CRISIS INTERVENTION PROGRAMS ' FOR DISASTER VICTIMS: A SOURCE BOOK AND MANUAL FOR SMALLER COMMUNITIES ‘ \ J I I ! Kathleenil Tierney f , I Barbara Baisden In! I“. Disaster Research Center The Ohio State University Project Directors: Dr. E. L. Quarantelli Dr. Russell R. Dynes Project Officer: Dr. Calvin J. Frederick, Chief Disaster Assistance and Emergency Mental Health 'U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Alcohol, Drug Abuse. and Mental Health Administration National Institute of Mental Health “3 i 5600 Fishers Lane Rockville, Maryland 20857 41%| ‘?’3é7/ (DJ-5k u I, l m m'rrflww nmuwmm v , ‘1, ",‘r , r‘ h 'H ‘1 , ’1.” u ‘3’: "‘m qh, ‘ 4, W, U. MW ll N l i > i , [Vilma/1;“: 1,5“. u 'u I , ‘ i 1‘. i ‘ "WW" w“ W l mu 5 m I ' my" , .‘ ’r ‘H l": ’1‘ Nu, m, mu ..,»;v,;.4,~ W,2,‘a‘y,'y:.,«,l.g.u’; n um. ".Hx'nr I! l ‘ ‘l’lN‘:1I14,'l,‘I'l,;ly"l‘:l“l“ll’|,;‘,‘I‘f‘lllly‘l‘lrflllylyinzhi’l‘LIlllNI,“‘"n“?lyl‘llyy‘lr‘! I r‘nmuuum'y'l‘nrm‘yw‘mn‘flm' y, mm”mm.,!.<,I,I,:,:,r,yn’m’mw‘m :V.I,v,.,l,l,m'.l,:Humanm‘rwwmWr H,mm.Mum”my,”mm'y'y‘mu mwmmmn my, mum. ”HM numml ”My, ,H,V,l,v‘Hv:1yHyl,V,H! ,, : my,r,:,.,mm'.t,l,mumw ”Wu. :mmwmmv,“ m u,,«,1‘..vn,nu.unmfl.u...m.’r"w . , vllluvnmuHlulirumuv , 'm v 1 .11. "FL"! '1’],”mill'1’,ll‘y"fl':,vl‘ ‘1‘ , H 1‘? ll" I‘H’l‘vyy‘ ‘ u, x i I,“ mum, , 0 "'I'Hmmlu HH: Prepared under Contract No. 278-76- 0032(SM) from the Disaster Assistance and Emergency Mental Health Section, Division of Special Mental Health Programs, National In- stitute of Mental Health. DHEW Publication No. (ADM) 79-675 Printed 1979 @V/w //49% For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 Stock Number 017—024~(X)918-l Foreword / ,— . PUBL Major disasters continue to wreak havoc yearly upon property, the economy, and the environment. Over the years, many of these compo— ments have been measured and studied with some degree of care; the psychological turmoil and mental anguish suffered by victims and ‘ friends of disasters have gone virtually unmeasured and untreated. While the emotional impact is difficult to assess, with the passage of the Disaster Relief Act, PL. 93—288, Section 413, the NationalSIn- stitute of Mental Health has recently begun to address the problem. Federal Disaster Assistance Administration figures disclosed that in 1975 in the United States there were 92,000 families stricken by 38 ma- jor disasters. This was the highest number of disasters since 1972. These families were supplied with various forms of assistance and counseling from appropriate agencies in the Federal Government. In 1977, more than 100,000 families sought aid following major disaster declarations. Total Federal expenditures for major disasters and emergencies reached approximately $885 million. Federally operated Disaster Assistance Centers served as a focal point to enable disaster victims to receive assistance for a variety of services, including crisis counseling and referral. A number of geographic regions seem to be disaster prone in the sense that they have been declared disaster areas on more than one oc- casion. Alabama was declared a major disaster three times during 7 1975, and there were two declarations each for Arkansas, Florida, Kentucky, Michigan, Minnesota, North Dakota, Oklahoma, and Texas. Unfortunate as this has been in the United States, disasters in other parts of the world in recent years have been even more dramatic in terms of loss of life. In July 1976, Tang Shan, China, suffered an earth- quake which took 655,233 lives. In Guatemala, 22,778 persons lost their lives on February 4, 1976. In northern Peru, 66,974 people perished on May 31, 1970. Bangladesh has suffered two severe hur- ricanes and tidal waves in recent years: on November 13, 1970, ‘ 300,000 persons were killed, and on August 12, 1974, 2,500 persons lost their lives. While working under the coordination of the Federal Disaster Assistance Administration, voluntary organizations also provided iii FOREWORD food, clothing, and other humanitarian services. Such organizations included the American National Red Cross, Salvation Army, and the Mennonite Disaster Service. Moreover, the young lawyers’ section of the American Bar Association offered legal advice to disaster victims, while the American Insurance Association provided advice on in- surance problems. Even with the advance of mental health services, there is a continu- ing question regarding the similarity of mental health services in non- urban areas and small communities to those in larger urban centers. Particularly, there has been a dearth of information in emergency mental health and disaster assistance. Should such services be of the same type, since different needs must be met and varying populations must be served? Certainly, all citizens in our country have a right to the same general quality of services on an equal basis, as much as it is possible to provide them. A statement to this effect was issued by the ' United Nations Policy Studies Panel on International Disaster Relief in June 1977, with the unequivocal recommendation that disaster assistance must be regarded as a basic human right, not merely a mat- ter of chance by birth of politics. Governments are obligated to provide assistance to_ all victims of natural disasters. One of the purposes of this monograph is to conduct a study into avenues like those noted above, so that more definitive data may be available to assist communities in the provision of crisis services in time of need. While all speculation has not been laid to rest as a result of the study and the specific information presented in this monograph, some gaps have been closed in our knowledge about the problem, and routes have been marked which will warrant further fruitful explora- tion. New light has been shed upon a number of shibboleths or myths concerning disasters which have obtained over the years. The earliest views were those apparently perpetuated by the lay public. These no- tions were founded upon expectation, anticipation, and some educated guesses. It was presumed upon the basis of these views that, in time of major catastrophes and disasters, there would be rather widespread chaos, panic, and looting. Other forms of behavioral reactions would be some type of a shock syndrome, accompanied soon afterward by overwhelming anxiety, depression, or psychosis. Later, much of this thinking was labeled, principally by sociologists, as nonfactual. In conjunction with academic studies, such as popula- tion mobility associated with flood plain management and other geographic problems, some sociologists believed the earlier views were overstated or unverified. As a result, perhaps the pendulum swung too iv FOREWORD far in the other direction, in effect disavowing all of the initial lay no- tions and educated guesses about how people behave in time of dis- aster. The position was advanced that virtually no emotional or men- tal health problems would occur and the people would almost always behave very rationally, act in a cohesive manner, never become panic stricken, and rise heroically to each occasion with remarkable self- reliance. Some recent data about those issues are presented in the ac- companying material from a survey carried out as a part of the con- tract for this monograph. In addition, on the basis of other informa— tion obtained through experience with a variety of recent disasters throughout the United States, it appears that the truth lies somewhere between these two extremes. Variations may occur from one disaster to another, on occasion, with people and populations differing, de- pending upon religious persuasion, cultural background, personality type, age, socioeconomic conditions, and intensity, duration, and type of disaster. One reason for some of these different opinions has been the fact that, until quite recently, skilled clinicians have not been ac- tively involved in disaster research or service. This may have ac- counted for a lack of awareness of the presence of less obvious emo- tional and mental health phenomena accompanying disasters. F or- tunately, a number of scholarly and progressive sociologists, psy- chologists, and other mental health workers have now become in- terested in doing solid research in the disaster field. Although this monograph was prepared under contract with Drs. Enrico Quarantelli and Russel Dynes, and their staff members, at the Ohio State University Disaster Research Center, the final editing has been the responsibility of the Disaster Assistance and Emergency Mental Health Section of the National Institute of Mental Health. We have attempted to preserve the thrust of the material presented by the Ohio State Center, while at the same time incorporating the essence of important recent clinical information which has come to the attention of the NIMH through a variety of major disasters in conjunction with implementing crisis counseling and training aspects of the Disaster Relief Act. We believe this work can prove. to be of inestimable value to planning groups as well as clinicians in nonurban settings. Calvin J. Frederick Preface This monograph has been written, in part, as a consequence of the growing interest in the delivery of emergency mental health services to residents of disaster—stricken areas. It is designed to provide knowledge of both a theoretical and a practical nature, which can aid personnel on the State and local level in planning and carrying out disaster—related mental health programs that are efficiently and effec- tively organized. In short, the report makes recommendations for postdisaster mental health programs based on systematic research findings. Although the report takes into account the characteristics of the smaller community, the rural area or small town relatively far removed from the resources of the large urban complex, the findings and recommendations it contains are of even wider interest and ap- plicability. Similarly, the monograph may initially appear to be focusing on a relatively specialized topic, namely, crisis intervention needs and resources in small towns. The question of how resources might best be mobilized in a postdisaster emergency mental health effort to deal adequately with this topic has required delving into a number of more general areas. In fact, the report contains a considerable amount of in- formation for any mental health professional or layperson interested in mental health problems of rural populations and the local resources available to remedy them: issues of disaster mental health; charac- teristics of individual and group behavior in disasters; and emergency mental health program development. This monograph is both theoretical and empirical. It contains dis- cussions on recent literature in the fields of psychology, community mental health, rural sociology, and disaster research. The monograph also reports on the findings of a recent research project, funded by the Disaster Assistance and Emergency Mental Health Section of the Na- tional Institute of Mental Health and conducted by personnel of the Disaster Research Center of The Ohio State University, which aimed at assessing both the need for services of a crisis intervention nature in nonurban communities in the United States and the availability of local resources capable of providing such services. Much additional data of a descriptive nature are provided so that richness of detail is not neglected in the course of abstract hypothesizing. vi PREFACE The emphasis in the report is both academic and applied. Con- sideration is given, for example, to questions of disaster mental health, such as the issue mentioned above, concerning the number, nature, characteristics, severity, and duration of the emotional problems ex- perienced by disaster victims. At the same time, however, we recognize that local caregivers will want to provide helping services to victims of disasters despite the fact that the long-term psychological conse- quences of disasters have yet to be fully understood and that they want advice about how to design and implement such services. Therefore, we have included in the report a detailed section of recommendations, grounded in current knowledge, for setting up an emergency mental health response to disaster. Chapter II of the report is devoted to a discussion of the nature and types of mental health needs that exist in rural areas of the United States. The literature on urban and rural lifestyles, on rural-urban differences in rates and types of mental disorder, and on varying at- titudes toward the treatment of mental health problems is reviewed. This chapter focuses on ways in which large cities and small towns contrast with each other and ways in which they are similar, noting the implications of these similarities and differences for mental health service delivery, both during normal times and in disasters. Chapter 111 contains a treatment of what is presently known about the mental health needs of disaster victims. Two contrasting case studies are presented in an attempt to orient the reader to the com— plexity of issues of disaster mental health. Commonly stated myths about psychological reactions to disaster are matched against empiri- cal findings on the prevalence of symptoms of mental disorder and stress following disasters, as well as against the reports of persons directly involved in mental health service delivery in disaster-stricken communities. Chapter IV describes the overall research strategy and the methodology of the Disaster Research Center’s study on emergency mental health and crisis intervention needs and resources in small U.S. communities. The steps followed in conducting the research are discussed, as are both the advantages and the disadvantages of the chosen research strategy. In chapter V, the findings of this year-long project are reported. Contained in the chapter are profiles of typical configurations of resources of both a mental health and a human service nature found in the communities studied. Particular emphasis is placed on the over- all capabilities inherent in the resource networks of each community, particularly those capabilities believed to be essential to the perform— ance of effective emergency mental health functions—outreach, vii PREFACE round-the-clock service, use of indigenous community workers, and the like. There is focus on both formal and informal caregiving net- works, with the latter receiving a substantial amount of attention. Scoring of resource capabilities in the sample communities reveals in- teresting patterns that are described and analyzed in this chapter. A large portion of chapter V is devoted to a discussion of the mental health-related needs of rural residents, which are found to be numerous and wideranging and are discovered to resemble those of‘ urban dwellers in some respects andidiffevrifromrthemiiniothers. In- formants’ views on the need for counseling services by disaster victims are also reported and discussed. Since over one-half of the com- munities studied in the course of the research had expereinced dis- asters in the recent past, much of the information reported in this and other chapters deals with disaster effects experienced on the com- munity, organizational, and individual levels. Thus, the effects of dis- aster on community needs, as well as on the operation of various men- tal health and human service agencies, are touched upon. In chapter VI, an attempt is made to combine all this data and to set forth guidelines for the planning and operations of disaster-related emergency mental health programs. The focus is on the kinds of serv- ices that can be delivered at the local level, by local people, in response to local disaster—generated problems. The mental health response on the community level is charted through various phases—- predisaster planning, emergency period operations, postdisaster programs—and detailed programmatic recommendations appropriate to each phase are outlined. We have attempted to advance recommen- dations in this chapter that are general enough to be widely applicable and specific enough to suggest concrete strategies. Many references are provided for those wishing even more detailed information for use in workshops, seminars, and training programs in disaster mental health. Throughout the chapter, program flexibility and applicability to‘areas that are relatively poor in resources, e.g., highly trained per- sonnel, are emphasized. Throughout the monograph, and above all in this last chapter, we attempt to convey a sense of what the disaster set- ting is redlly like. What problems of coordination in the delivery of services can be expected to arise? What problems are most likely to be encountered, and when? What kinds of therapeutic efforts are most likely to succeed in the aftermath of disaster? No single written work can be all things to all people. However, we believe that this report will be of use to planners as well as practi- tioners; trained mental health professionals as well as human service agency professionals and interested laypersons; in communities of any viii PREFACE size, but particularly in the small town; and to communities at any point in the disaster response, but preferably before disaster strikes, as an aspect of good overall community planning. ix Acknowledgments Typically, members of the Disaster Research Center (DRC) staff participate in the Center’s research and publishing efforts. Since this was also true of the research for and writing of this manual, we would like to acknowledge various contributions. Dr. Verta Taylor, the DRC Field Director, was responsible for over- all Supervision of the field work and assisted in developing the outline for the manual. Kathleen J. Tierney, the DRC Assistant Field Direc- tor, was in direct charge of day-to-day field operations, undertook the data analysis, and wrote the basic draft of the manual. Barbara Baisden, a DRC Research Associate, shared in the analysis and writ- mg. DRC Graduate Research Associates who assisted in the field work were John Ackelson, Benigno Aguirre, Harriet Ganson, Judith Golec, Patrick Gurney, Quinten T. Johnson, Joan Neff, William Spears, Janet Stroup, Robert Swisher, Marti Worth, and Joseph E. Wright. These Research Aides helped with library work and other chores: Carol J ankowski, who provided assistance in obtaining library materials, assembled the annotated bibliography, and drew several graphs; and Julie Cryder and Lou Ann Galloway who tallied the coded data. A note of appreciation is also due all the local mental health per- sonnel and other community officials for their help and cooperation in the field research undertaken. Because DRC followed its usual policy of assuring providers of information confidentiality as to their iden- tity, we cannot thank these interviewers by name, but they should know that their assistance made this work possible. We wish to convey special thanks to mental health professionals and social scientists in other parts of the country who talked with DRC researchers about their own disaster-related work, made availa- ble written material on their findings, and assisted in the research in other ways. Thomas M. Zarle, Ph.D., Don M. Hartsough, Ph.D., and Donald R. Ottinger, Ph.D., of Purdue University, provided significant information on the planning and delivery of psychological supportive services following the Monticello, Indiana, tornado. Sue Bowman, who coordinated the Monticello Neighbor-to-Neighbor Team, also dis- cussed the organization of a mental health outreach effort in disaster- stricken communities with the authors. Martin Sundel, Ph.D., of the ACKNOWLEDGMENTS River Region Mental Health-Mental Retardation Board in Louisville, Kentucky, and Steven P. Kirn, Ph.D., and Katrine Kirn, Ph.D., also from Louisville, made useful contributions to this report. A particular .note of thanks is due to Norman L. Farberow, Ph.D., Co-director of The Institute for the Studies of Destructive Behaviors and The Suicide Prevention Center in Los Angeles, who provided theoretical and practical input and made available materials from a training manual for disaster crisis intervention workers composed by his organizations. The Disaster Assistance and Emergency Mental Health Section, Division of Special Mental Health Programs, NIMH, headed by Dr. Calvin J. Frederick was responsible for initiating necessary research and sustaining the work as it proceeded. Janet Frank, of the same office provided useful comments concerning data analysis and in the writing of the manuscript. E. L. Quarantelli, Ph.D. Principal Investigator Co-director, Disaster Research Center Professor of Sociology xi Contents Foreword ...................................................... iii Preface ........................................................ vi Acknowledgments .............................................. x I. INTRODUCTION 1 The Present State of Empirical Knowledge About the Effects of Disaster ............................................... 2 Why Mental Health? ...................................... 4 II. MENTAL HEALTH NEEDS AND RESOURCES IN THE RURAL UNITED STATES 7 Rural and Urban Settings: Similarities, Differences, and Varieties .............................................. 7 Characteristics of Contemporary Rural Life .................. 10 Mental Illness in Rural America ............................ 14 Rural Attitudes Toward Mental Illness and Treatment ........ 16 Mental Health Resources in Rural America .................. 17 III. MENTAL HEALTH NEEDS IN DISASTERS 21 A Study in Contrast: Two Disasters and Their Psychological Effects ................................................ 21 Buffalo Creek ............................................ 2 1 Xenia ................................................... 25 Xenia and Buffalo Creek: Differences That May Make a Difference ............................................. 30 The Present State of Empirical Knowledge About the Mental Health Consequences of Disasters ........................ 31 Crisis Intervention: A Strategy for Meeting Disaster-Generated Needs ................................................. 40 xiii IV. VI. CONTENTS DESIGN AND METHODOLOGY OF THIS STUDY 45 Objectives of the Research .................................. 45 Methodology ............................................. 53 Advantages and Disadvantages of the Research Design ........ 59 What the Research Can and Cannot Tell Planners and Practitioners ........................................... 61 EMERGENCY MENTAL HEALTH AND CRISIS INTERVENTION NEEDS AND RESOURCES IN 12 US. TOWNS 63 Scoring the Communities .................................. 64 Mental Health Resources in the Areas Studied ................ 66 Evaluation of Mental Health Resources ..................... 68 Community Assessment of Mental Health Services ............ 70 Mental Health vs. Other Groups as Caregivers; Common Patterns of Human Service Resources ..................... 73 Evaluation of Human Service Resources ..................... 74 Community Assessment of Human Service Resources .......... 77 Percentage of Population Change and Resource Scores ........ 81 Actual and Potential Crisis Needs in Sample Communities ..... 89 PrevalentCommunityNeeds.........................._ ..... 90 Relative Importance of Three Types of Needs ................. 95 Groups Needing Social and Mental Health Services ........... 98 Impact of Disaster on Community Needs ..................... 100 Perceived Need for Mental Health Counseling in the Disaster Setting ................................................ 101 Conclusion ............................................... 103 MATCHING NEEDS AND RESOURCES 106 Strategies for Planning and Implementing a Mental Health Disaster Response in the Smaller Community ............. 106 Pre-Impact Phase: Planning for Service Delivery .............. 108 Impact and Emergency Period: The Provision of Psychological First Aid .............................................. 113 The Postdisaster Period: Long-run Program Options ......... 125 xiv CONTENTS APPENDIXES 1. Public Law 93-288 Title IV - Federal Disaster Assistance Programs ..... 140 11. Rules and Regulations for Implementation of Section 413 of the Disaster Relief Act of 1974 .................. 153 111. Training Manual for Human Service Workers in Major Disasters—Table of Contents ...................... 163 SELECTED ANNOTATED BIBLIOGRAPHY 167 I. General Social-Scientific Writings on Disaster and Dis- aster Planning ................................... 167 II. Recent Literature on Rural Mental Health Needs and Programs and Selected Works on Community Mental Health and Crisis Intervention ..................... 171 III. Mental Health Consequences of Disaster and the Delivery of Services to Victims. . . . . . . . . . , .................. 188 REFERENCES 198 TABLES 1. Sample communities ....................................... 55 2. Configuration of mental health resources ..................... 67 3. Distribution of sample communities by percentage of total possi— ble mental health score ................................... 69 4. Distribution of communities, compared on scores for mental health and human service resources ....................... 75 5. The distribution of mental health and human service resources in 12communities............., ............................ 79 6. Size of community populations and resource scores ............ 8O . 