by it, kind of a community memorial, talking, and bonding service. That might be something you would want to go to. That really sort of helps when people come together to talk about thei r experiences. I would also like our psychologist to give you some tests that will tell us how much this is affecting you. Those will help me better plan what we might want to do. Some of what you are experiencing is quite common. We just don't want it to turn into PTSD. (Explains the dif ference between ASD and PTSD and what they are all about. She puts a positive view on the disorders by explaining that while most people start out with these symptoms, they tend to go away, particularly when people are proactive about doings things like what she is proposing to the Benefields.) We are having some small support groups meet, and you are wel- come to join them immediately.

I will also contact Shawn's school counselor, Ja- net Beverly from the middle school, who is filling in there since Mr. Little is still in the hospital, and see if we can set up something for Shawn. We have worked pretty closely together. We might want to have you all in as a family. I know she is starting some family groups there for people whose kids are having some problems. I also want to tell you that I really respect your observations and request for help about your children. That tells me you are truly caring parents. That is going to be really im- portant in the days and months ahead.

The counselor does some psychoeducation with the Benefields in regard to ASD and PTSD. While there is limited evidence about the benefits of psycho- education, particularly self-help materials in regard to trauma, Wessely and associates (2008) recommend that any psychoeducation should promote resilience and adaptability rather than pathology. Therefore, the counselor commonizes and attempts to allay fears that this means they are losing their minds rather than having a naturally occurring response to what they have been through. For many people, the psychological symptoms of hypervigilance, startle

responses, nightmares, and the like, are as scary or more so than what they have just been through. While the education does not make the symptoms disappear immediately, it is calming to know they are common occurrences and that these survivors are not losing their minds.

The counselor also seeks to get them involved in a group. It is one of the best ways to share expe- rience, bond with other survivors, and start back on the road to recovery. Finally, the counselor reinforces the mother for thinking about her children and hus- band. It is extremely important that caregivers pro- vide a supportive, understanding environment in which children may manifest symptoms, can process thoughts and feelings without fear of recrimination, and otherwise attempt to integrate the trauma into their lives and come to terms with it (Gil-Rivas et al., 2010). Many times caregivers' ability to support their children will be compromised by their own trauma- related issues (Gil-Rivas et al. , 2007).

May 8, 09:00 Hours, Midville Baptist Church (Temporary Site for Midville Elementary School)

Janet Beverly, elementary school counselor: Shawn, I wonder how you are getting along?

Shawn: Yes, ma'am. All right, I guess.

Janet: I looked at some of your drawings you made when we had the classroom meeting about the tornado. (shows him one of his drawings) I wonder if you could tell me about this?

Shawn: Yes, ma'am. That's me and that there's Jamie and that's Leotis. They were mah best friends. Jamie was right next to me in the hall when the tornado hit, but he's dead now. Ah'm red 'cause I thought I was all bloody, but it was really his blood. Leotis was with Mrs. Cruz. He and her both got kilt, and Iah don't know why. Ma says it was God's will, but Iah jest don't rightly know. Iah don't think much of God if he done let this hap- pen, to tell the truth. Ma wouldn't like me sayin' that but Iah reckon that's how Iah feel. Iah don't slee~ too good at night neither, and Iah shore don't like storms. Sometimes Iah think Iah hear Jamie and Leotis. We used to play a lot together, soldiers and stuff down by Brunner's Creek. Iah miss them somethin' terrible.

Janet: I wonder if you might like to come to a group I am starting, Shawn. It is for a bunch of kids who have friends who died or got hurt or lost other things, who just plain feel sad and maybe a little lonely right now.

CHAPTER SEVENTEEN Disaster Response • 62 5

Shawn: Yes, ma'am. Iah guess that'd be OK. Iah sure wish Jamie and Leotis could come. Iah miss mah grandma too. She used to have cookies made when Iah'd git home.

As indicated throughout this book, when chil- dren are involved with traumatic events, as Stacy Overstreet, a Tulane University school psychology student who worked with post-Katrina students in the New Orleans school, stated, "There are two vital keys to recovery: social support and putting experi- ences in context" (Dingfelder, 2006). This is exactly what the school counselor is doing with Shawn when she uses expressive arts and group counseling to help him start to come to terms with his traumatic expe- riences, put them in his past, and grow from them (Malchiodi, Steele, & Kuban, 2008, p. 299). Groups are powerful ways to bring children together to share commonality of experience, own feelings that range from scared to angry to guilty, decrease isolation, en- hance coping and adaptation, seek commonalities, build cohesion and trust, and help members cope with those bad feelings (Nisivoccia & Lynn, 2007). There is not a lot of outcome evidence on postdisaster groups for children, but at least two studies indicate that they do help to reduce posttrauma stress symptoms (Chemtob, Nakashima, & Hamada, 2002; Salloum & Overstreet, 2008).

A child with traumatic grief can get "stuck" on the traumatic aspects of the death, which then in- terferes with the normal grieving process (DeAn- gelis, 2011). The fact that Shawn was covered with the blood of his close friend and lay there with his friends ' bodies admirably fits such criteria. Chapter 7 Posttraumatic Stress Disorder, describes how, by ~sing trauma-focused cognitive-behavioral therapy in creating a trauma narrative using a combination of stress management, play therapy, and cognitive behavior techniques to monitor and control emo- tional dysregulation, children can move through both their grief and the posttrauma stre~s symp- toms that often accompany it (Cohen, Mannarino, & Deblinger, 2006).

Indeed, if intervention is used as indicated in Chapter 13, Crises in Schools, the school can become a postdisaster anchor for children (Clark et al. , 2006; Munsey, 2006). The CD-ROM Transcending Trauma After a Disaster: A Guide for Schools (Clark et al., 2006) provides an excellent example of how a school district can mobilize its resources after a disaster to help nor- malize and bring a modicum of control into an any- thing-but-normal situation.