7. Percentage of nonwhite population and resource scores ........ 81 8. Median family income and resource scores .................... 82 9. Choice of caregiver by community ........................... 84 10. Choice of caregiver by occupation ............................ 85 11. Resource scores for disaster and control towns ................ 86 12. Disaster communities ....................................... 92 XV CONTENTS 13. Control communities ....................................... 93 14. All communities ........................................... 94 15. Percentage of informants choosing rankings of social services, mental health and material/financial needs ................ 96 16. 1975 Incidence of federally declared and nondeclared disasters in the continental United States by size of largest community in impacted area ........................................... 124 MAP Counties in the continental United States impacted by natural dis- aster agents in 1975 ............................................ 126 xvi Chapter I INTRODUCTION Disasters have complicated the existence of the human race throughout recorded history. In anthropological and historical records, in fiction, in the popular press, and even in the Bible, catastrophes created by the natural elements appear, along with war, famine, and disease, as major causes of the misfortunes of humankind. Worldwide, thousands of livesare lost each year as a result of natural catastrophes, and the social and economic impacts of disaster are fre- quently crushing. Disasters occurring in Third World and developing societies, such as the recent devastating earthquakes in Nicaragua, Turkey, and China, have an even greater potential for dealing a crush- ing blow than do those striking modernized societies, simply because the resources of the latter are greater. Nevertheless, societies such as our own are by no means immune to the devastating consequences of disasters. For example, in the United States, in the years 1972-197 6, 207 disasters were of a magnitude requiring a Federal disaster declaration; these catastrophic events involved the loss of hundreds of lives, the disruption of the life routines of thousands of survivors, and the cost of millions of dollars for financial assistance to stricken areas. In spite of the long tradition linking disasters and the fate of the human race, and in spite of the fact that major disaster events are an almost weekly occurrence in the United States, more myths than truths exist today regarding how people actually behave when disaster ' strikes. The notion that panic behavior is a common phenomenon in disaster events is one example of an erroneous popular belief that has been refuted by empirical research. Media accounts reporting in- stances of panic flight reactions at disaster sites have long been com- mon. At times, entire communities have been described as rushing to flee a potential site of disaster; however, the reality in the pre-impact period is that the vast majority of community residents can scarcely be induced to evacuate their homes, even when the possibility of damage and destruction is imminent. The correction of misconceptions is important because incorrect ideas are sometimes acted upon, not only by individuals, but also by officials responsible for community disaster planning and response. For example, there have been cases where local officials had warning CRISIS INTERVENTION FOR DISASTER VICTIMS that disaster would strike but did not give this information to the com- munity because they felt that doing so would create panic flight among residents. Many individuals could have benefited from a warning period to secure their homes and possessions and to prepare for the disaster impact. The sociologist W.I. Thomas noted many years ago that “Situa- tions defined as real are real in their consequences.” Because defini- tions of the situation that are based on faulty knowledge can have con- sequences detrimental to human life and property in the disaster set- ting, it is very important to dispel stereotypic notions about disaster behavior and to replace them with solid empirical knowledge. The Present State of Empirical Knowledge About the Effects of Disaster Fallacies, such as the panic myth cited above,‘exist because of the relative lack of systematically obtained knowledge about the impact of disaster on human behavior. In general, the oldest and most com- monly accepted definition and conception of disaster is economic, with financial and material losses receiving the most emphasis. The social consequence of disaster have been studied less frequently. With some notable exceptions, the psychological aftermath of disasters has yet to be studied systematically. Perhaps, as a consequence of the materialistic values of the American way of life, the severity of a disaster is most frequently ex- pressed in terms of material damage. Physical destruction is more dra— matic and more readily visible than some of the more subtle, hidden, and long-term changes communities undergo after disasters. Whatever the reason, dollar losses are mentioned early in public and official accounts of disaster events and are usually given more exten- sive coverage than are discussions of the loss of life, the injuries, and the social dislocation disaster typically leaves in its wake. Federal agencies unwittingly perpetuate this financial/economic definition of disaster by stressing dollar amounts in outlines of losses and by equat- ing disaster magnitude with the amount of financial aid that is dis- bursed. Only recently—in approximately the last 25 years—have researchers taken an interest in understanding the social charac- teristics and consequences of disasters and in describing and. analyzing the effect of disaster on aspects of life that are less obvious than bricks and mortar, streets and buildings. There has been increased interest in INTRODUCTION substituting fact for myth in social and community response to dis- asters. Fritz (1961), Form and Nosow (1958), and Barton (1970) were among the first to systematically treat such topics as stages in com- munity disaster response; changes in patterns of behavior such as roles, tasks, and the division of labor in the period following disaster; the effect of disaster on community solidarity; and the role of disaster in the creation of new groups, norms, and values. The bulk of this early research was based on firsthand observations by researchers in the dis- aster setting, thus providing an opportunity for the systematic gather- ing of information about what generally occurs in disaster com- munities and dispelling mythological notions based on the isolated, unique, or dramatic occurrence. Many of these pioneering inquiries into the social aspects of disasters were conducted by such organiza— tions as the National Opinion Research Center (NORC) at the Univer— sity of Chicago and by the Disaster Research Group of the National Academy of Sciences, as well as by individual researchers working at various universities. Research on the social aspects of disaster behavior gained further impetus with the establishment of the Disaster Research Center (DRC) at The Ohio State University in 1963. DRC is the oldest dis- aster research oenter in the world and the only one in the United States devoted to the study of organizational and community responses to disasters. DRC is structured so that teams of trained researchers can leave on short notice for the disaster scene and, thus, are able to observe the organizational and community response to dis- aster as it occurs. Since its founding, to date, DRC has conducted almost 300 disaster studies worldwide, using both field and survey research methods. Products of the research include books of a general nature, such as Dynes’ Organized Behavior in Disasters (1974), in ad- dition to monographs, reports, journal articles, and other writings designed to be of interest to behavioral scientists and to those respon- sible for the planning and execution of emergency operations in times of disaster. Most of DRC’s research has focused on community, organizational, and group responses to disasters. Public safety organizations, Civil Defense organizations, the Red Cross, and com- munity general hospitals are examples of the kinds of organizations studied. Social scientific concepts such as the division of labor, tasks, social structure, organizational domains, communications, and deci- sionmaking have also been analyzed in the disaster context. While we are beginning to know about the social aspects of dis- asters, little is known about the effects of disasters on the psychologi- cal functioning of individuals. One article reporting on the literature on psychological consequences of disaster (Kinston and Rosser 1974) CRISIS INTERVENTION FOR DISASTER VICTIMS notes that many psychologically and psychoanalytically oriented writ- ers presume that severe psychopathology is a relatively frequent con- sequence of disasters. The number of scholarly writings devoted to the psychological effects of disasters has increased somewhat in the last 5 years, and, in the main, findings indicate that disasters do not always result in widespread, severe psychological disturbance. Research find- ings are beginning to provide support for the hypothesis that a relatively small number of disaster victims sustain serious, long-range psychological damage. A somewhat larger portion of the stricken population may be expected to manifest at least transient symptoms of various forms of emotional disturbance. However, the focal point of most widespread difficulties experienced by victim populations in- volves problems in everyday living. These are difficulties which re- quire help in order to preclude more serious, long-term effects, includ- ing psychophysiological disorders. While researchers seem to be aware of the gross categories and relative frequency of problems that manifest themselves following disasters, the overall question of the nature, types, and intensity of disaster-related psychological problems requires more research and study. There have also been organized efforts, beginning approximately 5 years ago, to deliver mental health services to victims of natural dis- asters. In 1972 the National Institute of Mental Health (NIMH) became directly involved in a disaster-related mental health response, when an outreach/crisis intervention program was funded by NIMH to provide counseling and preventive mental health services to victims of the Wilkes-Barre, Pennsylvania flood. Since that time, mental health professionals and volunteers in other disaster-stricken areas, having heard about the programs or having perceived the need for such serv- ices on their own, have also engaged in the provision of counseling and other services as a part of a community mental health recovery effort. Indeed, the provision of mental health services to disaster victims, a phenomenon which was virtually unknown 10 years ago, has now become a common occurrence in communities stricken by major dis- asters and is actually specified as an element in Federal disaster relief. Why Mental Health? Why has the delivery of emergency mental health services to vic- tims of disaster assumed such importance in recent years? Briefly stated, the increasing belief that the delivery of mental health services should be an aspect of each community’s response to disasters can be seen, in part, as a consequence of the success of the community mental INTRODUCTION health movement of the 1960s, which was institutionalized by the passage of the 1963 Community Mental Health Centers Act. Local in- dividuals and mental health practitioners accepted several of the values contained in the community mental health ideology—the value placed on the community as a focal point for service delivery, the emphasis on prevention and on innovative treatment strategies like crisis intervention, and, especially, the emphasis on the external social environment as a potential source of individual problems. This accep- tance led logically to the conclusion that disaster victims, being in- dividuals who have collectively experienced marked disruption of their everyday lives, need specialized mental health services every bit as much as do those who appear at mental health clinics exhibiting symptoms of psychological disorder. (See Taylor, Ross, and Quaran— telli 1976 for a more comprehensive discussion of the relationship be- ‘ tween the values of the community mental health orientation and the delivery of disaster-related mental health services.) Matching this concern on the local level, in the past few years the NIMH has taken an increasing interest in the delivery of counseling services to disaster victims, and its role in the provision of these kinds of services is now specified by Federal law. Section 413 of the Federal Disaster Relief Act of 1974 states that the President is authorized, through the National Institute of Mental Health, to provide counsel- ing services, together with financial assistance, to local and State agencies for the relief of mental health problems caused by major dis— asters (see appendix I for the text of the law). Additionally, there is within the NIMH a special Disaster Assistance and Emergency Men- tal Health Section which is available to assist with mental health ac- tivities in presidentially declared disasters. Thus, changing attitudes about who can benefit from mental health services, new legislation, and changing institutional arrangements are all forces acting to in- crease the salience of issues surrounding the planning for and delivery of mental health services to individuals in disaster-stricken com- munities. This report, which stresses the disaster-related mental health needs of residents of smaller communities geographically removed from large urban centers, is a consequence of the newly forged Federal com- mitment to providing psychological first aid in the form of crisis inter— vention services as an element in Federal aid to disaster-stricken com- munities. The use of crisis intervention techniques and other forms of short-term psychotherapy in the disaster setting is discussed in detail in later chapters. Before turning to the topic of mental health needs in disasters, however, we will discuss briefly the needs, resources, and at- titudes toward mental illness which exist today in the smaller com- munities in the United States. Chapter II MENTAL HEALTH NEEDS AND RESOURCES IN THE RURAL UNITED STATES Rural and Urban Settings: Similarities, Differences, and Varieties The shape of any program—the problems it addresses and means by which it does so—is determined by the way the problems are ini- tially defined. It is essential, therefore, to consider the ways in which rural and urban areas are alike, how they differ, and how rural areas, individually, vary. The very term “rural America” is misleading, evoking as it does im- ages of dichotomy and uniformity. That is, everything about rural life is different from, indeed opposite to, the life of cities: agricultural vs. industrial; easygoing vs. aggressive; even provincial and narrow— minded vs. sophisticated and tolerant. Smith and Zopf (1970, p. 23) take cognizance of this stereotype: Nothing seems more apparent than the contrast between the city and the country. However, one who attempts to set forth the specific differences. . .to distinguish accurately between rural and urban is immediately confronted with some serious difficulties, obstacles that are not readily perceptible. Even though the two are generally treated as mutually exclusive, it seems that, regardless of the basis of differentiation used, analysis un- covers some inconsistency or weakness in the scheme. The message further conveyed by the stereotype is that there is a single rural lifestyle that is constant from a west coast town, through midwestern farmland, to the hamlets of the seaboard region. Smith and Zopf (1970, p. 261) call attention to the tremendous range of categories between X,, the farm, and X“, the great metropolitan center. For example, their notion of the urban community—in which the urban features of the nucleus are approximately in balance with the agricultural activities of the open country part of the locality—— provides a convenient midpoint between the two extremes and a way of beginning to refine the categories. CRISIS INTERVENTION FOR DISASTER VICTIMS The literature shows considerable disagreement among social scientists on the rural/urban distinction, per se, and even its impor- tance as a topic for study. According to Glenn and Hill (1977, p. 36): Recent American data reveal moderate to substantial farm-non- farm differences on a few kinds of attitudes and behavior, but since farm people now are only about 4 percent of the population, the farm-nonfarm distinction cannot account for much of the total variation of any kinds of attitudes or behavior. The kinds of attitudes and behavior which differ substantially. . .usually differ monotonically by community size; hence, “ruralism” seems to some extent to characterize residents of the smaller dense settlements and, to a lesser extent, those of intermediate- sized cities. Furthermore, city residents with rural backgrounds tend to retain rural attitudes and behavior characteristics, size of community of origin being a stronger predictor of some attitudes than size of community of current residence. . . . The explanatory utility of size of community of origin and of residence seems less than that of age and education but at least as great as that of several other explanatory variables. . .such as family income and occupational prestige. The current state of the art is such that definitive statements on the relative difference between rural and urban are difficult to substanti- ate. What the evidence at hand does demonstrate, however, is that, in general, similarities among various rural and urban settings outweigh differences, and that as much diversity as uniformity can be dis- covered within each of the setting types. Factors of population size and density, economic base, social differentiation and stratification, and income levels all vary from place to place in the nonmetropolitan communities of the United States. For instance, in towns surrounding large cities, population density may be relatively great, with most people commuting to work, while some vast areas of the West are virtually uninhabited. Depend- ing on geographic location, rural economies can be based on agriculture, mining, education, scattered mills, and/or welfare. People falling below the poverty level range from about 11 percent in affluent farming belts, to 50 percent in the South, the Appalachians, and the Ozarks (Segal 1973). At considerable distances from major cities there are small rural communities that evidence quite urbane lifestyles, just as there are rather large towns that manifest relatively backward pat- terns of living. Advantage, then, lies in visualizing a rural-to-urban continuum and not a dichotomy, since a continuum model leads to flexible definitions that yield fruitful comparisons rather than dra- matic but self-limiting contrasts. RURAL NEEDS AND RESOURCES Both conventional wisdom and social science have noted a con- siderable urban-to-rural cultural diffusion in recent generations. Mass communications, mass economies, industrialization, and back-and- forth mobility all combine to make country life increasingly like that of cities. Rural America has assumed a growing share of the social and economic problems that have been characteristic of metropolitan areas. Rural communities have become so urbanized, some argue, that unified planning approaches for major service programs are justified (Hofstatter et al. 1972). Views like these are prompted by a real con- cern for people, a push to get some kind of service where none exists, and a necessary interest in efficiency. Unfortunately, the assumption seems to be that “boilerplate” programs, designed at Federal and State levels for use primarily in cities and larger towns, will be equally acceptable in the hinterlands. Such programs may or may not be effi- cient, but they will probably not be effective. Rural communities are not yet identical with cities, and, while they are moving in this direc- tion, important differences will persist (Glenn and Hill 1977). Those who see only the obvious similarities, or who assume that in time all differences will be obliterated, might consider the following (Dewey 1960, p. 65): Culture can, and obviously does, move bilaterally between open country and city, but this does not mean that ruralism and ur- banism are exportable commodities. There is no such thing as ur— ban culture or rural culture, but only various culture contents somewhere on the rural-urban continuum. The movement of zoot suits, jazz, and antibiotics from city to country is no more a spread of urbanism than is the transfer or diffusion of blue jeans, square dancing, and tomatoes to the cities, a movement of rural- ism to urban centers. Recent data reveal moderate to substantial differences in attitudes and behavior that are likely to be highly relevant to the issues of men— tal health and mental health services. These differences tend to vary by community size, with the largest communities differing from the medium-sized communities about as much as the medium—sized differ from the smallest. Again, the utility of a continuum model becomes apparent. Clearly, attitudinal and behavioral differences associated by size of community will not—should not—become unimportant simply because the most truly rural section of the population is becom- ing a proportionately smaller part of our society. In actuality, the rural segment, which by U.S. Census Bureau designation includes in- habitants of farms, nonfarm open country, and dense settlements of 2,500 or less, has remained stable over the past 50 years, at about 25 CRISIS INTERVENTION FOR DISASTER VICTIMS percent of the total population. While there are fewer farmers today, rural communities have grown, their populations being fed by people leaving the farms and by immigration of city people to work in newly established industries, to commute and to retire (Segal 1973). In addi- tion to the 26.3 percent of the 1970 census tabulated as rural, another 31.3 percent were classified as nonmetropolitan, that is, living in inter- mediate-sized communities of 2,500 to 249,999 (Taeuber 1972). While the terms “rural” and “nonmetropolitan” are not precisely equivalent, it is safe to assume that a substantial number of people live in towns that are relatively isolated from the resources and cultural values of major centers. Thus, programs of service delivery more closely tailored to the needs of these smaller communities are an important priority. The information presented below is general, intended to provide an overview of relevant social science research on the rural and non- metropolitan United States; it is meant to be suggestive rather than prescriptive. There are inconsistencies in some of the findings, i.e., those regarding the relative vulnerability of women, racial minorities, and the elderly to stress and emotional disorder, and those regarding overall impairment rates, which varied widely—anywhere from 10 percent to 41 percent in the studies cited. Thus, it is urged that profes- sionals in each particular community use an overview as a starting point, going on from there to assess local needs, to find those people who are most vulnerable, those who under conditions of stress are likely to require mental health intervention, and to develop programs compatible with the community milieu. Knowledge of this type is especially important for the planning and delivery of services when disaster strikes. Characteristics of Contemporary Rural Life In a provocative work on rural/urban differences, Dewey (1960) ob- served that variation occurred around five basic qualities: anonymity; division of labor; heterogeneity; impersonal, formalized relationships; and symbols of status which are independent of personal acquain— tance. These are relative qualities, found to a lesser degree in more rural settings and to a greater degree in more urban ones. The lesser anonymity in rural areas is illustrated by the often repeated truism that “in small towns everybody knows everybody else’s business.” The fewer people there are, the easier it is for each to know—or to know about—a greater proportion of the total populace. 10 RURAL NEEDS AND RESOURCES Likewise, the fewer the people in a community, the more likely the necessary work of life is shared among generalists, rather than divided by specialists. Rural people, because of the lack of specialized resources, often have to service themselves rather than purchase the services of others. Because people know more about each other and do more of the same kinds of things, they are more like each other, more homogeneous. There is a greater likelihood that what is accepted or re- jected by the few will be accepted or rejected by the many. For much the same reasons, less anonymity and more homogeneity, relationships with others outside the family are more personal, infor- mal, and generally longer lasting. People know each other by name as well as by role or title, and standing in the community is more often determined by what is known about a person than by status symbols, such as titles, badges of authority, or material possessions. More recent research shows that some of the sharpest demarcations between small communities and urban-metropolitan settings fall into two broad categories: those concerning beliefs, values, and interper- sonal relations, and those relating to socioeconomic status. Studies on attitudes and behavior (Glenn and Hill 1977), political structure (Knoke and Henry 1977), and the rural church (Nelsen and Potvin 1977) indicate that conservatism is still a way of life in rural America. This conservatism, in the View of Knoke and Henry, “has been a more durable, pervasive orientation. . .suffusing not only politics, but religion, morality, and lifestyle. Grounded in the values of moral in- tegrity and individualistic self-help, rural Americans traditionally have long been suspicious and disdainful of urban centers” (Knoke and Henry 1977, p.52). Such conservatism and traditionalism are manifested in guarded views on big government, big business, big labor, resistance to social change and to newcomers, particularly if they are members of a racial or cultural group which is perceived as “different,” “strange,” or “other” than the basic population stock (Knoke and Henry 1977). De- pendence on self remains a major virtue, as illustrated by one com- munity leader, interviewed in our study, remarking, “People don’t ask much for help—~if they aren’t really more self-reliant, they try to be.” The moral value attached to being able to help oneself and the implied or suspected moral failure if one is not are evident in the fact that, when rural people do go outside the immediate family for help, they often go to the church. Another of our informants felt strongly that the church should take care of people when they really need and deserve help. 11 CRISIS INTERVENTION FOR DISASTER VICTIMS With regard to socioeconomic matters, it is well documented that there are several areas of deprivation among rural populations. Although some urban groups, particularly inner-city blacks, black youth, and women, may be as bad or worse off than rural people; in general, the proportion of people falling below the poverty level is twice as high in rural as in metropolitan areas—20-25 percent as com- pared to 11 percent. Unemployment rates for agricultural workers are considerably higher; underemployment is widespread, chronic, and severe. The result is that nearly as many rural people fall into marginal income brackets as into outright poverty (Segal 1973). The lower cost of living in rural areas makes up less than half the difference in actual income (Dillman and Tremblay 1977). Although terms such as “slum” are continually associated with city life, substandard housing is actually twice as prevalent in rural as in metropolitan areas, as are poor living conditions measured by degree of crowding, existence of plumbing, and quality of drinking water. Although more rural people are homeowners, tight credit, an absence of building codes, and an expectation of depreciation. have combined to limit both the quantity and quality of rural housing (Dillman and Tremblay 1977). Historically, fewer rural residents have completed high school, and the pattern continues with proportionately higher dropout rates. Functional illiteracy is still a significant problem—an estimated 3 million in 1960 (Segal 1973). Given the minimum educational require- ments for gaining entry into desirable occupations, or simply for living in an increasingly complex society, a relative disadvantage is likely to persist. Rural regions suffer from relatively high levels of mental and physi- cal health impairment, particularly from chronic conditions (Hollister et a1. 1973; Segal 1973). At the same time, these areas have fewer health and social service resources, and there is a continuing shortage of adequately trained personnel. Geography and lack of mobility are factors limiting the accessibility and, thus, the utilization of those resources that do exist. In short, what emerges is a cyclical pattern— people enjoying less regular preventive health care and receiving infre- quent, and perhaps inadequate, treatment from too few hands—lead- ing to ever greater imbalance of supply, demand, and need. The entire range of problems outlined above, from socioeconomic to those of value differences and the conduct of interpersonal relations, falls with special severity on the aged. By 1975, the United States had crossed a threshold; more than 10 percent of our population were over 65, making us officially an “aging” Nation. Many older people never moved away from rural areas; others who migrated to the cities during 12 RURAL NEEDS AND RESOURCES and after World War II are apparently moving back to their home communities to retire. Growing numbers of older people—some 5.5 million—are concentrated in the small towns of America (Youmans 1977). Even for rural areas, their incomes are markedly low. While in- dustrial development has done much to improve the quality of life for most rural people, it has left the elderly further behind. Since inadequate transportation is a problem for older people in the city, it is an even greater one in rural areas where public conveyances are either nonexistent or prohibitively expensive, and where essential health, social, and recreational resources may be widely scattered. Not surprisingly, the rural elderly report poorer physical and men- tal health than do their counterparts in urban areas. In a 1971 study, “the rural elderly reported double the proportion of cardiovascular difficulties, and slightly greater proportions having respiratory, sense organ, endocrine, urinary, and psychiatric problems” (Youmans 1977, p. 88). The effects of poverty, poor health, and isolation are reflected in re- cent studies of value orientations and attitudes of the rural elderly. These older people have a more negative outlook on life, less motiva- tion toward achievement, greater hopelessness and despair, more wor- ry about their financial condition, and less satisfaction with their housing and health; they find their lives more dreary and rate their communities less favorable in terms of visiting patterns, neighborli- ness, and general benefits (Youmans 1977). Born in the early years of this century or before, older Americans internalized the values of a truly “folk” type of society. Life has changed dramatically around them, however, as rural areas have become increasingly industrialized and modernized. For many, adjust- ment has been difficult, often painful. In the view of Youmans (1977, p. 84), who has conducted extensive research on aging, older people who are members of minority groups have been placed in double jeopardy: These older people, such as rural black Americans, rural American Indians, and rural Spanish-speaking people, ex- perience the trauma of witnessing the disappearance of the cultural ways that gave meaning and significance to their lives. Rejected, lonely, and out-of—touch with contemporary values and behavior, many of them have little to look forward to, and little to live for. They tend to be the forgotten and neglected people passed by in the modernization process. Racial minorities everywhere have long felt the impact of the same constellation of poverty, ignorance, and isolation from the 13 CRISIS INTERVENTION FOR DISASTER VICTIMS mainstream of social and political life that have beset the aging. After all, membership in one minority group is much like membership in another. This is essentially a national rather than a rural problem; rural life has proved no kinder to minorities than has urban. If rural populations in general suffer more deprivation, minorities suffer it most. Meanwhile, the somewhat ameliorating effects of the civil rights movement of the 19605 are slower to be seen and felt outside the cities. It is not our purpose to depict life in rural America as stagnant or hopelessly frozen in a primitive past. As we have indicated, the coun- try is moving cityward, or perhaps vice versa. Moreover, country life has many inherent qualities that make it attractive to those who live there and to the many who yearn to. Mass communication, industrial development, mobility, and other features of our complex modern society have bestowed on rural areas many of the advantages of progress along with the problems. There will always be city-country differences to take into account; however, we point out the areas where those differences are greatest and most relevant to the planning pro- cess. Mental Illness in Rural America Since the 18th century, proponents of country living have ap- plauded its tranquil, natural quality and the benefits of closeness to family, neighbors, and the land. There is a widespread belief that the harshness of the city and the stresses and strains of succeeding in an aggressive environment generate mental illness, while a rural exis- tence is conducive to mental health. Research indicates that this may be another stereotype. During this century, numerous epidemiological studies have been conducted to find both treated and untreated cases of a wide range of mental disturbances. The bulk of this work has been concerned with relating mental illness to variables such as age, sex, and social class. In a review of the literature, Dohrenwend and Dohrenwend (1974) found that nine of these studies reported data from both rural and ur- ban segments of the population, thus giving some comparisons of rural ' and urban impairment rates. They found that, in one study comparing rural and urban populations, the total rate for all psychiatric disor- ders was higher in the rural setting; there was one tie; and in the re- maining seven studies, higher rates were found in the urban settings. None of the differences was very large, however, with the median difference for total rates being around 1 percent. Although total rate differences, as reported in this research, were small, rates for specific categories of mental illness varied more 14 RURAL NEEDS AND RESOURCES widely. The functional psychoses are found more often in rural areas, while the rates for neurosis and personality disorder are higher in ur- ban settings. In another recent study reported by the New York Times (1977), Leo Srole discussed data collected in the early 19605. He found that people in rural areas and intermediate-sized towns reported 20 per- cent more symptoms of psychological disturbances than did big city residents. Several epidemiological studies have looked specifically at rural areas in order to determine which, if any, groups might be more vulnerable to mental illness. Rates of impairment have usually been related to variables such as age, marital status, education, occupation, and income level, as well as to sex, race, and locale within a given area. The findings are somewhat inconsistent, as they have been in studies looking only at urban populations. Actually, one of the similarities found in both urban and nonurban settings is that the same general groups tend to be more exposed and vulnerable to stress. Looking at a number of rural studies, principally in North Carolina (Hollister et al. 1973), Florida (Schwab and Warheit 1972), and Nova Scotia (Leighton et al. 1967), a composite emerges. High-risk groups in nonurban areas tend to be: a. the unmarried (single, divorced, widowed) as opposed to married people b. the less educated, unskilled, and lower-income groups as op- posed to the middle class those living in outlying areas as opposed to small town residents . women rather than men . the elderly rather than the young nonwhites rather than whites man—,0 The most universal relationship identified, as it has been ever since Hollingshead and Redlich published their classic, Social Class and Mental Illness (1958), is the one between low social class and high rates of impairment. The stresses and strains of bare economic sur- vival appear to take a definite toll on mental health. Although less striking, there is a significant relationship of impairment rates to fac- tors of sex, age, and race. In one study of just these variables, the authors remark on the position of blacks. It can be argued that these same remarks apply to the position of women, the very old, the very young, and members of other minority groups. Warheit et a1. (1973, p. 27) said: 15 CRISIS INTERVENTION FOR DISASTER VICTIMS From a sociological perspective, our finding that blacks as a group had higher rates of symptomatology than whites can be at- tributed to their position in the class structure. In both relative and absolute terms, blacks are poorer, have less political power and have been subjected to both prejudice and discrimination in our society—in Weberian terms, their capacity to compete for material goods, external living conditions, and rewarding life ex- periences has been limited by the institutional structures of American life. i In short, members of each of these groups, particularly those from the lower classes, “. . .are more likely to be influenced by a greater number of stressful life events and to have fewer internal and external mediating factors at their disposal. . . .” Although rural populations in general show slightly lower impair- ment rates than do city dwellers, those living in rural areas but in outlying districts tend to be more susceptible to stress than town resi- dents (Segal 1973). In relation to data showing higher impairment rates for single people and those of lower socioeconomic status, a salient factor in the incidence of mental disorder is isolation, whether it be emotional, social, or physical. Leighton et a1. (1967) believe that the degree of community integra- tion, as measured by broken homes, inadequate leadership, and unclear goals, is also an important factor. Their findings indicate that, in well-integrated communities, people of all kinds show fewer and less severe symptoms than do similar people in poorly integrated com- munities. Rural Attitudes Toward Mental Illness and Treatment Research in rural areas indicates increasing levels of acceptance of both mental illness and of mental health services, at least at the at- titudinal level. Most people view mental hospitals without the degree of fear and misunderstanding that once prevailed. Responses of people in general, and rural people in particular, indicate that the majority tolerate someone who has been mentally ill, if the relationship is not too close. As a result of the spread of the community mental health movement and widespread educational efforts on the part of mental health professionals, people are distinctly better informed about men- tal illness than in the past. In surveys of rural populations, most per- sons recognize mental illness to be a serious problem, consider condi- tions such as alcoholism and drug abuse to be forms of mental disturb- ance, and believe that much can be done to help people with mental 16 RURAL NEEDS AND RESOURCES health problems. Almost everyone agrees that it would be good to have a psychiatrist in town (Edgerton and Bentz 1969). On. the behavioral level, however, the situation is improving at a slower pace. An extensive review of the literature on public attitudes (Rabkin 1974) suggests that campaigns to inform people about mental health and illness have resulted in a cognitive rather than a behavioral acceptance. It is easier to express tolerance than to act upon it, especially, perhaps, in smaller towns where sanctions on behavior are more easily applied. Mental hospitals may be verbally acknowledged as places for the treatment of mental illness, but they continue to be used mainly for custodial care. This is attributed primarily, but not exclusively, to their uneven accessibility to the communities they serve. Whether or not mental hospitals are used for treatment depends also upon local sentiment, which in some communities is negative (Weiss et al. 1967). The makeup of the legislation may also determine, in part, how, why, and when mental hospitals are used. Rural people still shy away from intimate relationships with the mentally ill; when people encounter someone who has been labeled “mentally ill,” they are not pleased to meet him (Rabkin 1974), although there is somewhat more acceptance or allowance of “place” to eccentric behavior that has a different label. In much the same manner, rural people accept, even welcome, the presence of mental health practitioners in their midst—for others. Growing numbers are availing themselves of professional services for a wider range of problems, particularly where mental health centers have assumed an outreach stance. Yet, the majority continue to take their own problems to their ministers, their regular doctors, or perhaps to natural helpers—friends or personal servicegivers, such as beauti- cians and shopowners—who are known to be good listeners and have a fund of commonsense. Mental Health Resources in Rural America The failure to seek professional help stems from not only negative attitudes or lack of individual motivation but also from a complex of intrapersonal, interpersonal, and structural factors, from a dynamic interplay of perceptions, values, and attitudes. The seeking of help is also affected by the accessibility of resources and the availability of in- formation about them. Currently, all States have large public mental hospitals which, for the most part, are readily accessible only to those living nearby. Most towns have general hospitals whose efforts to meet mental health 17 CRISIS INTERVENTION FOR DISASTER VICTIMS needs are hindered by poor psychiatric facilities and untrained person- nel. Some rural towns, though by no means all, have private mental health or child guidance clinics; some have college counseling facilities. Hotlines and alcohol/drug abuse programs are fairly com~ mon. The greatest growth in past years has been in the construction of community mental health centers funded by the Community Mental Health Centers Act of 1963 and 1965. Currently, approximately 654 community mental health centers are funded. Eighty-three are in all rural areas and 161 in mixed, part-rural areas, for a total of 244 (37 percent) centers serving 46.8 million people, of whom 20 percent are designated as poverty groups. In terms of catchment, or CMHC service areas, 149, or 31 percent, of the 483 catchment areas with a rural population were served by federally funded community mental health centers (1977, unpublished NIMH program data). Our findings, and those of others, show no relationship between the presence or absence of other mental health resources and that of the community mental health center. Some communities are fortunate in having both, some have one or the other, and many have none. Coun- ties with low median incomes have obtained community mental health centers faster than others; however, predominantly nonwhite counties have not shared in this growth—only about 7 percent are covered. One important factor determining community mental health center construction is that of State or regional politics (Foley 1975). Some States, notably North Dakota, Florida, Kentucky, and those in New England, got an early start on comprehensive planning and were able to take advantage of the 1963 Act. Other States in the Midwest, the far West and the South have not been as farsighted (Segal 1973, pp. 56-57). Given the scarcity of mental health resources in rural settings, it is not surprising that relatively few people are aware of, and utilize, them. Nor is it surprising that existing clinics, centers, and practi- tioners are patronized mainly by the white middle class. Unfor- tunately, except where good working relationships with welfare and other social service agencies generate referrals, members of the high- est-risk groups are notably absent from caseloads, and it is precisely these groups which still attach the most stigma and have the least motivation to seek out services (Reissman 1967; Hollingshead and Redlich 1958). Yet, the presence of mental health resources invariably creates a market for their services, so that treatment becomes more common where it is more readily accessible (Rabkin 1974). Thus, the basic issue concerns adequate delivery that is sensitive, not only to what professionals have to offer, but also to what each community might need. 18 RURAL NEEDS AND RESOURCES Community need is a difficult concept to define. Among the factors to be considered, in addition to the epidemiological patterns and the attitudinal and behavioral variances already presented, there are specific kinds of emotional troubles experienced by rural people. They are not different from those seen in urban people: acute situational crises; long-term adjustment difficulties; intra and interpersonal problems manifested in marital, family, and social difficulties; psy- chosomatic complaints; and adjustment problems related to develop- mental stages such as childhood, adolescence, midlife, and aging. The mental health profession has the skills and the tools to help. The overriding need in rural areas is to make mental health plan- ners and practitioners aware of and sensitive to the characteristics of rural life that have been touched on throughout this chapter and are summarized below: a. proportionately large numbers of the socially and economically disadvantaged b. pride in independence and self-sufficiency c. lower levels of acceptance of the label of mental illness, resulting in a tendency to underestimate mental health problems d. general tendency to reject the unfamiliar and the specialized e. propensity, when seeking help, to go first to family, friends, doc- tors, and ministers f. physical limitations of distance, transportation, and professional manpower shortages With these in mind, mental health programs can be designed that are compatible with existing community patterns—beginning “where people are.” Programs built around the characteristics of rural life may seem less sophisticated and less professionally oriented, but they will have a better chance of acceptance and support, both in normal times and in times of disaster. When a tornado, flood, or fire strikes, or there is any traumatic oc- currence that intensifies human need at the same time that it disrupts the systems and structures that customarily meet these needs, plan- ning appears to be almost a luxury. The pressure is to do, to act. However, any steps taken beforehand in the way of assessing actual and potential community needs and idiosyncracies provide invaluable information and direction. Fortunately, the types of programs and ac- tivities that have been found to be effective in helping all victims, to be elaborated upon in later chapters, suit the smaller community. The town that has planned and provided for meeting the psychological needs of its citizens in the manner that smaller town dwellers find most acceptable finds that it already has the guidelines and basic strategies for an excellent disaster intervention program. 19 Chapter III MENTAL HEALTH NEEDS IN DISASTERS A Study in Contrast: Two Disasters and Their Psy- chological Effects Two recent disasters were, by any standard, among the most serious in our Nation’s history: the 1972 Buffalo Creek, West Virginia, flood; and the 1974 Xenia, Ohio, tornado. The two disasters are chosen for discussion here because both occurred in small towns, both have been the subject of social scientific research into mental health conse- quences of disasters, and both appear to have differed markedly in their impact upon victims’ mental health. Buffalo Creek The Community The community of Buffalo Creek is rural by anyone’s definition. Located in Logan County on the western side of the Appalachian Mountains, it consists of a group of settlements lining one of the many hollows along the sharp mountain ridges which are scarred by strip mining. At the top of a hollow, three forks merge, forming the Buffalo Creek. The valley floor along the creek ranges from 50 to 200 yards in width and stretches for a distance of 17 miles. The creek ultimately flows into the Guyandotte River. Sixteen small villages are located along the strip of land in the Buffalo Creek hollow. In 1972, 5,000 persons lived in the hollow, perhaps one-half of what the population had been in previous decades. The mechanization of coal mining was responsible for the exodus from the area, and the peo- ple who remained in the area were those who could profit from mechanization. Compared with the rest of the population in the Appalachian region, residents of Buffalo Creek enjoyed an income sufficient to maintain a lifestyle of relative affluence. At the time of the disaster, the majority of the population of Buffalo Creek depended directly or indirectly on the coal mining industry as their primary means of sup- port. Although a number of persons in the community were receiving 21 CRISIS INTERVENTION FOR DISASTER VICTIMS some form of public assistance, welfare was not a way of life in the hollow. According to Erikson (1976, p. 126): Sixty percent of heads of households were working regularly, some 15 percent were retired and living on pensions, and an ad- ditional 25 percent were drawing checks for disability, unemployment, death and so on. Buffalo Creek was an extremely close community before the flood; neighbors knew and cared about one another. The residents took pride in their possessions and land, knowing they had refurbished what had previously been company shacks into comfortable homes. People were likely to describe the kind of relationships they enjoyed with one another more in familial or kinship than in mere friendship terms. There was a deep sense of mutuality that comes from sharing equally in the same way of life. In short, as Erikson (1976, p. 131) said: On the eve of the disaster, then, Buffalo Creek was home for a close nucleus of people held together by a common occupation, a common sense of the past, a common community, and a common feeling of belonging to, being part of, a defined place. The Disaster Middle Fork, one of the three forming Buffalo Creek, served as a reservoir for coal mine refuse, dust, shale, and impurities. When the debris built up sufficiently, it formed a makeshift dam, or impound- ment, holding back black, murky water for reuse by the mining com- pany in coal processing. Every year, 200,000 tons of refuse were dumped into the impoundment. The days before February 26 were wet and rainy, although no more so than normal for that time of year. On that Saturday, at 8:01 a.m., the dam collapsed without warning, releasing 132 million gallons of black water—a “mud wave,” one witness called it. Rock and debris, dislodged by the bursting of the dam, became part of the writhing mass of water which thrust its way through Buffalo Creek, taking with it houses, automobiles, trailers, and whatever else stood in its path. In the 3 hours before the last of the water merged with the Guyan- dotte River, most homes in the creek had been inundated, and many of them were totally destroyed. The contour of the land had been reshaped, and trees were left without foliage. Everything in the valley was covered with black sludge. Strewn over the valley floor, buried in houses, and hanging from trees were the bodies of the 125 fatalities. 