626 • PART FOUR No Man's Land: Facing Disaster

May 15, 16:00 Hours, Hatchie County Mental Health Center

Kate McClain, licensed professional mental health coun- selor: (meeting with Sara Lee and Travis) I have talked with Janet Beverly, the school counselor. She is recommending that Shawn go into one of her counseling groups. Her report and what the psy- chologists report is that he has had a pretty rough time and is suffering from what we call acute stress disorder. (reiterates what ASD is and why it is important for it to be dealt with before it becomes PTSD) I am also going to recommend that you all come to the clinic as a family. I think it will be helpful for all the kids to talk about some of this stuff and see that, even though you have suffered some se- vere losses, your family is still together.

Sara Lee: I 'speer you're right. I don't suppose Travis will own up to it, but he's not the same, and neither am I. Shawn isn't the only one havin' nightmares. I jump near outta mah skin every time there's a thunderstorm. Travis and I have never had a hard word with one another, but the other night we done had a huge fight over nuthin'. It was jest nut- hin'. (Tears start to well up in her eyes.) It was awful. It was in front of his sister's family and the kids. (starts to cry) He went and apologized, and so did I, but that is not like us a t'all. I don't know what we're becomin', and it scares me half to death.

Travis: (puts his arm comfortingly around his wife) Iah 'speer you're right, honey. Iah still cain't git them durn tools off mah mind, and that is plumb ri- diculous. Iah got a whole new set, though. The church has really hept out and all, but it jest seems like things keep tumblin' through mah mind, and Iah cain't git no peace with them. That's why Iah got mad 'cause Sara Lee kept tellin' me to git over it, that we had other things to think about. And Iah got mad. Iah don't like it much neither.

Kate: I want to assure you that those are perfectly nor- mal responses to an abnormal situation. But that doesn't make them any easier to bear. I would re- ally like you to go to the NOVA "Y'all come" meet- ing. The ministerial association is going to put on some stuff along with it. I think you will find it helpful to hear and share some of the things you have gone through. You are strong folks , but ev- eryone could use a little help and support, and I think this would be good.

The counselor is very interested in how her cli- ent family is dealing with the traumatic wake of the

disaster. She coordinates her efforts with the school counselor and the clinic psychologist. The NOVA meeting and the church provide community support, but there are specific individual mental health issues that assail this family that need to be worked on so that the family does not fracture (Myers & Wee, 2005, p. 33). While most people are resilient in a disaster and will recover, it is critically important to intervene when there are indicators things are not going well (Ruzek, 2006). This emergency mental health is set up on a family assistance center model (Halpern & Tramontin, 2007, pp. 190- 191; Leskin et al., 2006), in which one person acts as a broker and communica- tor to deal with the many social, psychological, and financial issues that will assail them. Getting all the family into therapy is a positive move because no one then feels the stigma of being the identified "sick" person when everybody else is doing well.

May 22, 16:00 Hours, Hatchie County Mental Health Center

Travis: Well, we went to that "Y'all come" meeting, and I would say it was hepful. Sort o' gives you a sense of pride 'n' hope, I guess. Kinda like we'uns are all in this together. They had a pretty good community church memorial service and all af- terwards. Eighty-three dead and over 600 hurt. Lord A'mighty!

Sara Lee: Iah'd agree. But what Iah really liked was our first family meeting. Iah talked to the kids af- terwards. Lee Ann and Jason both didn't want to come, but they both said afterwards they wouldn't mind coming again, which means they really did like it. Iah jest feel a little more peaceful somehow. Like we'uns are on the right track.

Travis: Iah guess it is like gittin' back in control. Ain't felt like that much.

Kate: I am glad to hear that. We will take this slow and easy. We have plenty of time. We will work on this as long as you feel the need to.

The counselor seeks to reinforce the Benefields for their courage and willingness to commit to some pretty arduous mental health work in addition to all the other challenges they face . She reemphasizes that there is no rush to working through their problems. Kate is now working on what is called second phase cri- sis intervention in the crisis chronosystem. The im- mediate crisis is over. Basic physiological needs have been met. At this point, the crisis worker is more con- cerned about possible long-term effects on the whole

family; therefore, she is treating the family system as a client. She seeks to coordinate her efforts with other human services workers both from an individual per- spective, as in the case of Shawn, and a wider commu- nity perspective, such as helping support the NOVA and the community church program. The more so- cial support that can be generated, the more likely the victims are to use it to help with the distress (Yates, Axsom, & Tiedeman, 1999).

April 25 (1 year and 4 days after the tornado), 16:00 Hours, Hatchie County Mental Health Center

Sara Lee: Iah guess we'uns are ready to say good-bye, Kate. We'uns really 'preciate what you have done fer us. We'uns couldn't have done this a t'all with- out you. We all went to the big memorial service last week out to the Civic Center. It'll always be part of our lives, but it's behind us now, and we kin go on. Shawn is really doing well. He is off antide- pressants and has a couple of new friends . We'uns couldn't go back to Breezemore.Jest too many bad memories, but we done got a lot out south o' town and put our new manufactured home on it, and there are some new kids out there Shawn met at Southside Elementary. None of us are having any nightmares either, although Iah still don't like thunderstorms, and we have a tornado shelter by our home now.

Travis: Iah guess Ah'd agree. Iah shore do appreciate what y'all have done fer us. It was tough, but Iah think we'uns are better fer it as a family. We're a whole lot tighter than before. Iah don't even think about mah tools no more, and even though Iah got mah head shrunk it feels better. (laughs) Durndest thing about them tools. We got momma buried be- side paw out to Big Prairie Cemetery. Got her a nice stone, too. Pink marble. She always liked pink. She's at peace . . . and I guess fer that matter, so am Iah- as fer as one could be, given the circumstances. We are about ready to reopen the engine works, and Iah been workin' gittin' the machines all set up.

Kate: I am glad to have worked with you. I agree. I think we are ready to get divorced. (Everybody laughs.) I expect I will see you around town, so I look forward to seeing you out and about. I also want to tell you I really respect you for what you have done. I have learned from you, probably as much as you have learned from me, and I appre- ciate you coming into and touching my life. It makes me feel even more sure that this is the busi- ness I was meant to do.

CHAPTER SEVENTEEN Disaster Response • 627

Sara Lee: Well Iah think the good Lord put you in the right job. Thanks and good-bye.

Travis: Amen to that. (Both hug Kate and go out the door and on with their lives.)