22 NEEDS IN DISASTERS The Aftermath The Emergency Response. The National Guard and Civil Defense re- sponded within hours, opening an access road and transporting the in- jured to hospitals. The Salvation Army and Red Cross were on the scene, setting up refugee centers and distributing needed supplies. Federal agencies responsible for disaster response and recovery came to Buffalo Creek in full force. The Office of Emergency Preparedness allocated $20 million for emergency relief, and the US. Army Corps of Engineers engaged in cleanup. The US. Department of Housing and Urban Development (HUD) moved mobile homes into the area to shelter the many who were homeless. Thirteen trailer camps were set up to house nearly 2,500 persons. Consequences of the Disaster for Victims’ Mental Health. Subsequent to the disaster, community residents filed against the coal company for damages, claiming psychic impairment. In 1974, the plaintiffs in the case were awarded $13.5 million in damages, with the court finding that the disaster experience had indeed been psychologically crippling to victims. Psychologists, psychiatrists, and sociologists, called into Buffalo Creek to conduct research as a part of the lawsuit, reported that, even 2 years after the flood, survivors were still suffering from depression, anxiety, emotional instability, hypochondria, insomnia, apathy, and a variety of other problems. Of the 615 individuals inter— viewed, over 10 percent were diagnosed as suffering from some emo- tional disorder (Titchener and Kapp 1976). What accounts for the widespread occurrence of these kinds of symptoms in this population? According to Erikson (1976, p. 154), the trauma experienced by victims of the Buffalo Creek flood was so in— tense because it was not only an individual trauma, but also a blow to the solidarity of the community, a “collective trauma.” He defines the latter as “a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of communality.” The two dimensions of trauma are seen as closely re- lated, with one serving to reinforce the other. Erikson describes the important aspects of individual trauma ex- perienced by the survivors who were interviewed: 1. Numbness and exhaustion caused, in part, by the repression of the intense feelings of grief, loss, and horror that accompanied the disaster experience 2. Preoccupation with death, brought on by survivors being con- fronted with the sight of the corpses of family members, friends, and neighbors 23 CRISIS INTERVENTION FOR DISASTER VICTIMS 3. Survivor guilt; the feelings of those who lived that they had sur— vived at the expense of others, resulting in self-punishment 4. Grief over the sudden and almost total loss of home and property that represented a lifetime of labor and sacrifice 5. Loss of confidence in the natural order of things, resulting in a‘ deep sense of confusion and fatalism. Titchener and Kapp (1976) list the following common symptoms exhibited by victims of the flood: anxiety, grief, despair, severe sleep disturbances, nightmares, obsessions and phobias about water, depres- sion, listlessness, apathy, loss of sociability, and a lack of ambition and interest in life. Erikson (1976, p. 185) argues that in Buffalo Creek the collective trauma served to aggravate individual trauma, impeding individual psychological recovery and conferring “a degree of permanence to what otherwise might have been a transitional state of shock.” Two factors seem important in accounting for collective trauma: First, the disaster victims greatly outnumbered the nonvictims. In most dis- asters the ratio is reversed; the many who are comparatively well-off 1' . are available to aid the few who are in desperate need. With so many experiencing intense crisis involving physical and emotional damage, victims could not do much to help one another. Assistance had to come mostly from the outside; thus, from the first, victims were robbed of a sense of communality and control. Second, the relocation of the homeless in trailer camps was done on a random, haphazard basis, effectively destroying what remained of old neighborhood ties. One victim is quoted as saying, “We don’t have a neighborhood anymore. We’re just strange people in a strange place” (Erikson 1976, p. 211). The loss of feeling of communality and its impact on the survivors of the flood, vividly expressed by victims in interviews, are also reflected in more objective indicators: Theft increased after the flood; alcohol and drug use became more prevalent; marital problems were' more common; and juvenile delinquency increased. There was also an increase in the rate of reported illness after the flood, particularly backache, sore muscles, and other symptoms commonly associated with tension (Erikson 1976). No researchers believe that the Buffalo Creek disaster was typical in terms of its mental health consequences; the work on Buffalo Creek has attempted to account for the extensiveness and severity of the symptoms of psychological disturbance among victims. Erikson’s dis- tinction between individual and collective trauma is one such attempt. Lifton and Olson (1976) cite the following as factors which account for the widespread psychological impairment the flood left in its wake: 1. The suddenness of the flood 24 NEEDS IN DISASTERS . 2. The element of human blame that was present as a result of the mining company’s carelessness about the safety of the dam 3. The fact that survivors were essentially forced to remain in con- tinued close contact with the consequences of the flood, with lit- tle hope that things would change 4. The geographic and social isolation of the Buffalo Creek area '3 A look at the individual and community response to the Xenia tor- nado may reveal what is typical and what is unique where psychologi- cal consequences of natural disaster are concerned. Xenia The Community Xenia, whose name is derived from the Greek word for hospitality, is a southwestern Ohio town of 25,000, located in Greene County on the outskirts of Dayton. Xenia’s predominately lower-middle-class population consists mainly of community natives. The close proximity " = of two prominent black universities—Central State and Wilberforce, a large Air Force base, and Dayton, a city of nearly a quarter of a million. all give Xenia more social and cultural diversity than that of many small towns. The majority of Xenia’s working people are employed in Dayton, although there is some light manufacturing in the town and its environs. The lifestyle in Xenia is similar to that of many bedroom com- munities around the United States. The local vote is heavily Republican in Federal, State, and local elections. In 1974, single- family dwellings predominated, and 75 percent of the residential dwellings were owner occupied. Most people shop in Dayton, and local trade was on the decline even before the tornado. The Disaster On April 3 and 4, 1974, over 148 tornadoes passed through more than 200 counties in 13 States in what was the most massive outbreak ' of tornadoes in the history of the United States. At 3:50 p.m. on April 3rd, a tornado watch was issued for Dayton and west central Ohio counties, including Greene County. A tornado cloud had formed when a thunderstorm moving northeast from Cincinnati collided with col— der air. At 4:20 p.m., a tornado touched down at Bellbrook, 5 miles southwest of Xenia, and began moving northeast toward the town. Tornado warnings were announced by radio, by television, and by police cruisers equipped with loudspeakers from about 4:00 p.m. in Xenia. In spite of warning efforts, it did not occur to many people that a tornado might actually touch down in Xenia. 25 CRISIS INTERVENTION FOR DISASTER VICTIMS The tornado cut a path through Greene County about 16 miles long, averaging between 2,000 and 3,000 feet in width, and with winds esti- mated at times to be near 250 MPH. The funnel touched down in Xenia at 4:40 p.m. and proceeded in a northeastern direction, destroy- ing or damaging residential areas, schools, a cemetery, the downtown business district, and Central State University in nearby Wilberforce. Five minutes after it had entered Xenia, the tornado dissipated itself in the open country. Thirty-three individuals died in the tornado. Over 1,000 survivors, or approximately 5 percent of the population, were treated for tornado-related injuries. The destruction in Xenia was ex- intensive; two major residential areas and the central business district were almost entirely destroyed. One incomplete survey revealed that 1,135 homes were totally destroyed, 511 incurred major damage, and 1,500 sustained minor damage. In addition, over 100 businesses, city facilities, and churches were destroyed or damaged. The losses result- ing from the tornado in Xenia were estimated at $77 million. In other words, the devastation by the tornado resulted in the need to rebuild about one-fourth of Xenia and to repair extensively another one-third of the community. As in Buffalo Creek, the Xenia disaster sharply disrupted com- munity life. The Xenia tornado was indeed a community-wide dis- aster; it was a rare household that did not feel the effects of the tor- nado. All institutional sectors showed evidence of dislocation: Economic disruption was massive; business losses were staggering; and a little over a third of Xenia’s population experienced interrup- tions in employment for a month or longer. Additionally, the slow pace of downtown redevelopment occasioned intracommunity conflict involving local interest groups. The educational sector of the com- munity was also affected by the tornado. Since some schools had been destroyed, students were sent to nearby schools, and double sessions were initiated. The school day was shortened, and athletic programs were cancelled. Approximately half the children attended at least two different schools in less than 6 months. Family life was similarly dis- rupted, with taken-for-granted routines radically altered for some time after the tornado. Almost one-half of those evacuated from their homes were out of their houses for more than 2 weeks, and a substan- tial number of families lived for months in homes they did not con- sider permanent. Yet, as will be indicated, this disruption did not result in collective trauma of the kind seen in Buffalo Creek, nor did it eventuate in the appearance of severe psychopathology among victims. The Aftermath The Emergency Response. Individual and organizational responses during the first hours after the disaster were swift and effective. 26 NEEDS IN DISASTERS Search and rescue missions, performed by the Xenia Fire Department, nearby police and fire units, and units from Dayton, were called off by 12:40 a.m. The number and identity of casualties were known early; no victims remained undiscovered for long periods of time or were lost entirely. The Red Cross opened a shelter within hours after the dis— aster, and the local radio station broadcast only disaster-related programs. Resources of various kinds were brought from nearby Dayton. In short, local, State and Federal aid was reasonably swift in coming, was reasonably sufficient, and generally was provided effi- ciently and effectively. Even more important, there was no evidence of individual or organizational panic or immobilization, and the com- munity responded rationally to meet the needs of the situation. Of particular note, for the purposes of this discussion, is one aspect of the community’s disaster response which involved efforts by both established mental health agencies and new groups to provide mental health services to victims. One established agency was involved in at- tempting to provide counseling of a crisis intervention nature im- mediately after the disaster impact and in the months that followed, and two additional groups emerged in the days following the tornado to assess needs, to provide broad human services and referrals, and to engage in advocacy on behalf of victims. These three organizations believed strongly in outreach to victims, in prevention of problems as opposed to their clinical treatment, and in the use of innovative methods for dealing with the crises victims were experiencing. Consequences of the Disaster for Victims’ Mental Health. Three types of mental health-related responses have been identified by Taylor, Ross, and Quarantelli (1976) in the report on their research on in- dividuals in the stricken community: mental illness, mental health problems, and problems in living. According to this research, the Xenia tornado did not generate or precipitate serious, long-term psychopathology among tornado vic- tims. Indications of hysterical breakdowns, loss of contact with reality, or severe psychological disturbances were not found among disaster victims either in the short or long run. Taylor, Ross, and Quarantelli (1976, p. 275) note that: . There was little demand for services oriented toward severe dis- aster-related psychopathology. In fact, organizations which specialized in providing more long-run clinical treatments through the use of psychotherapy, drugs, or hospitalization ac- tually experienced a decline in the demand for their services sub- sequent to the tornado. This decrease in the more severe forms of psychological dysfunction and in the demand for clinically oriented kinds of services occurred in 27 CRISIS INTERVENTION FOR DISASTER VICTIMS spite of the fact that some mental health practitioners expected a postdisaster increase in the incidence of severe mental illness. The second type of psychological reaction, mental health problems, or “difficulties primarily associated with the lack of positive psy- chological adaptation. . .rather than the presence of some underlying disease process” (Taylor, Ross, and Quarantelli 1976, p. 73) were prevalent after the tornado, but findings still do not suggest that there was an overt incidence of mental health disorders among the tor- nado victims. While various subjective and objective indicators of mental health reveal that “a significant number of the population ex- hibited mental health needs after the tornado” (Taylor et a1. 1976, p. 273), the incidence of severe mental disorders was below what was anticipated by the personnel of local mental health service deliv- ery and by the citizens themselves. Additionally, the mental health problems which appeared were usually of a minor and short-term nature. In the survey conducted on a random sample of the population of Xenia 6 months after the disaster, the Disaster Research Center (DRC) found that only 9 percent of those surveyed reported their emo— tional/mental health to be “poor” or “very bad.” However, 56 percent did report feeling depressed or low, on occasion, after the disaster. In addition, 27 percent reported having had sleeping problems, at some time, since the tornado; 15 percent admitted to some loss of appetite; and 25 percent reported having had headaches; but a second survey conducted 18 months after the disaster indicated that the incidence of most of these symptoms declined dramatically in the year following the tornado. There was, however, one important exception, the signifi- cance of which is not yet wholly understood: Some victims were more likely to report being depressed 11/2 years after the tornado than they were in the first 6 months afterward. This finding could indicate that some mental health problems may be longer lasting or may emerge later than others, but more study is needed before this assertion can be made. In terms of social adjustment, both positive and negative conse- quences of the disaster were discovered. For example, 2 percent of the respondents reported that relationships with friends and family had deteriorated since the disaster, but 27 percent reported that these rela- tionships had improved. Similarly, while 3 percent of respondents report their marital relationships to be less satisfying since the dis- aster, 28 percent reported them to be more satisfying. Apart from vic- tims’ own subjective perceptions, objective statistical data used to measure stress among the population indicated mixed effects also. For example, there was no significant change in either marriage or divorce rates, or suicides, as compared with predisaster rates; deaths resulting 28 NEEDS IN DISASTERS from heart problems decreased, but there was an increase in reported physical illness. Only 3 percent of the population reported any increase in the use of alcohol after the tornado, but 7 percent actually claimed to have decreased their consumption. In the year after the tornado, there was an overall rise in the number of cases filed in all courts—in- cluding juvenile court—but, at the same time, there was also a signifi- cant decline in the actual number of offenses reported to the police. With regard to the demand for mental health services after the dis— aster, Taylor, Ross, and Quarnatelli (1976, p. 272) note, “There was no massive onslaught of clients seeking the services of either existing or newly emergent disaster mental health agencies and groups. In all, less than 10 percent of the total population received services from the various mental health agencies in Xenia in the 6 months after the dis- aster.” This figure dropped to half or to about 5 percent of reported agency use in the year following the disaster. The data, therefore, indicate that victims of the Xenia tornado ap- parently experienced a variety of mental health problems; however, they were usually minor and short-term in nature. In fact, many in- dividuals felt that they were emotionally and psychologically healthier after the tornado. For instance, about 70 percent of Xenians indicated that they were better able to cope with adversity, having res- ponded to the challenges the disaster presented. The third type of psychological consequence of disaster, problems in living rather than mental illness or mental health problems, appeared to be the largest cause for concern after the tornado. The amount of destruction posed considerable immediate difficulties for victims. Most problems that surfaced were of the sort typically dealt with by social or human service agencies. For example, in one DRC survey where a sample of the population was asked to rank the need for different kinds of services, youth problems, public transportation, and recreation programs were ranked highest, followed by free food, con- tinuing education programs, and low-cost housing. Counseling was ranked 20th on the list of needed services. In summary, the victims of the Xenia tornado, unlike those of the Buffalo Creek flood, did not evidence symptoms of either mental ill- ness or severe, prolonged mental health problems. The actual inci- dence of cases of severe psychopathology was minimal, with the most frequently manifested symptoms those of the anxious/depressive variety, which were generally of mild intensity. Problems in living— difficulties associated with obtaining food, shelter, clothing, and com- munity services—were quite severe after the tornado, especially in terms of victims’ subjective perceptions of their needs. . Nevertheless, the data show that there was a clear need for specialized types of services, particularly emergency mental health or 29 CRISIS INTERVENTION FOR DISASTER VICTIMS ‘crisis services, by some people, at some time after the disaster. Moreover, the widespread evidence of problems in living certainly in- dicates the existence of a continuing stress situation with relevance for the mental health of at least some of the population. Although no ex- act data exist to measure their effectiveness, local attempts to deliver mental health services almost certainly had positive effect on the reci- pients. Xenia and Buffalo Creek: Differences That May Make a Difference As has been emphasized throughout this discussion, the Buffalo Creek flood was so atypical as to be almost unique in terms of psy- chological consequences it reportedly had for victims, In order to avoid a tragic recurrence of this kind of event, it might be useful to ask if something might have been done to reduce the severity of the problems that emerged. Individual trauma resulting from the flood was, understandably, massive; but apparently it was the additional blow to the solidarity of the community in the weeks and months following the flood that mag— nified the effects of the victims’ trying experiences. The populace was reportedly so overwhelmed by the devastation of the disaster that a feeling of helplessness and dependence on outside aid occurred, which was probably detrimental to efforts to reinstate a sense of com- _ munality. Although neighbors and family members labored long and hard to help one another, it was not possible for local people to organ- ize any sort of sustained effort to reach those who were most affected. The isolated nature of the locale meant that nearby communities could not become involved in extending personal, neighborly, or sup- portive kinds of aid. The material assistance given, while sufficent, , was dispensed by an impersonal bureaucracy, administered by out- siders. After the homeless were relocated in their trailers, anything that was left of the old ties was obliterated. Thus, victims of the flood 3‘ were robbed of the sense of adequacy, of mastery, that comes from col- ilectively responding to the challenges of a crisis—the positive kind of feeling that many individuals belonging to disaster-stricken com- munities express during the recovery period. In short, there was an ab- sence in Buffalo Creek of what Fritz (1961) has termed the “therapeutic features” of disaster; psychologically speaking, the flood victims experienced all of the bad and none of the good effects of com- munity crisis. In Xenia, on the other hand, there was evidence of the kind of in- creased community solidarity, intensified collective effort, and general 30 NEEDS IN DISASTERS optimism Fritz has noted in his studies of disaster-stricken com- munities. People were able to help one another and to regain a sense of collective strength. An important part of this helping behavior in- volved the extension of psychological support to victims through for- mal, as well as informal, helping networks. Xenia possessed a com- paratively elaborate network of mental health and human service agencies even before the tornado. Many of these organizations became involved in the disaster in response (although not always in an effi- cient, effective way), but perhaps even more important, new local groups formed for the expressed purpose of giving victims whatever kinds of support were needed. Also, resources for providing counseling and other types of human services were available from nearby Dayton, if needed. Thus, although there was no prior planning for the delivery of mental health services to disaster victims, Xenia was, at least po- tentially, able to meet the crisis-related needs of community residents. No one would naively argue that it was solely the lack of the provi- sion of emergency mental health services to the victims that made the long-term effects of the Buffalo Creek flood so severe. It is obvious that some organized, ongoing, indigenous effort to provide crisis serv- ices in a supportive and neighborly fashion might have lessened the effects of the trauma suffered by the flood victims. We think that com— munities should learn from the disaster experiences of both Xenia and Buffalo Creek and should plan on the community level for an ap- propriate response to disaster-related needs of all kinds, including those of mental health. Since part of planning involves knowing what to plan for, we will discuss what recently has been learned about dis- aster-related mental health needs, noting how these findings differ from what conventional wisdom leads us to expect. The Present State of Empirical Knowledge About the Mental Health Consequence of Disasters Most people equate the term disaster with intense and prolonged human suffering, anguish, loss, and despair. Even the commonsense observer would agree that the impact of a tornado, an earthquake, a hurricane, or the water surging from a crumbled dam goes far beyond the immediately recognizable loss of life and the sheer physical damage and destruction associated with such events, impressive though they may be. As the above examples indicate, what is even more important about a large-scale disaster is the disruption and destruction of community life, the marked alterations of routine pat- terns of social expectations and of day-to-day personal habits which 31 CRISIS INTERVENTION FOR DISASTER VICTIMS follow in its wake. While the physical impact of a disaster may be over in a few minutes, as in Xenia, these other consequences extend for weeks, months, and even years. A major disaster does far more than wreck buildings and cut lifelines; it interrupts the rhythm, cycles, and very social fabric of community life. Disasters are part of a class of collective stress situation in that, since they disrupt social life, they also induce psychological stress for their victims. How do human beings respond in these collective stress situations? Can it be assumed that the social disruption occasioned by a large—scale catastrophe also creates psychological disorder or mal- function among victims? The answer is twofold: how people are believed to respond and how they actually respond. Although much more intensive, systematic research is needed in order to satisfactorily answer both of these questions, the general answer is clearly indicated by current research evidence. Folk Wisdom For some time, conventional wisdom has held that human beings do not react well to large-scale catastrophes. It is commonly believed that, when people are faced with the threat or the actual occurrence of a major disaster, they disintegrate physically, mentally, and morally. They engage in bizarre, antisocial, irrational, and destructive acts such as wild and disorderly panic, looting, and other forms of criminal deviance. Popular beliefs about how people react to extreme stress situations are so grim that hysterical breakdowns and psychotic episodes are thought to be common among disaster Victims in the short run, and a wide variety of forms of severe psychopathology are expected to be manifest among victims in the long run. The image is essentially that disasters create or exacerbate severe forms of mental illness for their victims. These common stereotypes of how persons respond to, and are affected by, disasters are not new. While there are, undoubtedly, many reasons why such stereotypes exist, one of the basic reasons is that mass media and journalistic accounts often reinforce and support such beliefs, as seen in the images played up by news and magazine ac counts of disasters, dating as far back as the late 1800s and early 19005. For example, in a Harper’s magazine article of 1889, survivors of the Johnstown, Pennsylvania, flood were described as “crazed by their sufferings.” A Saturday Evening Post account of the devastating hurricane which hit Galveston, Texas, in 1900, wrote of 500 people who went “insane almost in unison” following the disaster. Similarly, Har- pers Weekly wrote that the 1906 San Francisco earthquake and subse- quent fire brought about cases of “men gone mad.” While the ter- minology used in these articles is, of course, outdated, they do, 32 NEEDS IN DISASTERS nevertheless, illustrate the long history of the view of disasters leading to severe psychopathology. Perhaps even more importantly, the same general stereotypes con- tinue to be emphasized in present mass media accounts of disasters. Following a series of major floods in 1973, Newsweek, for example, reported that once the immediate postimpact period is over, a new reaction starts to appear among victims—a “kind of shared psychosis that hits just about everyone affected directly or indirectly by the event.” The story then goes on to assert that, within a few weeks after such a catastrophe, symptoms of emotional problems become disturb- ingly obvious: The number of successful suicides rises by about a third; hospital admissions for psychiatric reasons run at double the normal rate; and the frequency of accidents skyrockets. Indeed, the picture painted by this story is a grim one. While numerous other examples of journalistic writings which ad- vance similar ideas could be cited, we all know that most people do not believe everything that they read in newspapers or magazines; or do they? How widespread in actuality is the belief that disasters trig- ger extreme emotional and psychological reactions among the general public? Two surveys have recently been undertaken to ascertain em- pirically what the general public actually does believe about human behavior in disaster situations. The first, a survey conducted by Den- nis Wenger and his colleagues in the State of Delaware (Wenger et a1. 1975) found that large blocks of the population do, in fact, believe that disasters evoke extreme reactions in their victims. For example, these researchers report that 74 percent of those surveyed agree with the statement that “immediately following the impact of a disaster, vic- tims are in a state of shock and unable to cope with the situation by themselves.” The second survey conducted by Blanshan (unpublished paper 1975) in a small community in Ohio not far from Xenia, only months after the tornado, produced similar findings. The attribution of problems of a mental or psychological nature to victims of disasters was widespread among the population surveyed. In other words, ac- cording to these studies, the general public does, indeed, hold to the image that disasters produce extreme psychological and emotional reactions in their victims. What do psychiatrists, psychologists, and other experts in the men- tal health field have to say about human response to disaster? Like the mass media and a majority of the general public, a large number of mental health professionals also assume that extreme emotional and psychopathological reactions are a typical consequence of disasters. While the terminology used varies somewhat, psychiatric and psy- - choanalytically oriented writers, like some of those who conducted research in Buffalo Creek, often note that immediately after impact, 33 CRISIS INTERVENTION FOR DISASTER VICTIMS victims of major natural catastrophes can be expected to display what is often termed the “disaster syndrome.” This condition is supposedly characterized by an unrealistic absence of emotion, inhibition of ac- tivity, docility, indecisiveness, lack of responsiveness, and automatic behavior on the part of disaster victims. During the later postimpact phases, victims are likely to exhibit reactions such as an increase in the use of alcohol and other drugs; acute, traumatic neuroses; tormenting memories and guilt feelings over survival; and irrational hostility and scapegoating. An often cited numerical projection of the numbers of victims likely to display psychological disorders was set forth over two decades ago by Tyhurst, one of the first professionals writing on the subject. Ac- cording to Tyhurst (1951), about 12—25 percent of a disaster-affected population will show grossly inappropriate behavior, anxiety and effective states, hysterical reactions, and psychosis. Another 75 percent will be “dazed, stunned, bewildered,” or otherwise exhibit the disaster syndromes noted above. On the whole, until the last few years, the issue was not whether severe pathological reactions occur in victims of disasters, but what the incidence and duration of these assumed problems were. , Of course, as asserted in the first chapter of this report when the “panic myth” was discussed, “situations defined as real are real in their consequences,” the importance of the beliefs and perceptions held by professionals and the general public is the implication they have for what is done in a disaster situation. It is apparent that people do not come into disaster situations with blank minds about the ways in which human beings are expected to react. Rather, there are com- mon beliefs even before a disaster occurs about the response to be ex- pected. The general tendency is to assume that victim populations will exhibit varying degrees of extreme psychological disorder, although the popular vocabulary is to frame these disorders in terms of a state of “shock” or of an “emotional” reaction. Typically, anecdotal stories circulate about “unusual” behaviors on the part of some victims. Thus, the widely held image that disasters evoke extreme psychologi- cal responses is bound to affect people’s overall perception of what prevails in such a situation. Empirical Findings How accurate are these widespread, commonsense beliefs about human response to collective stress situations? Most of them are based either on isolated anecdotal examples and occasional clinical causes of severe postdisaster problems or on the somewhat questionable assumption that research findings based on wartime could be ex- tended to natural disasters. Only in the past 3 or 4 years has 34 NEEDS IN DISASTERS systematic research actually been undertaken to determine how humans react psychologically and emotionally to disasters. The find- ings suggest that the belief that disasters trigger widespread incidence of severe emotional and pathological reactions is one of the major myths about human response to extreme collective stress. Recent researchers tend to agree that very few people become grossly psychotic in the face of major disasters and that incapacitating psychological reactions are unusual phenomena in catastrophes. In some areas, seeking help for severe psychological disorder is notable for its absence. Although further research is needed, the NIMH program, under PL. 93-288, Section 413, has accumulated recent clinical evidence indicating that emotional and psychological problems in major disasters heretofore may have been unsuspected or missed. Frederick (1977a) has alluded to some of the differences in psychological crises occurring in wartime and those in major natural disasters. This may supplement writings on collective stress situations such as war bombings, studied by Janis (1951), and civil disorders in Northern Ireland, reported by Peipert (1975). Other research corroborates this notion, at the same time indicating that disaster is not entirely without psychological impact. In a study conducted to determine whether disaster leads to increased stress in the victim population, Hall and Landreth (1975) collected com— munity-level data on changes in arrest records, school attendance, suicide, and a number of other statistics considered to be related to in- dividual stress, following the 1972 Rapid City, South Dakota flash flood. They also collected data on a sample selected from the 550 families relocated to mobile homes following the flood. They reported that, for the 18-month period following the disaster, no significant in- crease occurred in the community in: 1. The number of attempted or actual suicides, or single car acci- dents (often considered suicide attempts) . The rate of juvenile delinquency . The number of citations for driving while intoxicated . The number of automobile accidents . Infant mortality . Rates of scarlet fever, strep throat, and hepatitus . The number of prescriptions written for tranquilizers \ICDUTJRQDN) However, they did find changes which seem to indicate that at least some people were worse off, psychologically, following the flood. Divorces and annulments increased significantly in the 17 months after the flood. There was also a significant increase in the number of arrests for public intoxication and in applications for aid to dependent children. 35 CRISIS INTERVENTION FOR DISASTER VICTIMS Although victim families housed in the public trailer parks did not evidence greater involvement in selected deviant and illegal activities (e.g., public intoxication) and did not make more use of community mental health center services than the general population, their mem- bers did appear to manifest symptoms of stress. The authors concluded that, while the flood did not engender a ma- jor community mental health crisis, it did result in an increase in social stress for nonaffluent victims. They also concluded that the stresses of group life in the temporary mobile-home parks set up‘ after disasters are probably detrimental to the psycological well-being of residents in that this way of life tends to destroy victims’ natural help- ing networks. It was not only the impact of the disaster itself which affected victims’ psychological well-being, but also the more long-term impact of frustration and stress brought about by the often conflicting and misunderstood rehabilitation procedures set up by Federal, State, and local agencies. Thus, while few researchers would claim that disasters create severe and chronic mental illness on a wide scale, victim populations do seem to undergo considerable stress and strain and do experience varying degrees of concern, worry, depression, and anxiety, together with numerous problems in living and adjustment in postdisaster. Ap- proximately 10 studies have been undertaken in other disaster- stricken communities, and they tend to corroborate this view. The communities include: Wilkes-Barre, Pennsylvania (flood); Omaha, Nebraska (tornado); Topeka, Kansas (tornado); Los Angeles, California (earthquake); Monticello, Indiana (tornado); and Buffalo Creek, West Virginia. Except for the Buffalo Creek study, none of the research found a link between disaster and severe psychopathology. However, the studies agree almost unanimously that disasters do in- duce symptoms of psychological stress among victims and fairly exten- sive problems in living which may, in turn, contribute to further emo- tional difficulties. Incidentally, most of the studies also point out that acute mental illness reactions were anticipated in the first few days after impact. When these reactions failed to materialize, existing men- tal health agencies usually found it difficult to determine their ap- propriate role in this new context. What, then, are some of the needs of the victims? The research indi- cates that the needs are many, complex, and interrelated, reflecting the combined physical, material, psychological, and social damage that disasters inflict. During the immediate emergency period, disaster Victims face multiple problems characterized by varying degrees of urgency, difficulty, and emotional impact. These commonly include loss of a loved one, total or partial loss of home and possessions, physi- cal injury, disruption or loss of employment, sudden relocation, 36 NEEDS IN DISASTERS separation from familiar surroundings, and extreme demands on physical endurance. Of course, many disaster Victims exhibit signs of stress upon having to face such circumstances. It is obvious that any One of these problems might conceivably have adverse effects on an in- dividual’s mental health; in concert, if allowed to persist, such problems could place the individual in an extreme crisis situation. Many examples show how varied and complex disaster-generated needs can be. Regarding client problems encountered during the course of Project Outreach, a crisis intervention service instituted to provide aid to the victims of the 1972 Pennsylvania floods created by Hurricane Agnes, McGee (1973) reports that the highest percentage of the project’s clients, 19.58 percent, expressed “emotional problems,” with “property damage,” “medical,” “financial,” and “living condi- tions” next in order of frequency. McGee presents anecdotal evidence of individuals so overwhelmed by demands that they could not decide what to do first, and of persons too exhausted and discouraged to at- tempt to help themselves. Other categories of needs mentioned by McGee include persons faced with having to adjust to temporary hous- ing and those who had experienced other extreme personal or family difficulties close to the time of disaster. Bowman, a mental health professional who participated in the emergent crisis intervention response to the Monticello, Indiana, tornado of 1974, tells of victims’ overwhelming need to relate their disaster experiences to someone willing to listen, and to be made aware of how to go about obtaining a range of disaster-related services. Volunteers from the Monticello Neighbor-to-Neighbor Team consequently played the role of the “friendly listener” and kept up to date on where to refer clients for services (Bowman 1975). Other evidence indicating the wide-ranging nature of disaster-re- lated needs is provided in the final report of the Omaha Tornado Proj- ect, a group which received funding under Section 413 of the new dis- aster statute (P.L. 93-288) to provide mental health services to victims of the 1975 Omaha, Nebraska, tornado. Problems mentioned most fre- quently by adults during the months following the tornado included “lack of leisure time, interpersonal stress, children getting under foot, depression, sense of loss, and the consequent grieving process that must be worked through” (Omaha Tornado Project 1976). Volunteers working with this group performed a variety of services for in- dividuals, including listening to victims relate their tornado ex- perience, giving victims assistance in obtaining information about needed services, and providing counseling on an informal, one-time basis. Additionally, program reports from current Section 413 projects in Logan-Mingo and McDowell Counties, West Virginia, and Cambria County, Pennsylvania, are providing new information regarding the 37 CRISIS INTERVENTION FOR DISASTER VICTIMS actual kinds of mental health and human service needs which exist among victims coming from varying backgrounds. These are still to be analyzed and integrated with the research findings previously cited. Groups With Special Needs Although little solid, systematic data exist on the differential psy- chological impact of disaster on various community groups, many programs concerned with the delivery of disaster-related mental health services have attempted to focus on groups believed to require particular attention and, perhaps, special services. Target groups men- tioned most frequently are children and the elderly. For example, in the early 19505, attempts were made to study the impact of the 1953 Vicksburg tornado on children in the affected population (Bloch, Sil- ber, and Perry 1953). After the San Fernando Valley earthquake of 1972, crisis mental health services were offered to families with children for the purpose of reducing the children’s disaster-related fears (Howard and Gorden 1972). Similarly, the notion that older in- dividuals may find it particularly difficult to adapt in the wake of dis- aster is expressed over and over in the literature. Moreover, in almost all proposals and program outlines for delivering services to disaster victims, the elderly are designated as a group needing special atten- tion. Many other potential target groups can be identified, such as the poor, minority group members, persons who had been receiving the services of some community agency prior to the disaster, and pre- viously hospitalized patients. These kinds of groups, together with children and the elderly, constitute logical target groups on the basis of the assumption that their members probably had needs or lacked coping resources prior to the disaster, which the disaster may have ex- acerbated. Another potentially needy category consists of persons upon whom the disaster had a particularly intense impact. A hy- pothetical set of target groups might include: families who lost one or more loved ones; those who lost their homes and had to relocate; the uninsured or underinsured; and those left unemployed by the disaster. Assessing potential disaster-related mental health needs involves more than the a priori identification of target groups, however. First, it should be emphasized again that research on the psychological conse- quences of disaster has not yet firmly established which groups of vic- tims need what kinds of services of a mental health nature more than others. On the contrary, in one survey on postdisaster needs, elderly in- dividuals manifested a relatively high need for “hard” services (hous- ing, financial aid, income maintenance, and medical services), together with a relatively low need for counseling and other “soft” services (Poulshock and Cohen 1975). Second, communities differ in 38 NEEDS IN DISASTERS the distribution of postdisaster needs, just as they differ in many other ways. Moreover, different kinds of disaster agents affect populations differently and create a variety of needs and stresses. For example, total loss of possessions with insurance compensation is more charac- teristic of floods than of tornadoes or hurricanes. Similarly, a com- paratively localized agent, such as a tornado, may have a heavy im- pact on a part of the community occupied by low-income or nonwhite families, and a particular constellation of needs may subsequently emerge. With these kinds of considerations in mind, we wish to stress the fact that, no matter how logical they may seem, predisaster assumptions about what groups in the population may most need dis- aster-related services are no substitute for accurate, thorough needs assessment after disaster strikes. Stages in the Appearance of Disaster-Related Mental Health Needs Another aspect of postdisaster needs involves the time dimension. Research on community response to disaster events indicates that communities go through stages in their response to, and recovery from, disasters. Community needs and, subsequently, organizational tasks are known to vary according to the disaster phase in which a com- munity finds itself. For example, Dynes (1974), following Powell, divides disaster impact into eight time stages: predisaster conditions, warning, threat, impact, inventory, rescue, remedy, and recovery. Dynes notes that these stages are characterized by the differential in- volvement of various community organizations, by varying types of organizational behavior, and by different community norms. Barton (1970) distinguishes the following phases of community response: the predisaster period; the detection and warning period; the period of im- mediate response; the period of organized social response; and the longrun postdisaster period, in which permanent disaster effects begin. This stagelike quality is also characteristic of the individual’s response to disaster. The needs of individuals, or groups of affected in- dividuals, occur in phases, with different problems coming to the fore in different postdisaster periods. For example, in a disaster-stricken locale, the most common needs manifested in the immediate postim- pact emergency period may be for food, shelter, first aid, information about the whereabouts of loved ones, and an opportunity to ventilate feelings in the presence of a sympathetic listener. These kinds of needs may be superceded in later days by the need for help with cleanup, the need for information about available material aid and social services, and the need for assistance in coping with exhaustion, frustration, and discouragement at the amount of work that still remains to be done. During the long-term recovery period—say, 9 months to 1 year after 39 CRISIS INTERVENTION FOR DISASTER VICTIMS the disaster—the most acutely felt needs of victims may be for legal aid or for more and different kinds of community programs. At this time, some people may still be struggling with insurance problems, or with unemployment, or may be experiencing emotional difficulty in adjusting to the long-term consequences of the disaster. Disaster impact, disaster recovery, and long-term redevelopment are events community members experience together. Hence, many community members will experience the same types of needs at ap- proximately the same time. Fortunately, programs can be devised for the entire community which recognize the stagelike character of dis- aster-generated needs and which perform different functions for vic~ tims in different stages. Additionally, the knowledge that needs change as time passes indicates the necessity for periodic reassessment of both needs and services provided as the disaster experience recedes into the past. Crisis Intervention: A Strategy for Meeting Disaster- Generated Needs It seems rather surprising that the widespread mythological belief that disasters trigger severe mental illness has, in the past, had such a minor impact on the kinds of services delivered in large-scale, com- munity-wide disasters. Perhaps, in American society, losses resulting from disasters tend to be defined almost solely in economic terms. ‘In the past, disaster relief organizations focused mainly on assuring that victims were provided with food, clothing, and shelter in the immedi- ate emergency period, and that property and physical facilities were restored in the long run. No deliberate, organized