Over the long haul, most people, even when they suffer comprehensive and horrific loss like the Bene- fields, are resilient and equal to the task of moving on with their lives (Gist, Lubin, & Redburn, 1999). What the crisis counselor provides is not so much therapy as information and programs that help families like the Benefields normalize an abnormal situation and address their material resource losses (Farberow & Frederick, 1978). The crisis worker also takes precau- tionary steps to monitor this family very closely for a while. While people sometimes do develop delayed PTSD, the vast majority are amazingly resilient and do not (Drabek, 1986).

The major role that the crisis worker initially plays is one of victim advocate by facilitating the re- turn of basic services to survivors (Salzer & Bickman, 1999). The crisis worker then shifts from problem- focused to more emotion-focused coping (Lazarus & Folkman, 1984) and seeks to help the family move forward and reframe the crisis and distance them- selves from it through preventive and support therapy (Chemtob, 2000).

Often the lack of use of mental health services by families like the Benefields is not happenstance (Norris & Alegria, 2006). There are many reasons, some good and some bad, why mental health ser- vices are underused after a disaster (Yates, Axsom, & Tiedeman, 1999). Some individuals see the use of such services and facilities as a sign of mental illness and therefore a major character flaw that would la- bel them as "nut" cases. To avoid being perceived as outcasts by peers, these individuals may be very loath to use mental health services (Bethel & Oates, 2007). If such services are poor, uncoordinated, culturally insensitive, and intrusive, they indeed max do more harm than good. In this instance, good mesosystem coordination and communication among a number oflocal and national agencies in the micro-, exo-, and macrosystems worked to provide nonintrusive help and support. The sensitivity, caring, support, and un- conditional positive regard of a variety of different helping professionals working in close coordination- including social workers, psychologists, licensed pro- fessional counselors, school counselors, and "just plain folks"-helped make the Benefield family's ex- perience with mental health services a positive one.

628 • PART FOUR No Man's Land: Facing Disaster

The anniversary of the disaster is a benchmark for positive resolution, and like most people, the Bene- fields are resilient and capable of moving forward with a little help. The tornado has left an indelible im- print on their lives that will never go away, but like the Chinese symbols that start every chapter in this book, they have found opportunity in the crisis and have come out of it stronger than they were before.

Multiculturalism at Work. While the Bene- l!iiJ fields represent the stereotype of a white, Anglo- Saxon, fundamentalist Christian, blue-collar family in the south-central United States, you might gather from the surnames of some of the people who came to their assistance or who worked on the overall disaster that they represented a rainbow coalition of Ameri- cans of all races, ethnicity, and cultural backgrounds. That was not done to be politically correct. The fact of the matter is that even in rural west Tennessee, we are becoming a melting pot of races, ethnicity, and diver- gent cultural backgrounds. As such, a multicultural perspective is critical to any crisis intervention-and, indeed, people with just such divergent surnames work on crisis teams with which we are involved.

A Top Down-Bottoms Up Cultural Approach. This crisis team operates on Wei Chen Hwang's (2012) psychother- apy adaptation and modification framework (PAMF) and formative method for adapting psychotherapy (FMAP). While Hwang generated these approaches with Chinese Americans in mind, we believe these ap- proaches have universal transferability to any culturally different environment crisis workers enter. The PAMF has a top-down three-tiered approach of domains, prin- ciples, and rationales. Domains are general areas that practitioners should consider when modifying thera- peutic approaches to client. Principles involve more specified recommendations of adapting therapy for spe- cific groups. Rationales are corresponding explanations for why these adaptations may be effective when used with the target population. This paradigm serves two critical purposes when applied to the real world of crisis intervention with people whose culture is very differ- ent from our own. PAMF seeks to build evidence-based therapies (EBTs) and manualized treatments that can be used universally and to help practitioners shift from the abstract notion of "multicultural sim" into being concretely multicultural competent in real time under crisis conditions.

The FMAP is a community-based bottom up approach that consists of five phases: generating

knowledge and collaborating with stakeholders, integrating generated information with theory and empirical and clinical knowledge, reviewing the initial culturally adapted clinical interven- tion with stake holder and revising the culturally adapted intervention, then testing it and finalizing it. The FMAP was developed to generate ideas for culturally adapted EBTs while the PAMF was de- signed to improve the cultural competency of clini- cians (Hwang, 2012). It appears that Goodman and associates (2014) successfully used an approach that closely resembles Hwang's FAMP model in their work with Haitian communities in Florida af- ter the 2010 Haiti earthquake. During peer supervi- sion sessions, they used content information on the community's culture, strengths, and sociopolitical issues to conceptualize the community's needs and informed their outreach process. Their success ap- pears to be in stark contrast to a number of inter- national programs that offered help after the 2004 Indian Ocean tsunami which was not well received in the Indian state of Aceh because sensitivity to and building intervention strategies with the local culture didn't happen (Fananay & Fanany, 2013).

As these two concepts are integrated, they can be used to build EBTs that are custom made to different cultural groups whether they be Chinese Americans in San Francisco or Southern Caucasians in Appa- lachia. We would propose that using this protocol is critical in crisis intervention and should be opera- tionalized in real time in conjoint dialogues between leaders in the local population and crisis team leaders in the daily debriefings that occur in the context of a large-scale disaster. This approach fits admirably into contextual/ecological models of crisis intervention (Cook, 2012; Myer & Moore, 2006).

A Final Word on Multiculturalism. The worker should also understand that his or her own cultural biases have an even higher potential for surfacing when faced with oppositionally defiant clients who may not think, talk, act, look, or even smell like the worker. For example, more than one of the editors of this book has queried the author when reading the dia- logues of the Benefield family.

Editors have questioned words such as we'uns (which literally means "we ones") and fer (mean- ing "far" or "for") because they were unsure them- selves of the meaning and were equally unsure that you, the reader, would understand what was being said. Those words were intentionally used in the

dialogues to test readers ' responses to the deep southern rural dialect of Travis Benefield and his family. If you were put off by that dialect, found it hard to understand, and knew it was not proper English, then you might be put off by Travis as an "ignorant redneck" as well. Despite all your good works and good intentions, you might then unin- tentionally treat him with less respect than you would a person who talked like a 6 o'clock network news broadcaster. As a result, do you suppose Tra- vis's reaction to you would be different than it was to the social workers, licensed professional coun- selors, and other crisis workers who were culturally sensitive to him and treated him respectfully de- spite his language? Cultural sensitivity is displayed when the worker translates into primary language that the client can understand (Myers & Wee, 2005, p. 62), whether that be Spanish, Urdu, or English with a deep southern accent.