attempt was made to deal with the psychological and emotional losses suffered by disaster- impacted populations. The situation began to change in 1971-1972, however. For the first time, attention was paid to the mental health of victims of some of America’s major disasters. Following catastrophes, local and outside groups launched efforts to deliver psychological support to victim populations. To date, disaster-related mental health services have been provided in a number of communities, including: the San Fer- nando Valley in California; Wilkes-Barre, Pennsylvania; Corning, New York; Buffalo Creek, West Virginia; Rapid City, South Dakota; Xenia, Ohio; Monticello, Indiana; Bradenburg, Kentucky; Canton, Il- linois; Omaha, Nebraska; the Grand Teton Dam region of Idaho; the Big Thompson Canyon region, in Colorado; West Virginia and Ken- tucky communities which sustained damage in the spring floods of 40 NEEDS IN DISASTERS 1977; and the Johnstown, Pennsylvania area, also in the spring of 1977. The nature and scope of the services provided to victims varied considerably from case to case. Some programs consisted of reaching out to provide emergency mental health and crisis services, but there were, in the beginning at least, an equal number of attempts to offer traditional clinical and psychotherapeutic treatments. Over time, however, outreach for casefinding and diagnostic pur- poses, crisis intervention, and the provision of supportive services has come to be defined by those actually involved in service delivery in time of disaster as the most appropriate, effective techniques to employ in dealing with the problems of disaster victims. (See Tuck- man 1973; Schulberg 1974; Zarle, Hartsough, and Ottinger 1974; Kim 1975; Heffron 1975; Taylor, Ross, and Quarantelli 1976; and Fre- derick 1977, for discussions of crisis intervention as an aspect of dis- aster response. For a more thorough treatment of the principles of crisis intervention theory, see Caplan 1964.) The judgment that strategies employing the principles of crisis in- tervention may be the most useful strategies for mental health service deliverers to adopt following disasters seems to rest on several founda- tions. One foundation is the finding cited above that, generally, dis- asters do not result in serious mental illness or sustained and severe psychiatric impairment for significant segments of the victim popula~ tion. Another is the reluctance to seek psychotherapy and related clini- cal services following disasters in some geographical regions. Quoting from the Omaha Tornado Project (1976, p. 13): It was borne out by our experience that traditional mental health services in clinic settings seem to be appropriate to the needs of a limited number of people, usually those who are dis- playing serious emotional distress. . . . Post-disaster mental health programs face the challenge of establishing services for es- sentially “normal” and “healthy” people who are experiencing some emotional difficulty that stems from the losses and stress resulting from natural disaster. Perhaps most important, those involved in postdisaster mental health service delivery have witnessed firsthand the great variety and cumulative nature of victims’ postdisaster psychological reactions and, therefore, have become aware of the necessity of adopting an open, flexible approach to the provision of mental health services. Often, they learned the overwhelming need of victims is for the render- ing of immediate, tangible aid on any number of fronts. The notion that the delivery of effective mental health services involves the provi- sion of aid in whatever areas seem most pressing to victims is com- monly advanced, as in Kirn’s discussion (1975, p. 4) of the participato- 41 CRISIS INTERVENTION FOR DISASTER VICTIMS ry role the community mental health center worker should play in the days immediately following the disaster: CMHC staff must do whatever needs to be done. They must behave as good neighbors would, but it is most important that they be there; digging out, sawing trees, and so forth. Especially in sudden disaster, real physical needs are dominant, and the situation does not lend itself to playing formal mental health roles. McGee (unpublished paper 1973, pp. 1-2) sums up the role of the crisis intervention worker, both during normal times and in the post- disaster setting: It is difficult to imagine any problem which would fall outside the scope of appropriate response by a crisis intervention agency. There are no eligibility requirements for clients of a crisis service. The crisis worker is best conceptualized as an ombudsman, facilitator, or expediter in behalf of people with any type of problem. The need for food, clothing, and shelter can be just as much of an emergency to a family as the need for impartial mediating intervention in an angry family dispute. Both types of human problem should receive equal attention with suicide threats and attempts when they are brought to a crisis interven- tion service by a client or another community agency. , Three other themes predominate in the reported experiences of those faced with providing mental health services in time of disaster, which indicate why an outreach, crisis intervention model seems ap- propriate. One is the notion that victims require services where they are, rather than in a mental health facility, or in some other tradi- tional setting. Another is that the mental health worker in disaster must act as a resource for knowledge about other community services and must be aware, at all times, of what other agencies and groups are doing. Again, there is the notion that providing this kind of informa- tion and referral during times of extreme uncertainty—and indeed even physically bringing the victim to the place where he or she can receive aid—is performing a real mental health function. A third theme expressed in writings on disaster mental health services stresses the use of paraprofessionals and volunteers in outreach and crisis in- tervention activities. It is seen as especially important to enlist the aid of individuals who are already perceived as friendly helpers or resources by community members, e.g., clergy or a general practi- tioner. 42 NEEDS IN DISASTERS The rationale for adopting a crisis intervention approach to dis- aster mental health has been summarized by Frederick (1977, p. 19): It has been shown repeatedly that traditional psychotherapy is often quite inappropriate (in the post-disaster setting). . . . Radi- cal departures from some orientations are a sine qua non to effec- tive crisis treatment. People need help in very material ways. It can be mentally and emotionally therapeutic simply to go through the process of making arrangements to get a loan, transport someone in a car to another part of the city where a relative or loved one may be, to arrange for care of children, or to help provide more living room so that cramped, crowded condi- tions of space are alleviated, which have long been known to con- tribute to psychological difficulties. As indicated, crisis intervention techniques have been practiced in the aftermath of disaster, and their use in future disasters is widely ad- vocated. However, the assumption that crisis intervention techniques are the most effective way to reduce the likelihood that disaster vic- tims will manifest serious psychological disorders is just that—an assumption. Actual research evidence is needed to lend definitive sup- port for such an assumption. To be able to accurately estimate the ex- tent to which mental health services are needed in disasters and to state what kinds of mental health services these should be, we must first answer two separate but related questions. The first question con— cerns how psychological disorders arise out of extreme environmen- tally induced stress and, if they do, what the exact nature and dura— tion of these disorders may be. The second is whether alternative sources of social and psychological support can also mediate the im- pact of these stressful environmental events on the individual. Stated succinctly, we need to know how the creation of new helping networks can enhance a victim’s ability to cope with stressful events. The evidence indicates unequivocally that disasters do provoke ex- treme environmental stress for their victims. However, the claim that this stress has the potential for inducing more longrun symptoms of psychological disorder in otherwise normal individuals requires further research. Most research assessing the effects of stressful life events on psychological functioning suggests that the individual psy— chological reactions or symptoms which arise out of these kinds of events may be as transient as the environmental stress which induces them. This implies that, for many individuals, symptoms of disturb- ance will disappear as the extreme situation alters. (See Dohrenwend and Dohrenwend 1974; Hinkle 1974; and Holmes and Rahe 1969.) This work also needs further documentation by clinically trained research investigators. 43 .— CRISIS INTERVENTION FOR DISASTER VICTIMS This conclusion supplies the basic rationale favoring the use of crisis techniques in extreme situations. The underlying reasoning is that, if providing additional sources of social and psychological sup- port can change a victim’s environment, it is possible to alter the effects of the stress induced by disasters, thus reducing the chance that otherwise transient disorders will persist. 44 Chapter IV _ DESIGN AND METHODOLOGY OF THIS STUDY Objectives of the Research Using the rationale that crisis intervention/emergency mental health programs for dealing with disaster-related problems must build upon existing capabilities, we attempted to obtain baseline infor- mation about the needs and resources which now exist in our rural areas and small towns. Both DRC and the National Institute of Men- tal Health, which funded the study, believe that this information will be useful to local planners, officials, mental health professionals, and human service workers who can use it for developing programs to meet disaster-related needs. In general, the interest was in gathering data that could be applied to the following six questions: 1. What are the general demographic, economic, social, and politi- cal characteristics of the area studies? The focus in this phase of the research was in learning about some of the characteristics of life in each of the areas studied to better un- derstand the nonurban setting. Besides providing information about rural and small town lifestyles, such factors as income, occupation, ethnicity, and religion have been shown to be related to incidence of psychological disturbance, attitudes about mental illness and mental health, and a variety of patterns of service utilization, including men- tal health services. Additionally, we expected that community charac- teristics, such as size and racial composition, might relate not only to the mental health and human service needs of the community resi- dents, but also to the number and nature of community resources and to their use by the respective communities. 2. What are the mental health and human service resources availa- ble in the areas studied? This aspect of the research focused on learning about what organizations, individuals, and groups exist in nonurban U.S. com- munities, which either actually or potentially give support to in- dividuals in times of emotional crises. Again, it should be noted that 45 CRISIS INTERVENTION FOR DISASTER VICTIMS we studied what presently exists, with an eye toward assessing the po- tential for adaptation to a disaster situation. Three kinds of emergency mental health/crisis intervention resources were studied: (1) formal mental health agencies; (2) human service agencies responsible for providing a wide range of community services, from income maintenance and child protection to recrea- tional programs; and (3) informal caregivers. Formal agencies with trained personnel having a clear-cut respon- sibility for promoting mental health in the areas studied were, of course, of major interest. The research was designed to discover, among other things, the extent to which such facilities exist in nonur- ban communities, what kinds of programs are offered, what popula- tions are served, whether or not emergency mental health services are offered, and whether any kind of community outreach is emphasized, since these services and activities might be needed following a dis- aster. Information was also gathered on referral patterns between mental health facilities and other community organizations, inform- ants’ perceptions of the adequacy of local mental health services, perceptions of public awareness of community mental health services, and gaps in services. Because a relative lack of organized community resources is one of the distinguishing characteristics of life in nonurban U.S. com- munities, we knew that formal mental health agencies would not al- ways be present in the communities studied. Additionally, given this relative paucity of mental health resources, we expected that other community organizations, e.g. welfare, public health, and the courts, might serve a variety of functions and might provide more services of a mental health nature on an everyday basis than their urban counter- parts would. Thus, there was an interest in learning whether, and to what extent, crisis intervention, counseling, outreach, information and referral, and other such services were performed by human service organizations, either as a planned aspect of service delivery, or infor- mally, in the absence of other community resources. As with inform- ants in the mental health sector, we were interested in how human service professionals rated the local mental health and human serv— ice resources and community awareness of these services. Informal caregivers constituted the third category of community resources in this research. We were interested in learning not only about the activities of established and designated community organizations which deal with people’s problems, but also about the identity of individuals to whom community residents typically turn in crises. All community informants were asked the questions: “If some- one were experiencing a lot of stress or some sort of personal emergen- cy, what would he or she be likely to do about it in this community?” 46 STUDY DESIGN and, after discussing a variety of problems community residents might face, “What do people usually do who have problems like these?” The questions were designed specifically to discover whether formal agen- cies of a mental health or human service nature are commonly sought out, or whether less formal contacts (e.g., the minister, the family doc- tor) predominate for people experiencing crises in these communities. Several factors combined to create an emphasis on informal caregivers. One is, of course, the documented finding that the preva- lence of mental health problems can be expected to far exceed treated cases. Thus, it can be inferred that many persons either do without help or seek it through sources other than formally designated agen- cies. Second, in spite of some findings arguing that the attitudes of rural and smalltown persons toward the treatment of mental health problems and mental health agencies and practitioners in general are becoming more positive (Edgerton and Bentz 1969), there may still be a marked tendency in some small communities for people to shun agencies with explicity “mental health” labels because of latent or overt concern about the stigma attached to mental illness. We also ex- pected that the typical smalltown emphasis on independence and self- sufficiency might act to reduce utilization of public human service agencies except in cases of extreme need. Indeed, a widespread reluc- tance on. the part of citizens to use such agencies was borne out in the remarks of many of our informants. Besides these factors, there was also the notion that, on the whole, problem solving in nonurban com- munities might be approached by more traditional, personalized means through contacts resembling primary, rather than secondary, relationships. Finally, there were the findings of several studies con- cerning help-giving in disasters, which indicate that informal and family networks often play a more important role in giving assistance than do formal relief organizations (Drabek 1968) in these kinds of crises. It was hoped the survey would yield information about sources of informal or stopgap crisis counseling on an everyday basis. The data could be of help to persons responsible for such tasks as needs assess- ment, program development, and the recruitment and training of crisis counselors, when needed in time of disaster. In addition to discovering what organizational capabilities exist in the communities in our sample, we were interested in finding out how resources are arranged in each community; there was an effort made to outline typical configurations of resources or typical systems. We were interested in knowing whether certain agencies were invariably present in even the smallest communities, whether certain groups of organizations tend to occur together, and similar questions. We also 47 CRISIS INTERVENTION FOR DISASTER VICTIMS attempted to relate resource configurations and organizational rich- ness to such variables as population size, median community income, and changes in population, to determine whether any of these factors were consistently associated with either presence or absence of com- munity resources. 3. What kinds of crisis intervention and emergency mental health needs exist in the areas under study? In this part of the research, an attempt was made to discover, through the use of community informants, the most prevalent problems and needs in the communities studied. Informants were shown a list of 22 problems and were asked to classify them according to their seriousness for community residents. The problems listed represented a very wide range, from those which would, by any stan- dard, be indicative of mental illness (psychosomatic problems, depres- sion, suicide), through problems which would be sufficiently stress producing to have consequences for the individual’s mental health (marital problems, drinking), and problems in living (housing, unemployment, living conditions). A variety of problems were chosen because of the nature of the subject matter of this study—that is, its dual focus on emergency mental health needs of rural populations and on disaster-related needs, two topics about which little that is defini- tive is known. Relatively little is known about the nature, range, duration, and in- cidence of mental health problems after disasters. Studies suggest that, on balance, disaster victims do experience emotional discomfort as a result of the disaster event, although this stress is not usually seriously incapacitating in the long run. There is also evidence that disaster victims, at least in the short run, see the need for various kinds of tangible aid, listening, and friendly support as more compell- ing than the need for traditional counseling services. This is, of course, the reason for advocating the use in the disaster setting of crisis inter— vention techniques similar to those employed with individuals ex- periencing other kinds of emotional crises, e.g., loss of a family mem- ber. A decision was thus made to cast as wide a net as possible when attempting to obtain judgments on community problems and needs, so that the relative importance of the various kinds of problems might be clearly established. Concerning the mental health and human service needs of popula- tions in rural communities, the research that has been performed has yielded disparate findings. Different methods of needs assessment have been employed, and needs have been defined in a variety of ways. For example, Edgerton et al. (1970) carried out a population survey, 48 STUDY DESIGN administering the Health Opinion Survey (HOS) to a rural popula- tion. This survey, relatively common in needs assessment (see Leighton et al. 1963; and Warheit et a1. 1975, for other rural studies using this method), focuses solely on mental or emotional symptoms, particularly as they relate to stress. Thus, while the survey is excellent for gauging prevalence of psychiatric symptomatology, there are no data on other individual and community needs which might even- tually result in psychiatric emergencies, particularly if exacerbated by disaster or some other community crisis. Another survey (Willie 1972), concerning health care needs in a rural—urban area, used community informants and focused only on the disadvantaged. While the survey did obtain rankings of mental health needs as well as a variety of men- tal health-relevant needs (e.g., ambulatory care needs, needs of the elderly, nutritional needs), these categories were not detailed enough to be truly enlightening. A psychiatrist in rural practice (Guillozet 1975) notes that marital and intrafamilial problems and acute situa— tional crises occur frequently among his patients; however, his generalization is based on treated cases from a single practice. To complicate matters‘further, Huessy (1972) observes that there is a ten- dency for rural areas to underestimate the extensiveness of their men- tal health needs. Other techniques were employed in an effort to obtain information about needs of community residents in disaster and control towns. All informants, both agency professionals and community influentials, were asked to rank “mental health needs,” “social or human service needs,” and “material and financial needs” in order of their impor- tance or urgency in each community. All informants were asked whether there are groups or individuals in the community needing mental health or social services and not receiving them. Reasons were sought in cases where lack of access to services was reported. Finally, informants were asked to judge whether natural disasters and com- munity crises generate a need for counseling by trained personnel. Since the sample includes both disaster-impacted and nondisaster- impacted rural communities, we felt that a number of important ques- tions regarding needs could be answered by means of this approach. It could be determined, for example, how important mental health needs are viewed in rural communities, relative to other needs. The most prevalent problems in rural areas, as perceived by residents, could be identified. It would be possible to learn whether the needs and problems of disaster communities, as judged by informants, differ in number, nature, or degree from those of similar nonimpacted com- munities, and whether emotional or mental health problems (anxiety, depression, and the like) are considered more prevalent or serious in disaster communities. 49 CRISIS INTERVENTION FOR DISASTER VICTIMS 4. What types of crisis intervention and emergency mental health services are delivered in the communities studied? In this phase of the research, we first attempted to learn what kinds of emergency mental health and crisis intervention services are pro- vided on an ongoing basis in the nonurban communities studied. This effort involved learning about whether, and to what extent, it is ac- tually possible to obtain 24-hour crisis care in these areas; which organizations provide these services; what kinds of problems are en- countered; what social and demographic characteristics clients ex- hibit; and what treatment strategies are employed. Second, we attempted to learn whether efforts were made to deliver services of a mental health/crisis intervention nature in the disaster- impacted communities studied. Because the formally organized provi- sion of mental health services in disaster is a comparatively recent and still uncommon phenomenon, we expected to be able to document relatively few cases of this kind. However, we believed that obtaining information on what few programs had been carried out, particularly those in small towns, might provide planners and service providers‘in other areas with insights into the emotional and other needs of dis- aster victims, as well as into strategies of program design and opera- tion. As with rural communities in general, we were interested in know— ing about the nature and types of services delivered in disaster- stricken communities, in who delivered them, to whom, and in response to what kinds of needs. In the disaster-impacted communities we also attempted to discover whether the emergency mental health/crisis intervention services delivered were in any way distinc- tive when compared to those which are normally provided as part of ongoing programs, in terms of such aspects as: (1) who provided serv- ices; (2) what kinds of services were offered; (3) where, when, and to whom they were provided; and (4) by what means they were provided. If outreach, nontraditional methods of therapy, paraprofessionals and volunteers, and the like were used, we were interested in learning whether and why they were thought to be advantageous. Particular attention was paid to whether or not mental health and human service agencies experienced changes along any of several dimensions following the disaster. Whether caseloads changed, whether the nature of problems encountered changed, and whether the nature of the relationships among agencies altered after the disaster were all subjects of the research. Additionally, there was an interest in determining whether any new citizen groups emerged to provide serv- ices of a mental health nature to victims. If such groups were active in disaster communities, we wanted to gain information about the scope 50 STUDY DESIGN of their activities, as well as their relationship to ongoing community agencies. 