Although you might think that Travis's obsessive concern about his tools is somewhat bizarre, in fact it has a deep cultural basis. Bethel and Oates (2007) have found that an Appalachian male like Travis, the patriarchal head of his family, is expected to be a good "hunter" who provides for and takes care of his family by supplying them with food, shelter, and clothing. The loss of his tools strikes at the very heart of who Travis is and how his culture defines him as an independent, hardworking, self-reliant provider for his family. In Travis's world, a blue-collar job in which a man can be skillful with tools may be more valued than a white-collar job. It is no accident that Travis persists in brooding on the loss of his tools, for those tools are in fact symbolic of his very identity as a man. The wise and culturally sensitive crisis worker will understand that the loss of his tools is as critical to Travis as the loss of his house, and that worker will be empathic and supportive, placing a high priority on helping Travis get his "durn" tools replaced.

Spiritualism/Religion. Aten and associates Im (2015) report a great deal of research on the central role of religious institutions and prayer in recovery from a disaster and maintain one of the most criti- cal components for the recovery of a community is through the religious organizations that support it. The deep roots that the Benefield family have in their religion and spiritual values should also be understood as a significant part of their life and culture. Religion and spirituality help buffer indi- viduals from the negative and emotional and physical

CHAPTER SEVENTEEN Disaster Response • 629

consequences that happen after a disaster. Ai and as- sociates (2005) found that their stronger faith, hope, and spirituality staved off the depression and anxiety that was related to exposure of those who experienced 9/ 11. Conversely, Cook and associates (2013) found that lack of religious faith exacerbated poor physi- cal and mental health following a disaster. Given that support is one of the most critical components to moving through any crisis, to not use and honor their religion and spiritual values to help salve the wounds of their losses would be a grave mistake in- deed (Bethel & Oates, 2007; Stambor, 2005). Graham (2014) proposes that provision of pastoral care is a critical part of a community's recovery after a disaster and occurs in three parts: sharing the anguish with God, examining the causes from a spiritual perspec- tive, and reinvesting in hope and rebirth. Graham also maintains that organized religion plays a critical part in the political aftermath of a disaster in process of ensuring solace and safety along with guidance and influence in helping rebuild the community and its sense of coherence and meaning.

In that regard, any crisis worker who enters a di- saster area would be well advised to follow Aten and associates' (2015) general guidelines for how to han- dle spiritual issues in a crisis aftermath.

1. If you don't feel comfortable discussing religious is- sues, say so and refer the person to another worker.

2. Do not argue with or try to persuade a person that your spiritual beliefs are better.

3. Let people tell you what their beliefs are. Don't as- sume anything.

4. Help people use their spiritual beliefs to cope. 5. Assure individuals that it is normal to ask ques-

tions about God and/ or their beliefs. 6. If they are angry with God, let them cathart. 7. Do affirm the injustice and wrongness of what has

happened. 8. Encourage people to use the spiritual v.;ritings in

their religion to find answers, solace, and peace.

Focus on the Worker Debriefing Models Im "Debriefing is an intervention designed to assist work- ers and survivors in dealing with intense thoughts, feel- ings, and reactions that occur after a traumatic event, and to decrease their impact and facilitate the recovery of normal people having normal reactions to abnor- mal events" (Myers & Wee, 2005, p. 173). Probably no

630 • PART FOUR No Man's Land: Facing Di saster

emergent technique in crisis intervention has created more controversy than debriefing procedures. The at- tacks on debriefing psychotherapy (Gist & Lubin, 1999) have been some of the most vituperative we have seen in 50 years in the field of counseling, and while there are several different models of debriefing (Armstrong, O'Callahan, & Marmar, 1991; McWhirter & Linzer, 1994; Myers & Zunin, 1994), these attacks have been especially virulent in regard to Mitchell and Everly's (1995a) critical incident stress debriefing (CISD) model and their lack of hard research evidence to demonstrate its effectiveness (Gist, Lubin, & Redburn, 1999). Further, like most wishful searches for a panacea in dealing with an intractable problem, debriefing has been hailed as a potent vaccination against PTSD. However, research in- dicates it is not (Bisson & Deahl, 1994; Bisson,] enkins, & Bannister, 1997; Deahl, 1999; Hobbs et al., 1996; Kenardy et al., 1996; Lee, Slade, & Lygo, 1996; Raphael, Meldrum, & McFarland, 1995). It has come to the point that psychological debriefing cannot be endorsed for use with survivors (Brymer et al., 2009; Gray & Litz, 2005).

In fact, Mitchell and Everly have not been able to provide scientific evidence that CISD does much of any- thing beneficial for workers or victims (Gist, Woodall, & Magenheimer, 1999), and at least one study found it to be harmful (Avery & Orner, 1998a, 1998b). Further, caustic rebukes have rained down on CISD as a get-rich- quick scheme for "quack" therapists and a "get out of jail free" (or almost free) card for businesses and insurance companies who can claim it is an effective vaccination against PTSD and therefore do not have to pay for much more expensive rehabilitation procedures to employees who come down with PTSD symptoms (Gist, Woodall, & Magenheimer, 1999; Raphael, 1999). CISD has also been roundly criticized for mandating that all workers who were victims of the crisis obtain CISD, even though it may be personally or culturally inappropriate (Silove, 1999; Weisaeth, 1999). Finally, there is a serious ethical question as to the blanket use of CISD for all kinds of populations for all kinds of trauma under all kinds of conditions (Raphael, 1999). At the National Institute of Mental Health consensus conference, the following rec- ommendation was approved:

Early intervention in the form of a single one-on- one recital of events and expression of emotions evoked by a traumatic event (as advocated in some forms of psychological debriefing) does not con- sistently reduce risks of later developing PTSD or related adjustment difficulties. Some survi- vors (e.g., those with high arousal) may be put at

heightened risk of adverse outcomes as a result of such early interventions. (National Institute of Mental Health, 2002, p. 8)