5. What political, social, transportation, and service boundaries affect accessibility to and utilization of existing services? It is evident that limitations and barriers to the provision of mental health services exist in rural communities that are not present in more populous areas. One such limitation is the paucity of mental health professionals in the nonurban setting; unfortunately, the need for services is, in all probability, not proportionally low. As Guillozet (1974, pp. 249-250) notes: In rural and outlying areas, the struggle to provide acceptable levels of mental health counseling may demand more effort than is required to supply acceptable basic medical care. The distribu- tional problems are more severe with psychiatric care manpower than with primary care physicians. Among 55,000 non-Federal practicing physicians in 1970, there were 16,500 psychiatrists rendering patient care. In 1969, a National Institute of Mental Health (NIMH) survey disclosed that in excess of 96 percent of non-Federal psychiatrists practice in urban areas. An estimated 6,400 practicing clinical psychologists and 4,400 counseling and school psychologists were primarily urban-center based. Rural areas rarely have a tradition of locally available social and mental health services. Notwithstanding the availability of funds from State as well as Federal sources, in many instances, rural communities rarely demand these services that are tradi- tionally available to urban areas. More than one-fourth of the Nation’s population resides in towns of under 2,500. This signifi- cant minority shares the stresses of the American population as a whole and bears its share of disrupted marriages and family dis- solution. Indeed, rural areas have an unusually high proportion of low-income residents, as well as the special problems of agriculture-based economics during times of rapid inflation. Those residents of rural areas and small towns wishing to avail themselves of mental health services must also contend with the bar- rier posed by distance. Because of the scarcity of resources in many nonurban areas, their scattered nature, and the relative lack of development of public transportation, those who are far from services may not even be aware of them, much less utilize them. Additionally, distance almost certainly provides the greatest barrier to those per- sons who may most need services: the old, the poor, and individuals and families with multiple problems. Distance is a variable believed to 51 CRISIS INTERVENTION FOR DISASTER VICTIMS be extremely important for the understanding of patterns of utiliza- tion of healthcare services of all kinds. In the area of rural mental health, Cohen (1972) found distance to be a significant factor affecting use of outpatient services in a rural mental health center serving a large catchment area. Use of outpatient services was reduced by 50 percent at a 30-mile distance from the center and 66 percent at a dis- tance of 60 miles. He concluded that “at distances of 30 miles or more from the center, utilization rates for outpatient services were likely to drop from 50 to almost 80 percent” (Cohen 1972, p. 80). He added, however, that community attitudes toward mental health also had an effect on utilization, regardless of distance. (For a more comprehen- sive treatment of research on the influence of distance on health serv- ice consumption, see Miller 1974.) Lee, Granturco, and Eisdorfer (1974, p. 339) also cited negative at- titudes toward mental health services as a major factor leading to nonutilization of mental health services by rural poor and concluded that: Despite 4 years of full-time operation and 12 years of consulta- tive work, the comprehensive community health center is still not viewed as a major resource for problem solving by lower—class poor in the catchment area. Problems of the delivery of mental health services to the community are not only related to the geographic propinquity, temporal availability, and the visibility of the center, but also to clients’ definition of what constitutes mental health problems and their fear of being identified as men- tally ill. This research was designed, in particular, to gather information about this last-mentioned area: the social and attitudinal factors which influence access to mental health services in rural areas. We at- tempted to determine whether social barriers of any sort exist which would act consistently to exclude certain individuals or groups, be they particular age groupings, members of ethnic groups, foreign- language groups, or socioeconomic groupings. We also attempted to determine whether general community attitudes toward mental ill- ness and mental health services tend to influence utilization patterns. Barriers and boundaries discouraging use of service such as those mentioned above——shortage of trained personnel, distance from facilities, poor transportation, social exclusion, attitudes about mental illness, stigmatization—are all relevant to the disaster setting, because disasters have the potential for intensifying many of them. Thus, we felt that knowledge about the extensiveness of such limiting factors in rural communities during nondisaster times would have 52 STUDY DESIGN direct implications for disaster planning as well as for strategies of service delivery during the postdisaster period. 6. How effective are the services delivered to meet existing emergen- cy mental health/crisis intervention needs in the areas studied? Massive funding would be required to evaluate the effectiveness of emergency mental health and crisis intervention services in rural areas. We could not attempt to perform this task comprehensively and definitively within the scope of this research project. A decision was made that it would probably be most useful to at- tempt to obtain data on the effectiveness of programs which were devised in disaster-stricken communities to meet disaster-generated needs. This was done by gathering information about the appropriate— ness and efficacy of these programs from a variety of sources. These in- cluded personnel involved in the programs, other mental health and human service professionals, community leaders, and consumers of services. It was our intention to devise a set of generalizations and recommendations about the modes of service delivery that seem to work best in disasters. Methodology The Sample In selecting a sample of communities in which to carry out the research, several considerations were involved. First, in recognition of the fact that US. communities differ in their vulnerability to disasters, a sample of communities had to be developed which would include communities of moderate to high disaster vulnerability. Thus, an early step was to identify high-risk areas in the continental United States. Second, since the research specifically concerns localities outside ur- ban areas which have recently experienced disasters, it was necessary to locate communities within high-risk areas which were both rural and disaster stricken. A complete list of localities impacted by dis— asters during the chosen year was obtained from the 1975 Red Cross listing, “Earthquakes and Weather-Related Disasters Affecting 75 or More Families.” One problem in this stage of the research was that of developing an operational definition of “rural” which would be relevant to our research concerns. The Census Bureau classifies rural areas on the basis of size; yet, for several reasons, community size alone was not a useful criterion for the purposes of our research. One reason, of course, is that the research involves community responses to real and poten- tial disasters. Disaster occurring in the sparsely settled open country, 53 CRISIS INTERVENTION FOR DISASTER VICTIMS while perhaps devastating to the isolated forms or settlements, does not affect large enough numbers of persons to be considered disaster in the social sense of the term. Another reason is that our focus on com- munity resources requires that we conduct research in localities with sufficiently large populations to provide at least rudimentary human services on the local level. Of equal importance was our awareness that what we were actually seeking was information about the quality or style of life in nonurban areas, rather than merely data from communities of less than 2,500 in- habitants. Few, if any, established guidelines exist for making this kind of distinction. We felt strongly that residents of a town of 2,500, located 5 or 10 miles from a metropolitan center, might be much more cosmopolitan in outlook and might have access to many more resources than residents of a community of 15,000 in a predominantly rural State, or residents of a community of 20,000, 80 miles from a large city. As Smith and Zopf point out (1970, pp. 23-24): Nothing seems more apparent than the contrast between the city and the country. However, one who attempts to set forth the specific differences between the city and the country, to dis- tinguish accurately between rural and urban, is inevitably con- fronted with some serious difficulties. . . . Regardless of the basis selected for the differentiation, usually some inconsistency or weakness in the scheme will appear. . .distinctions made on a basis such as the size of the community, legal incorporation or the lack of it, the possession of a charter. . .may be quite inade- quate for sociological purposes. Thus, we concluded that what we were in fact seeking was informa- tion about needs and resources in communities characterized by a relative absence of urban dominance—that is, communities 50 or more miles from a large city—together with a relative lack of specialized mental health services. Once we had located communities of this kind which had ex- perienced natural disasters of several types (tornadoes, hurricanes, floods), we then matched these communities with nondisaster, or con— trol, communities in the same States that were similar along a number of sociocultural dimensions which we anticipated would be relevant for both community needs and resources. These variables were: 1970 population; 1960 to 1970 population change, median income, distance from nearest federally assisted comprehensive community mental health center, percentage of white population, and economic base. Reasonably good fit was obtained between disaster and nondisaster communities. Greater accuracy in matching was not possible, given 54 STUDY DESIGN Table 1. Sample communities 1960-1970 Mental 1970 Population Median Health Percentage Economic City Agent Population Change Income Center White Base Minot, ND, River 32,290 +55% 9355 in community 99% Schools Flood Hospitals Bismarck, ND. Control 34,703 +25.4% 9756 in Community 99% Manufacture Schools Charleston, Mo. River 5,131 43.2% 5241 30 miles 70% Wholesale Flood Manufacture Hay‘ti, Mo. Control 3,841 +28% 5025 20 miles 68% Wholesale Professional Panama City, Hurricane 32,096 3.5% 7292 in community 75% Manufacture Fla. Flood Public Admin. Fort Pierce, Fla. Control 29,721 +17,6% 5825 in community 50% Agriculture Construction Eagle Pass, Tx. Tornado 15,364 +27.0% 4370 none Spanish Manufacture 96% Retail Uvalde, Tx. Control 10,764 +46% 5853 none Spanish Retail 55% Construction Warren, Ark. Tornado 6,433 4.7% 5820 40 miles 65% Manufacture Wholesale Hope, Ark. Control 8,830 +49% 5876 60 miles 66% Wholesale Manufacture Canton, ill. Tornado 14,217 +4.69% 9437 30 miles 99% Manufacture Entertainment Monmouth, 111. Control 11,022 +62% 8732 30 miles 99% Manufacture Retail the number of dimensions employed and the additional criteria. (See table 1 for the listing of the sample communities and their sociocultural characteristics.) In addition to conducting research in these 12 sample communities, DRC studied 5 other disaster-impacted small towns. Two of these—a midwestern town with a population of 5,000 and a border-State town with a population of about 1,600—sustained major damage in the massive April 1974 outbreak of tornadoes. These two communities were of particular interest because, in both cases, there had been an organized effort to provide mental health services to disaster victims. Field studies were also carried out immediately after impact in three communities which experienced disasters early in 1977. This group of communities consisted of a midwestern town of 12,000 and an eastern community of 30,000 which were overwhelmed by the blizzards of January and February 1977, and a small Appalachian mining community inundated by flood waters in April 1977. In these three communities, our interest was in determining, through firsthand observation, whether and to what extent emergency mental health/crisis intervention services were contemplated or actually delivered to victims. The final aggregate of communities was one capable of supplying information on a number of salient topics. First, from the 12 matched communities came uniform, quantifiable data on perceptions about 55 CRISIS INTERVENTION FOR DISASTER VICTIMS the resources available for emergency mental health/crisis interven- tion services in nonmetropolitan areas; perceptions concerning mental health and other community needs in impacted and nonimpacted localities; evaluations by professionals and community leaders of the adequacy of local mental health and human services, and also of com- munity awareness of these services; and a number of other subjects. Second, from those small communities which had in the past ex- perienced disaster came general observations about helping behavior in disasters in addition to information about the most common emo- tional problems encountered and conclusions about what kinds of problemsolving methods actual service deliverers found most effec- tive. From the recently impacted communities came additional obser- vations about the perceived emotional needs of victims and about available community resources, together with information about the perceived importance of mental health services in the immediate postimpact period. Data Collection 7 Since the inception of DRC in 1963, research teams have been in— volved in some 35 field studies of disasters in the United States and overseas. A typical DRC data collection strategy involves sending teams of field personnel to the site of a large-scale disaster while the response is ongoing, in an effort to obtain firsthand data about com- munity response to the emergency. Indepth interviews are subse— quently conducted with personnel responsible for various phases and aspects of the disaster response, and other data are gathered. Products of DRC research include papers and monographs, in addition to reports, journal articles, books, and a newsletter devoted to broad problems of disaster preparedness and response of interest to those in disaster planning and operations. In the research on emergency mental health/crisis intervention needs and resources, the same basic procedure was followed: Teams of trained interviewers traveled to the communities in the sample and conducted interviews with key community personnel, spending up to 1 week in each community. Interviewers contacted agency heads in all major mental health and human service organizations and ad- ministered an open-ended interview guide covering the areas dis- cussed above. Field workers also determined whether other auxiliary resources, indirectly related to mental health, were present in each community (e.g., Alcoholics Anonymous, Senior Citizens Programs, Red Cross), interviewed representatives of some of the organizations, and prepared an “Inventory of Community Mental Health and Human Service Resources” for each community studied. 56 STUDY DESIGN Community leaders were also believed to be important sources of information on community needs and resources. Field workers were instructed to contact persons in each community reputed to be influen- tial sectors, such as religion, law and the courts, city government, education, and the medical sector. A particular effort was made to contact persons who might, by virtue of their positions, be knowledgeable about the extent and types of emotional crises ex- perienced by community residents. Physicians in family practice, hospital emergency department personnel, juvenile court judges and probation officers, law enforcement personnel, health department officials, and lawyers were among the kinds of persons sought out. Community leaders were given the portions of the interview guide concerned with emergency mental health needs and resources and with rating service adequacy. They were also used as sources of infor- mation on community attitudes toward mental health and on patterns of service utilization. In the communities stricken by disaster in 1974, key persons who developed programs and delivered services to meet victims’ emotional needs were interviewed about all aspects of the organized attempts to provide mental health services, including their perceptions about the effectiveness of these efforts. In the three communities impacted dur- ing 1977, workers interviewed members of organizations involved in immediate relief efforts, persons working in mental health facilities (where these were present in the community) and other persons ac- tually or potentially involved in counseling victims, e.g., clergy and social service workers. A total of 147 indepth interviews were conducted in the 12 sample communities over a period of 7 months in 1976-77. Additionally, ap- proximately 50 unstructured exploratory intervieWS were conducted in the other communities, all during 1977. While they were conducting field work in the 17 communities, DRC workers also attempted to collect community statistics considered to be indirect indicators of the mental health needs of community resi- dents. It was believed that, through the analysis of such data, some generalizations could be made concerning possible crisis intervention needs in disaster and control communities and that these indicators could be compared to determine whether they showed any difference in magnitude. Examples of statistics sought include: divorce and unemployment rates; welfare caseloads; mental health and social service agency caseloads; arrest and court records; records of school absenteeism; drug sales; records of hospital emergency department visits and hospital admissions. 57 CRISIS INTERVENTION FOR DISASTER VICTIMS A number of problems were encountered in this phase of the research. Much of the information collected from the 12 sample com- munities was not useful for purposes of comparison. Often, needed data were simply not available in any form. When information did ex- ist, the form in which it was recorded frequently did not permit com- parisons among communities; moreover, even though the research focused on records of events that were relatively recent, primary records had often been destroyed, and, therefore, statistics could not be converted into comparable form which would allow for cross-com- munity comparisons. Additionally, it was common for organizations to radically change their recordkeeping procedures over time, further confounding efforts toward obtaining uniform data. Organizations tended to use data classifications unsuitable for the purposes of the research. Gaps existed in the records of some agencies, sometimes simply because they did not have a permanent recordkeeper. (Many such agencies were very small, with only two or three full-time employees.) Access to some records was refused on the grounds of client confidentiality and even, in one case, because the organization in question was involved in a lawsuit at the time. Thus, despite con- siderable effort, we were unable to assemble indices capable of yield- ing comparative, quantitative data on the sample communities. In summary, the data-gathering problems can be traced back to numerous factors: In the majority of US. communities, both large and small, mental health and social service agencies do not cooperate to engage in the systematic, ongoing collection of comparable client data. Across the spectrum of US. communities, there is great variety among agencies in recordkeeping practices. Differences in terminology and classification of client problems abound; variety, not uniformity, is the rule. Organizations vary widely in the extent to which recordkeeping is a priority. In small, direct-service agencies, for example, recordkeeping is one of the first functions to be suspended in times of high demand for their services or when cutbacks in funding occur. Both agency and other community data had been collected for pur- poses other than this research. This meant, of course, that the data were kept in categories and classifications different from those which we would have preferred, but, more importantly, it meant that little was known about the accuracy and reliability of the various statistics. We believe that these data-gathering difficulties merit mention here because the great variety and unevenness in recordkeeping practices, both within and across communities, constitute an obstacle which other planners, service deliverers, and researchers will have to over- come. Those interested in assessing mental health needs in rural 58 STUDY DESIGN areas, those involved in developing emergency mental health programs, and those engaged in evaluating the effectiveness of ongo- ing programs should be mindful of the difficulties inherent in using data which have already been gathered for other purposes. Advantages and Disadvantages of the Research Design This research project broke new ground by attempting to systematically study disaster-related crisis intervention needs and resources in America’s small towns and rural areas. Research find- ings, however, are only as good as the methods used to obtain them. We believe that, for this research, the strengths of the strategies adopted outweigh the weaknesses. One advantage of the design is its attempt to focus on the need for services in the communities studied as opposed to the demand for such services. In other words, we tried to learn about the needs that exist, independent of both the supply of services and of data on who is utiliz- ing those services that exist. Demand for, and utilization of, services are affected by many factors besides need, and for program-planning purposes it is important to gain knowledge about the nature and range of services actually required or desired by the population—knowledge which is not influenced‘by the supply of services. The perceptions of knowledgeable community members were used in obtaining data on typical community problems, and wide latitude was allowed for the identification of needs. This, of course, made possible the discovery of community problems and needs which may not have been anticipated beforehand and which otherwise might have been overlooked. The polling of community informants is also advan- tageous in that it is inexpensive, when compared to population survey methods, and it can be accomplished in a relatively short period of time. Conducting field work in the sample communities was useful because it provided researchers with some firsthand knowledge of community life. Face-to-face contact with agency personnel helped researchers to appreciate the challenges of providing mental health and human services on limited resources. Also, there was the oppor- tunity to discuss disaster-related mental health programs with per- sons who had been involved in developing and implementing such programs. Perhaps the most significant advantage of the design is its compara- tive focus. The research design allows for comparisons to be made along a number of dimensions—between disaster and control com- munities, and between the perceptions of professionals and those of 59 CRISIS INTERVENTION FOR DISASTER VICTIMS community leaders, for example. Through the selection of disaster-im- pacted and nonimpacted communities, it is possible to determine whether or not disaster experience sensitizes community residents to questions of disaster mental health and to see whether different needs are cited as crucial. One possible weakness of the research design is that field studies were conducted some time after disaster impact—as long as 2 years after the disaster event for some communities. Memories, no matter how vivid at first, fade rather quickly, and there is a tendency for in- dividuals to interpret events retrospectively and to remember selec- tively. Fortunately, in this research informants were not required to recall or reconstruct chronologies of postdisaster events or to report extensively on their own or others’ past activities. Rather, the ques- tions were of a general nature. Thus, while not eliminated, problems surrounding long-term recall were somewhat reduced. Another possible drawback of the design involves the use of inform- ants to report on mental health-related community needs. Inform- ants are one step removed from the population experiencing the needs, thus introducing the possibility of selective perception, bias, and outright distortion. A survey administered to a random sample of the population of each community would have been a good instrument for assessing community needs; however, budgetary constraints and the overall scale of the research precluded .the use of this kind of V survey. Additionally, we believe that qualitative research of the type conducted in this study is perhaps better suited to the exploratory stage of research than are survey methods. Another reason for using community informants in this kind of research is that their perceptions concerning community needs—- especially the perceptions of community leaders—help determine the number and types of services that come to be offered in a community as well as who uses them. Thus, the impressions community leaders have about the need for crisis intervention or other mental health services after disasters, or about the relative importance of mental health needs in their communities, may ultimately have more impact on the provision of disaster-related mental health services than will the actual needs of victims. While we would be even more confident about the research findings if they were supported by large quantities of community-level statistics, in many cases, as indicated above, these kinds of figures were simply not available in usable form. A reduction in the scale of the study, to focus in depth upon a small number, might have yielded a few community-level indices with possible mental health relevance. This option was rejected in the interest of comprehensiveness, repre- sentativeness, and comparability of findings. 