On the other side of the debate, adherents ab- solutely believe in its effectiveness, and there are studies to support that (Chemtob, 2000;Jacobs, Horne- Moyer, Jones, 2004; MacDonald, 2003; Pender & Prichard, 2008, 2009; Robinson, Sigman, & Wilson, 1997; Wagner, 2005). Many of its adherents tend to be frontline workers. Their responses to those who would vilify CISD are that it does work-if the procedure is used correctly and if the people who do it are trained to use it the way Mitchell and Everly (1999) propose (Freeman, 2003; Lane, 2003; Montano & Dowdall- Thomae, 2003). One of the major issues has been its profligate use for anybody for any kind of traumatic event. Mitchell and Everly (1999) never intended it to be that. It was intended to be applied directly to emer- gency service workers, firefighters, and police officers to help them quickly integrate feelings and thoughts so that the experiences would lose their potential to become disturbing. Part of why it has been so suc- cessful (and so abused and misapplied) is that at face value it should work, survivors appreciate that some- one cares enough about them to listen, and talking bad stuff out is a good way to get rid of it (Halpern & Tramontin, 2007, pp. 265-266).

Sharing experiences is one way of bonding through an adverse experience. If you don't believe that, get invited to an American Legion bar and talk to some ex-marines, or spend some time with police officers at "choir practice" after a tough drug bust where shots were fired. Debriefing objectives of ventilation of feelings, reordering and reorgani- zation of cognitions, normalization of experience, increased group support, verbal reconstruction and integration, and screening for traumatic stress referral would seem to be laudable goals for pos- tintervention with any disaster worker (Halpern & Tramontin, 2007, pp. 267- 268; Myers & Wee, 2005, pp. 172-174).

Your authors tend to be in guarded agreement with the use of CISD for specific populations of first responders . We have seen this technique work in pow- erful ways with some very cynical and tough police field commanders who were very much in need of de- briefing a multitude of traumatic events and the stress and pent-up emotions that went with them (Addy & James, 2002). It is also worth noting that when we do role-play CISD shooting scenarios with our students

(Dr. James is certified as a CISD-trained debriefer), they almost universally agree that they thought the debriefing was helpful. Having presented the forego- ing arguments for and against, the fact stands that different types of debriefing strategies still predom- inate in the field of trauma work. For that reason alone, the following description of debriefing emer- gency workers is presented.

Debriefing Emergency Workers Critical Incident Stress Debriefing (CISD). CISD was developed by Jeffrey Mitchell, a firefighter and para- medic in Baltimore County, Maryland, as a result of his own responses to the traumatic incidents he con- tinuously witnessed. Originally designed to deal only with firefighters and EMTs who were first responders to fi res, accidents, and other events where they saw and dealt with horrific sights, sounds, and smells, CISD is now used with a variety of people who have suffered trauma (Morrissey, 1994). CISD teams are typically composed of two members who must hold a minimum of a master's degree in the mental health professions and who have undergone training and received certification in CISD. Debriefing is designed to mitigate the psychological impact of a traumatic event, restore homeostasis and equilibrium, prevent PTSD from developing, and identify people who will need professional mental health follow-up (Mitchell & Everly, 1995a, p. 270).

Informal Defusing. Informal defusing is a first- order intervention following traumatic incidents and is typically performed by CISD-trained on-site personnel. The goal of defusing is to lessen the im- pact of a traumatic event and accelerate the normal recovery process by providing a brief, time-limited format to air feelings and thoughts of the event (Myers & Wee, 2005, p. 167). This three-stage in- tervention is a shortened version of a full-scale de- briefing and usually takes about 1 hour. First, team members introduce themselves and then explain the process and delineate expectations. Second, the traumatic experience is explored via participants' disclosure of facts, cognitive and emotional reac- tions, and finally symptoms of distress related to the traumatic event. Third, participants receive in- formation to normalize the dissonant cognitions of the event and educate them with regard to stress, stress management, and trauma (Mitchell & Everly, 1995a, p. 275).

CHAPTER SEVENTEEN Disaster Response • 6 31

Formal Debriefing. The formal debriefing process has seven stages and typically takes place within 24 hours to 7 days after a traumatic event. It is gen- erally 2 to 3 hours long. It is a combination of psy- chological and educational elements formatted in a structured group setting, and it involves personnel who have been directly affected by a traumatic event such as police officers, firefighters, EMTs, and ER staff It is not intended for use with the general pub- lic (Pender & Prichard, 2008). Debriefing helps make the transition from processing facts about the event to emotional responses to the event and, finally, back to cognitive information about reactions and coping with traumatic experiences. It is not psychotherapy, but rather a controlled meeting that allows partici- pants to discuss their emotions and thoughts about the event in a nonthreatening environment (Mitchell & Everly, 199Sb).

The seven stages are described as follows:

1. Introduction. The introduction is crucial to setting the tone of the debriefing. Besides introducing team members and explaining the process and guidelines for the CISD, the introduction also seeks to lower resistance and motivate the partici- pants by discussing sensitive issues such as confi- dentiality (Mitchell & Everly, 199Sa, p. 271).

2. Fact finding. Facts are discussed first because they are easiest to deal with and are typical of what may be discussed with emergency workers after a trau- matic event. The leaders typically start by making statements such as "We only have a sketch of what happened. We'd like you to fill us in on what hap- pened. So we can get an overall picture, we'd like everyone-no matter what part you played-to give us your perspective on it. If you don't feel ready to do that, that's OK too. Just shake your head, and we'll move past you. We need to know who you are, what your involvement was, and what hap- pened from your point of view." Order doesn't matter; the episode will sort itself tli.rough the facilitative ability of the CISD leaders (Mitchell & Everly, 199Sa, p. 272).

3. Thoughts. The CISD leaders ask the participants for their initial or most poignant thoughts about what happened. Moving from facts to thoughts starts to personalize the event and allows emo- tions to surface. As participants voice their thoughts, the leaders should elicit those emotions that come naturally with their thinking about the situation and that allow for movement into the

632 • PART FOUR No Man's Land: Facing Disaster

next phase, reaction (Mitchell & Everly, 1995a, p. 272).

4. Reaction. This phase is the most emotionally powerful for participants. Questions that elicit responses are variations on a theme of "What about the situation was most bothersome to you? If you could change one part of it, what would it be?" Leaders will act more as passive facilitators at this point, as participants spontaneously speak to their affective responses to the event (Mitchell & Everly, 1995a, pp. 272-273).

5. Sy;,,ptoms. The symptom phase is used to shift the group back to more cognitive material. The discussion deals with what went on both during and after the event. The leaders ask the group to describe their experience in terms of affective, be- havioral, cognitive, or physical experiences they had. To get the group going, the leaders may give examples such as "My whole body was shaking for 5 minutes after the firing quit; I was under con- trol, but I kept thinking I can' t stand another minute of this; I wanted to say something, but my tongue was tied; I'm scared to death, but I know I have to go back into that building so my feet move me there somehow" (Mitchell & Everly, 1995a, p. 273).

6. Teaching. Leaders may point out that what the participants have talked about fits precisely into the symptoms of acute stress. The leaders let the participants know that these are normal, typical reactions, that they are not losing their minds or are otherwise somehow not equal to the task. The participants are instructed in how to recognize and understand symptoms that might not have sur- faced yet. Participants are also given information in stress management techniques. This phase moves the participants even farther away from the emo- tional content they have worked through in the reaction phase (Mitchell & Everly, 199Sa, p. 274).

7. Reentry. The reentry phase is a final opportunity to summarize and bring closure to all the issues that have been discussed. The CISD team's job at this time is to answer questions, provide reassurance, reflect on any agendas they believe have not been brought out, dispense handouts, and provide referral sources for extended psychological work (Mitchell & Everly, 1995a, p . 274).

In summary, the CISD derives its effectiveness from early intervention, the opportunity to experi- ence catharsis in safety, the opportunity to verbalize the trauma, a definite behavioral structure, group

and peer support, and a provision for follow-up if needed (Mitchell & Everly, 1995b, p. 41).

Debriefing Crisis Workers Whether one buys the CISD model or not, it seems abundantly clear that some kind of debriefing process is indispensable in assisting crisis workers themselves to regain a state of emotional, cognitive, and behav- ioral equilibrium following their intensive interven- tion work in the aftermath of a chaotic crisis. The detailed procedures that follow are provided because it is essential for crisis workers to know how to de- brief disaster workers as well as to understand the value of being debriefed themselves. The techniques and perspectives offered here may even enable the cri- sis worker to debrief the debriefers.

The Need for Debriefing. Throughout this book crisis intervention is often depicted as complex and cha- otic. Natural disaster, mechanical, or human-caused large-scale accidents, mass murders resulting from terrorism, or death and destruction from floods and tornadoes all create the confused and chaotic disor- der that, much like a battle, are so disorienting that, for crisis workers, there are no scripts and little time for reflection, planning, or rehearsal. It is not surpris- ing that crisis workers themselves tend to suffer psy- chological problems from the same trauma they are trying to alleviate in others. What the crisis worker sees, hears, smells, and touches may also rattle long- buried skeletons in the worker's own emotional closet. This phenomenon is known as vicarious traumatiza- tion (Saakvitne & Pearlman, 1996) or compassion fa- tigue (Figley, 2002), wherein the worker unwittingly absorbs and internalizes the very trauma that the cli- ent manifests (see Chapter 16, Human Services Work- ers in Crisis, for more on this phenomenon).

CERT team members are all citizens with dif- ferent occupations. They are not therapists and they do not receive supervision. Corey-Souza (2007) conducted a study of 96 members of the Florida Crisis Responses team on measures of compassion fatigue and compassion satisfaction. She found a strong negative correlation between compassion fatigue and compassion satisfaction, and that burnout is one of the strongest predic- tors of compassion fatigue . So put yourself in the place of Jeffrey Chung, the Midville morgue coun- selor, or any of the CERT team members who found Loretta Benefield. Do you think you would be up for some kind of psychological debriefing? Finally,

compounding it all, mental health crisis workers may be called on to debrief other emergency per- sonnel who have been up to their arms in blood, gore, wreckage, and a panoply of human tragedy. It is important, then, that crisis workers themselves go through debriefing and that certain precau- tions are taken to arm them against the multiple stressors they will face when doing disaster work (Armstrong, O'Callahan, & Marmar, 1991). As an example, Leffler and Dembert (1998) conducted a study of U.S. Navy divers involved in the recovery of wreckage and passenger remains from TWA Flight 800, which crashed en route to Paris in 120 feet of water off the coast of Long Island, New York. They reported that divers who were exposed to human remains, especially those of children, found that experience to be far more stressful than the safety hazards they encountered.

First responders to the twin towers of the World Trade Center manifest all of the themes of what Robert Lifton (1983) calls the psychology of survival-psychic numbing, guilt over having not done enough or living when others did not, paranoia over attempts to pro- vide psychological help, vivid death imprints, and futile and abortive attempts to make sense out of what they saw, heard, smelled, and touched (Henry, 2004). If this sounds to you suspiciously like PTSD or the vicarious traumatization you read about in Chapter 16 on burn- out, you are correct. Compound this with Henry (2004) and Addy andJames's (2002) research, which found that responders such as police officers tend to be very wary of "headshrinkers." If you are an EMT, firefighter, or police officer, just to admit you may have some kind of men- tal problem puts you at risk because your partners may fear that your inability to function under pressure may harm them (Henry, 2005). So what is to be done? Above all else is self-care (Merlino, 2011), which means know- ing you are not a super crisis worker, nor is anyone else, and having enough sense to look out for yourself and your team both physically and psychologically.

Precautions. First of all, crisis work of this kind is done in teams. Whether at the scene with a number of specialists or in an after-action debriefing, work- ers do not act in isolation. Using the buddy system allows workers to rotate with difficult clients, venti- late to one another, check out perceptions, watch each other for signs of fatigue, and give each other a break (Hayes, Goodwin, & Miars, 1990; Mitchell & Everly, 1995b; SAMHSA, 2003; Talbot, Manton, & Dunn, 1995, p. 286; Walker, 1990).

CHAPTER SEVENTEEN Disaster Response • 6 3 3

Second, crisis workers in a disaster need to take time off to sleep and decompress. An 8-hour shift un- der disaster conditions is a long time (Hayes, Good- win, & Miars, 1990). Crisis workers need to be rotated out of high-stress jobs, such as body identification and survivor notification, on a regular basis and be given less stressful duties (Walker, 1990). They also need time off between crises to rest and recuperate physically and psychologically (Talbot, Manton, & Dunn, 1995, p. 293). The U.S. Department of Mental Health proposes a maximum of 12-hour shifts fol- lowed by 12 hours off. They also propose that work rotations should change from high-stress to lower- stress functions (SAMHSA, 2003).

Third, as trite as it sounds, it is important to have plenty of water and nutritious food at the scene (SAMHSA, 2003). One of your authors has been in a crisis negotiation situation in which he and two police officers were unable to get food or water. The salvaged contents of the lunch box of one of the officer's children that had been left in the backseat of her squad car was a lifesaver after we had been there from 5 P.M. until 3 A. M. without food and with very little water!

Fourth, have a clear chain of command with clear role and function statements. Nothing is worse or po- tentially more lethal than going into a disaster with- out a clear understanding of what one is going to do and to whom one is going to report. Correlative to the foregoing is having adequate and timely supervision to process what one is doing (SAMHSA, 2003).

Fifth, on-site crisis workers should not de- brief one another (Spitzer & Neely, 1992; Talbot, Manton, & Dunn, 1995, p. 286). Another team of crisis workers who have not been at the scene should be brought in to lead debriefing. In this manner, the leaders cannot be construed as engag- ing in recriminations, second-guessing, or accusa- tions about who did or didn't do what .

Sixth, the debriefing should be held away from the crisis scene if possible (Talbot, Manton, & Dunn, 1995, p. 286). Moving away from the scene physically allows the crisis workers to move away psychologically.

Seventh, the organizational context within which the group operates should be taken into consider- ation because it too plays a part in how the group is affected (Talbot, Manton, & Dunn, 1995, p. 286). The way the organization-and this includes even chari- table organizations such as the Red Cross-runs its disaster relief program is critically important to how the individual handles stress at the disaster site.

634 • PART FOUR No Man's Land: Facing Disaster

Eighth, the crisis workers need to be in excellent physical and mental health themselves. From both a physical and mental standpoint, they will be stretched to the limit. Diving into the wake of a traumatic event is no place for someone who is out of shape either phys- ically or mentally (Walker, 1990). But even if a crisis worker is in excellent physical and psychological con- dition, no one is immune from the cumulative and acute onset of stress (see Chapter 16, Human Services Workers in Crisis).

Although overuse of the procedure and policies requiring mandatory CISD attendance can create passive participation and even negative resentment, it would seem that a standing operational order for all emergency workers and crisis workers should be some kind of regular debriefing (not necessarily the CISD model). There are a variety of models that focus on different aspects of the event, such as positive refram- ing (Charlton & Thompson, 1996), group processing (Dyregrov, 1997), intensive follow-up after the de- briefing (Solomon, 1995), multiple stressor debriefing (Armstrong, O'Callahan, & Marmar, 1991), dynamic understanding of the event (Talbot, Manton, & Dunn, 1995), and disaster debriefing (Myers & Zunin, 1994).

While there are concerns that traditional CISD may sabotage personal integrity in favor of victim status by emphasizing pathology over resiliency and trauma over strength, Echterling, McKee, and Pres- bury (2000) believe that linking people in crisis, hearing one another's crisis stories, normalizing reac- tions, and facilitating the group's coping are positive outcomes that are critical to resolution. Your authors absolutely agree. Debriefing should be the natural and final act of the emergency and crisis workers' job and should be no less expected than that of a fighter pilot after a combat mission.

Dynamics of Debriefing. The debriefers of crisis work- ers are dealing with a matrix of issues: the crisis event and its victims, the response to that event by the crisis workers, the individual crisis worker's personal and professional response to the survivors, the dynamics of the group as it goes through the debriefing process, and developing a collective plan for handling the next crisis (Echterling, McKee, & Presbury, 2000; Silove, 1999; Talbot, Manton, & Dunn, 1995, p. 286).

From a professional standpoint, each crisis worker needs to understand and evaluate the usefulness of his or her interventions, explore alternatives, and plan future courses of action. Focusing on survivor aspects rather than victimization is important in refocusing

the individual on perseverance, creativity, and sensitiv- ity, which often fade into the background in the face of the pain, anguish, and helplessness that the worker feels (Echterling, McKee, & Presbury, 2000). Individual crisis workers also need to look at how they operate as mem- bers of the group. Group dynamics and cohesiveness im- part a powerful influence on each worker, so the group as client may need to be examined. Such dynamics may, in fact, parallel the dynamics of the victim group and are referred to as parallel processing (Talbot, Manton, & Dunn, 1995, p. 291).

On a personal basis, the debriefers need to explore with workers their own personal issues that may in- trude into their crisis intervention work. Particularly, parallel processing and countertransference issues need to be examined. As opposed to the CISD ap- proach of Mitchell and Everly (1995b), which does nor delve into the personal dynamics of emergency work- ers, Talbot, Manton, and Dunn (1995) believe that psychological understanding and integration are ex- ceedingly important to crisis workers, because this is the stuff they are made of and how they operate. The personal history of the individuals in the group and of the group itself may also be of importance. Past bag- gage of the group, or the individual workers' issues with the group, may carry over into the present, and everyone needs to acknowledge that baggage and be helped to set it down and leave it.

Confidentiality. A continuing issue in debriefings cen- ters on ethical concerns about acts of commission or omission, issues of responsibility or integrity, and even larger questions concerning life-and-death decisions (Walker, 1990). In that regard, all debriefings of emer- gency workers or mental health workers should be ab- solutely confidential, and that fact should be stated and enforced from the beginning (Mitchell & Everly, 1995a).

Understanding. One of the main tasks of the de- briefer is to make psychological sense of what is going on and to help the crisis workers absorb that knowledge. Thus debriefers should be well grounded in group dynamics , group function- ing, and group counseling skills. They need to be able to compliment workers on their respective strengths- accentuating the positive rather than the multitude of negatives that can easily pervade a crisis (Echterling, McKee, & Presbury, 2000).

The debriefer needs to summarize, and allow peo- ple to verbalize, what they have learned from the cri- sis and the debriefing, in order to minimize workers '

vulnerability to the phenomenon of vicarious trau- matization (Saakvitne & Pearlman, 1996). Crisis workers need to have a sense of mastery over what they have done as well as to feel positive about them- selves as they take leave of the traumatic event and the debriefing (Echterling, McKee, & Presbury, 2000; Silove, 1999; Talbot, Manton, & Dunn, 1995, p. 296).

Qualifications to be an excellent debriefer do not come from one weekend workshop such as one of your authors went through. An excellent debriefer, according to Jordan (2002), will have experience not only in crisis intervention but in trauma counsel- ing as well. Jordan proposes that anyone who does trauma supervision needs to have not only an excel- lent understanding of what trauma is about, but also an understanding of oneself as he or she operates in a traumatic situation both with people who are suffer- ing from trauma and with those who are intervening with the traumatized. Knowing how secondary trau- matization affects first responders and mental health workers is critical. Also knowing what to do about secondary traumatization and how to convince hard- headed veteran first responders and mental health workers are the zenith of this business, and not many achieve those heights.

In summary, the combined processes that Mitch- ell and Everly (1995a), Echterling, McKee, and Pres- bury (2000), and Talbot, Manton, and Dunn (1995) describe derive their effectiveness from:

1. An early intervention before the trauma is con- cretized and becomes a disease reservoir.

2. An opportunity for catharsis by ventilating emotions in safe surroundings with a structured environment and a knowledgeable and trusted facilitator.

3. An opportunity to verbalize the traumatic event and the parts played by reconstructing it, making sense of it, and integrating it into awareness.

4. The provision of structure through the debriefing procedure of a definite beginning and a definite end that provides a clear, linear sequence of events that leads to closure, as opposed to the chaos so recently encountered.

5. The dispelling of myths that one must be able to "handle" all things and that emotions are liabilities.

6. Peer support from others who belong to the same "club."

7. Provision of follow-up if the traumatic stress and the symptoms are not expunged.

8. Education about the effects of stress and the con- cept that it is a naturally occurring process and not a "weakness."

CHAPTER SEVENTEEN Disaster Response • 6 3 5

9. Dynamic understanding of both past and present motivators and causative factors that actuate spe- cific responses in each individual.

10. Reframing and emphasizing the positive out- comes and strengths demonstrated by the worker.

11. The knowledge that such debriefings allow individuals not only to survive job stress but to do their jobs better.

However, when debriefings don't work and crisis moves beyond acute stress disorder into PTSD terri- tory, then we revert back to the heavy duty prolonged exposure and cognitive-behavioral therapies you read about in Chapter 7, Posttraumatic Stress Disorder (Olden et al., 2015).

Final Thoughts It has now been 27 years since we wrote the first edition of this book. Burl Gilliland, coauthor of the book, has been dead for 14 years, so these fi- nal thoughts will be those of your other coauthor, Richard "Dick" James. Claire Verduin, our editor at Brooks/ Cole at the time of the first edition in 1988, remarked with some humor and some cynicism that it would probably be a nice onetime edition that would wind up gathering dust on library book- shelves, and that would be it. At that time there were three or four books on crisis and very little research or theory that made it into professional journals. Burl Gilliland started a crisis class at the University of Memphis back in 1975 with little more than pam- phlets, mimeographed handouts, and guest speak- ers from various grassroots organization that were doing crisis work of different kinds. Crisis interven- tion was a psychological backwater that had few ad- herents and even fewer practitioners. Almost none of the material that appears in this closing chapter was in existence at that time. In fact, most of the mate- rial in the entire book was not! That should give you an idea about how much this field has grown in that short time.

I was on a panel of Brooks/Cole authors at the 2007 American Counseling Association conven- tion in Detroit. That panel met with students to discuss careers in the field of human services. I started out in my professional life as a junior high school counselor 40 years ago, and I am now the coordinator of the counselor education doctoral program at the University of Memphis. Those have both been great experiences, but they pale in com- parison to the field of crisis intervention. I got into

636 • PART FOUR No Man's Land: Facing Disaster

the crisis business through sheer dumb luck and the inability to say no to a request to start the Cri- sis Intervention Team program with the Memphis Police Department that has since become world re- nowned. That has been the best career decision I

This chapter is predicated on emergent trends that encompass the total ecological and cultural environ- ments in which we live and work. It is a multisystemic approach to crisis intervention. The five-dimensional circle and cylinder of systems that impact crisis workers and the individuals and groups who are their clients include the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. These five systems, based on the Bronfenbrenner model, make up the arena in which crisis workers intervene in situations that may include individuals, families , groups, and organizations in a variety of crises at the local level as well as in widely dispersed geographical areas and cultural settings.

The rise of the Federal Emergency Management Agency (FEMA) and the various state and local emer- gency management agencies has given a great deal of impetus to the integration of emergency services and the crisis intervention that goes along with them. The case study of the Benefield family as a model of in- tegrated crisis intervention services is the ideal and demonstrates how these various systems interface and act on individuals in the microsystem. Given hur- ricane Katrina's traumatic wake, it appears that ideal state of service has not yet been reached.

ever made. There is now little question in my m inci that crisis intervention is in the mainstream of psychotherapy. That's what I told the students in Detroit. If you want a career that will give you the ride of your life, get into this business!

Crisis workers and first responders to disasters and other traumatic events themselves need a fo r- mat to air their thoughts and feelings , to ventilate and decompress from the horrific work they engage in. In response to this need, defusing and debriefing strategies have been developed. Chief among them has been critical incident stress debriefing (CISD). CISD in particular has come under sharp criticism as being not helpful and in some cases harmful to go through. However, adherents just as vehemently state that it is absolutely necessary to keep them sane. From that standpoint, it appears that some model of debriefing for crisis workers is imperative. However, at the start of the 21st century one thing is abundantly clear: Crisis intervention is a growth industry, and it is here to stay.

Visit CengageBrain.com for a variety of study e tools and useful resources such as video ex- ~ amples, case studies, interactive exercises, fta:~: W I cards, and quizzes. __J