60 STUDY DESIGN What the Research Can and Cannot Tell Planners and Practitioners The findings of this study are, of course, preliminary and are limited to the group of communities studied. However, the conclusions and recommendations are of a sufficiently general nature to be widely applicable in the disaster context. The study’s findings should be a good source of information about perceptions that informants in small U.S. towns now have about community needs in general and disaster- related mental health needs in particular. The findings also present a clear and comprehensive description of the nature, types, and arrange- ment of mental health and human service resources available for ameliorating needs in the areas studied. Additionally, material of both a general and specific nature is included, which should be of help to those responsible for planning and implementing programs for the delivery of crisis intervention/emergency mental health services to communities stricken by disaster. This monograph does not attempt to definitively settle the question of the impact of disaster on the individual psyche. So far, we have at- tempted to supply some information about what kinds of emotional and emotionally related problems typically occur in the aftermath of disasters and how some communities have dealt with them. More important, this study cannot tell the local mental health planner or practitioner specifically what kind of crisis intervention program should be instituted in a given area to deal with disaster-re- lated needs. As has already been discussed, communities differ in their characteristics, and disasters differ in their impact to such a degree that one ideal plan cannot, and probably should not, be devised. Local personnel must be flexible, on the basis of local realities, in deciding what kinds of services to provide and how best to deliver them. In all probability, their decisions will be based on a variety of factors, in- cluding the geographic, demographic, and sociocultural charac- teristics of the impacted area; the extensiveness and severity of the damage; immediate needs of victims; the characteristics of the existing organizational networks; the availability of community resources, especially trained personnel; and the potential for additional funding. What the findings, conclusions, and recommendations collected in this report can offer is valuable input into these types of decisions. In- put will be provided in later sections through the report’s emphasis on: 1. Relating what others have done and found effective in the postdisaster setting 61 CRISIS INTERVENTION FOR DISASTER VICTIMS 2. Suggesting general rules and strategies for delivering mental health services in rural communities 3. Discussing several options that are open to local personnel in- terested in launching a postdisaster mental health recovery effort 4. Providing information on where to seek additional technical assistance and support for local efforts In the chapter that follows, we report data concerning the ongoing and disaster-related needs of rural populations and the resources which now exist to meet these needs. This information will, in turn, serve as a basis for later recommendations which can be put into practice in the local setting. 62 Chapter V EMERGENCY MENTAL HEALTH AND CRISIS INTERVENTION NEEDS AND RESOURCES IN 12 U.S. TOWNS As previously stated, one major goal of this study was to obtain baseline information about community resources in rural areas that are either directly or indirectly supportive of mental health, par- ticularly those resources capable of providing emergency mental health services. Baseline data on resources were gathered because we believe that, while postdisaster community problems may be both quantitatively and qualitatively different from predisaster problems, the two are not entirely unrelated and because, given this fact, it seems most practical for communities to plan for a disaster—related mental health response that builds upon existing capabilities. Building upon existing resources in community emergencies may seem a simple, obvious suggestion; yet to understand how this might occur in a disaster situation, it is necessary to understand how com- munities actually respond in disasters. The occurrence of a disaster places great demands on the com- munity affected. Some of these demands are entirely new, the need for large-scale search and rescue, for example, and some represent quan- titative increases in old demands such as the care of the sick and in- jured. Whether old or emergent, these demands mean that the com- munity has a new and different set of tasks to perform, many of them extremely urgent and all of them taking place in an atmosphere of un- certainty. In order to carry out these tasks, new groups emerge, and novel forms of organization are improvised; often, innovative ways of doing things are discovered, and untraditional patterns of authority and decisionmaking become evident. For this reason, people tend to believe that communities react to disaster in an unorganized manner. Rather than being characterized by total lack of organization, the postdisaster community scene manifests new forms of organization that emerge to respond to disaster-generated demands. The emergence of new forms of organization to deal with the new community subtasks created by the disaster agent is often accompanied by the creation of new community resources. Food, clothing, and personnel are sent to 63 CRISIS INTERVENTION FOR DISASTER VICTIMS the community from the outside, for example. It is equally typical, however, to see existing community resources mobilized into different areas to meet new demands. A high school gymnasium is designated as an emergency shelter; nurses from the general hospital work as Red Cross volunteers during the emergency period; corporations volunteer employees to work as cleanup crews; and so on. Thus, while the postdisaster period evidences much that is novel in terms of organiza- tion, resources previously present in the community constitute impor- tant building blocks in the organized disaster response. Moreover, the main challenge many communities face after disaster is not a shortage of resources but rather the need for integrating and coordinating the resources that are on hand. (See Dynes, Quarantelli, and Kreps 1972, for a more thorough discussion of the emergent community system and its relationship to disaster planning.) Use of existing resources in planning for, and implementing, a men- tal health response to disaster may be even more important in the rural than in the urban area. While our findings show that the areas in which research was conducted are not impoverished organizationally, usually more facilities and personnel are needed them are available, and many community agencies, particularly mental health agencies, are functioning to capacity during normal times. Thus, it appears that in emergency situations rural areas and small towns can ill afford to waste the mental health and human service resources that do exist and, therefore, should make a special effort to see how they might be mobilized. Just as with other community sectors, planning for the mobilization of psychological supportive services can make a great difference in the adequacy and effectiveness of disaster-related mental health services. Of course, community resources of a mental health and human service nature need not be viewed as existing only in agencies carrying those kinds of labels. For this reason, our research focuses not only on established organizations, but also on informal caregiving networks in the communities studied. We did, however, begin our study of com- munity resources by attempting to gain a thorough understanding of the state of existing organizational capabilities in each community. Scoring the Communities We divided community resources under the rubrics of Mental Health and Human Services. What we termed “mental health resources” are those agencies or individuals, with formal mental health training, designated as providers of mental health services. By 64 NEEDS AND RESOURCES IN 12 US. TOWNS community mandate, they have a clear-cut and central responsibility for the promotion and maintenance of mental health through the pro- vision of services that are generally defined by traditional psychiatric treatment models. Since the passage of the Community Mental Health Act of 1963, all governmentally funded centers, as well as a number of privately funded clinics, have defined their treatment more specifically in terms of the 10 essential service categories outlined by the Act. These are inpatient care, outpatient care, emergency services, services to those partially hospitalized, consultation and education, diagnosis, rehabilitation, precare and aftercare of the hospitalized, training, and research and evaluation. While the research was in progress, the numbers of essential serv— ices to be provided were increased, and the categories were somewhat modified. Our research design was, nevertheless, appropriate, since, at the time of the study, community mental health centers were still adhering to the older guidelines. The services now designated as essen- tial are aftercare, alcoholism services, children’s services, consultation and education, day care, drug abuse services, emergency services, geriatric programs, prescreening, rape crisis services, transitional care, and 24-hour services. Human service resources are represented by those agencies and organizations which are mandated to meet a wide variety of social, economic, and cultural needs, from income maintenance and family and child welfare, through recreation, law enforcement, and help for special populations such as minority groups and the elderly. The serv- ice domains of these resources often overlap with mental health, and, in the process of dealing with the problems presented to them, they may exercise a counseling/supportive/therapeutic capacity that con- tributes to mental health. Particularly in rural areas, where desig- nated mental health resources are relatively scarce, we expected that other community agencies might be providing a great deal of day-to- day services of a mental health nature. These two groupings, mental health and human services, were looked at separately and together in order to comprehend the overall pattern of resources in the communities studied, as well as the inter- relationships among them and the effects of their combined efforts in behalf of mental health. Initially, we developed a list of 12 mental health and 18 human service resources which included the many types of agencies commonly found throughout the country. In each of the six disaster and six con- trol towns a resource inventory was taken. Additional resources were also recorded when found. This inventory yielded typical configura- tions of the kinds of mental health and human service resources found in our sample and likely to be found throughout rural America. 65: CRISIS INTERVENTION FOR DISASTER VICTIMS In addition to simple presence or absence in a community, each item on the list was also inventoried for program, that is, for the range of services each resource provided. To aid in the comparison of one town to another and of one type of service to another within a given town, a scoring system was devised. Each item was given equal weight, with a potential score of five. We recognized that some items are more significant for mental health than others; however, of necessity, we limited our efforts to measuring the quantity of services, the evalua- tion of their quality being far beyond the scope of this project. Mental health resources were scored separately from human service resources and then totaled, giving three sets of scores which could be compared differentially. The maximum possible score for mental health was 60, for human services, 90, with 150 possible for a total community score. All scores were converted to percentages for purposes of standardized comparison. We found that the inclusiveness of the inventory list and its sen- sitivity to the nature of the direct and indirect services provided made this a reliable method of assessing the general level of the overall range of services, with a scoring system sufficiently sound to enable us to draw general conclusions from the data. Our next step was to obtain frequencies and configurations for each type of service provided by each resource, with a special eye toward those types of services which are potentially most useful for crisis in- tervention and emergency mental health programs. For example, we wanted to see which agencies offered, and how often, direct rather than, or in addition to, indirect services—emergency services as op- posed to information and referral. We also tried to determine if the patterns of service provision varied from the six disaster towns to the six towns in the control group. The final step of our analysis was to take a closer look at those six communities which had experienced a disaster, to identify those agen- cies which had helped victims, and to examine the nature of these relief efforts. Mental Health Resources in the Areas Studied Common Patterns of Resources The most prevalent constellation of mental health resources in the 12 communities studied is a combination of a general hospital which, in some manner, treats psychiatric patients, a hotline and/or an alcohol substance abuse program, and either a federally funded, a county-administered, or a satellite community mental health center. This is the pattern in 7 of the 12 communities. Some of the seven have 66 NEEDS AND RESOURCES IN 12 US. TOWNS more types of resources or more than one of the types mentioned above, while the remaining five have fewer. Table 2 depicts graphically what we found. Table 2 Configuration of mental health resources Disaster Control Public mental hospital Private mental hospital General hospital with psychiatric facilities X X X X General hospital that treats psychiatric patients X X X X X X X X X X Drug alcohol program X X X X X X Hotline X X X X X X X Federally assisted CMHC X X X X X State/County CMHC X Satellite CMHC X X X Outpatient MH Clinic X X X X Children’s residential facility College health center X X X X Other X As can be seen, the most nearly universal mental health resource is the general hospital. Ten of the communities have a general hospital which treats mentally disturbed patients, though it does not have psy- chiatric facilities. The hospitals in four of the communities do have specialized psychiatric facilities, while three of the towns have both types of general hospital. Only one town has neither. None of the com- munities has either a public or a private mental hospital within the immediate vicinity, although one community is only about a half- hour’s drive from the nearest State institution. The next most common resources are the hotline, or telephone crisis counseling service, and the alcohol/substance abuse program. Four towns have both, five have one or the other, while the remaining three have neither. 67 CRISIS INTERVENTION FOR DISASTER VICTIMS Community mental health centers with various funding and staff- ing levels are fairly common, appearing in 8 of the 12 towns. For- tunately, the most frequently found type—the federally assisted com- munity mental health center—is also generally the most liberally funded and sophisticated. We found only one community mental health center and three satellites administered by the State/county. One of the larger towns in our sample has both a federally assisted center and a satellite which brings mental health services close to those who might have trouble availing themselves of the main center. In the other two communities the satellites are branches of larger com- munity mental health centers located elsewhere in the same county or in a neighboring county. Operations in satellites like these tend to be limited. Most of the staff are part-time, usually driving from the main center to man the satellite a few days per week, while what full-time resident satellite staff do exist are usually spread so thin they can meet only the most emergent of needs. We found certain instances, for ex- ample, of some professionals from a relatively distant agency coming to town as infrequently as once every 2 weeks to provide mental health services, often of a specialized nature. The quantity of actual service was so slight in these cases that we could not deem them “resources” in and of themselves, and, therefore, they do not appear on the table of configurations. We did, however, include these services in our tally of the frequency with which 10 specific mental health services were offered by the various kinds of mental health resources in each town. As the table shows, private outpatient clinics or mental health cen- ters and college health facilities were distributed unevenly in half of the sample. None of the communities has a residential treatment facility exclusively for children. There is no apparent relationship be- tween the presence of private resources and that of community mental health centers. In the overall supply of mental health resources in all 12 categories, we find no significant variance between disaster and control towns. In sheer numbers of existing agencies, disaster and control communities were identical, each group having 22. Evaluation of Mental Health Resources Gross totals on numbers of resources give no indication of the rich- ness of the program of each one or of the overall supply of mental health services available in a given town. Our next step, therefore, was to examine the nature, the number, and the general availability of the services provided by each resource. As explained earlier, a scoring 68 NEEDS AND RESOURCES IN 12 US. TOWNS system was devised assigning each resource equal weight, with a po- tential score of five. The maximum possible score for the 12 mental health resources was 60. When scores were obtained and converted to percentages, a distribution appeared. Scores tend to fall on the lower half of the range, with an average score of 25.5 percent. Table 3 Distribution of sample communities by percentage of total possible mental health score Scores Number 0 - 10% 2 11 - 20% 4 21 - 30% 3 31 - 40% 0 41 — 50% 2 51 - 60% 1 61 - 100% 0 On the whole, the picture looks somewhat better than the scores would indicate. To begin with, it is highly unlikely that any com— munity—rural or metropolitan—with the exception of the very largest, will possess all the possible types of mental health resources. The mental health profession has long advanced and has empirically supported the concept that institutionalization is not the preferred mode of treatment, except at a certain stage of mental illness. Even then, it seems feasible that the availability of a well-equipped general hospital providing appropriate facilities and psychiatrically trained personnel would usually meet local needs for inpatient care. In the communities studied, the findings indicate that most do have hospitals which make some effort to meet the needs of short-term psychiatric pa- tients. Nationwide, however, unpublished preliminary data from a re- cent study of 1,500 community mental health center catchment areas show that only some 40 percent had inpatient facilities that were both accessible and available to the population in these areas.1 A com- parison across rural-urban status categories is not yet available for comparison with our data. With regard to outpatient and counseling services, the situation is somewhat less encouraging. Just as a small-to—intermediate-sized town does not need both a private and a public mental hospital, it would also not need, or be able to support, several comprehensive community mental health centers. There is evidence, however, that many people both need and want a fuller range of services available 1“A Study of Deficiencies and Differentials in the Distribution of Mental Health Resources and Facilities,” University of Maryland, 1977. .69 CRISIS INTERVENTION FOR DISASTER VICTIMS from a comprehensive center than is now either accessible or availa- ble. Caseloads at many agencies are growing to the point of overload, and our findings indicate that a significant proportion of the respond- ents rate their local mental health agencies as inadequate in terms of accessibility and available staff time. Better than half of the towns in our sample had some sort of community mental health center and/or private facility. The low scores, however, indicate that this is not enough to meet needs even in those towns which have such facilities. Community Assessment of Mental Health Resources Representatives of the mental health and the human services professions and community leaders in each of the towns studied were asked to assess the level of mental health services in their com- munities and the level of awareness of these services among the general public. In general, about half of the respondents rated local services as “adequate.” Mental health professionals and community leaders were slightly more likely than human service professionals to rate services as adequate or better. Favorable responses were not universal among mental health workers, however, as about 40 percent openly stated that local services could and should be doing more than they are. The responses of community leaders are noteworthy in that they consistently more highly assess the level of mental health services in their communities than do members of either profession. The remarks of some agency workers suggest that such positive evaluations may be a form of “boosterism” or, perhaps, a denial of problems In at least one community, a professional believed that the local political struc- ture is such that both mental health and social services are systematically discouraged because the politicians feel they neither want nor need them. In another, a mental health professional stated: . .in a small community like this, mental health is a back door and mental health takes a back seat to everything, and nobody wants to admit anybody has any mental health problems. They. . .particularly the power structure. . .deny the fact that there is any such problem existent, or if it is existent they don’t care what happens to it as long as nobody mentions it in public. And they will not grant the local match money generally. . . . There appears to be more criticism of mental health services in dis- aster towns as opposed to control towns, particularly among members 70 NEEDS AND RESOURCES IN 12 US. TOWNS of the mental health profession. Even though these resources in dis- aster communities scored slightly higher, ratings of adequacy are sig- nificantly lower among all three groups of respondents. It could be that the services in communities affected by disasters, having been put to a more severe test, have been found more lacking, or at least more disappointing. These differential ratings may also be the result of a phenomenon noted by Wright (1978), which is the tendency for at- titudes about disaster-related organizations to become polarized simply because the organizations have become more visible as a conse- quence of aiding victims. Thus, while mental health and human ser- vice agencies have supporters, their increased publicity also means they have critics in the community. Criticism sometimes focuses on lack of financial and political sup— port and sometimes on shortages in professionally trained personnel. Most often, however, it has to do with low levels of community aware- ness of, knowledge about, and subsequent utilization of mental health services. More than half of all respondents said that awareness was “low,” more than a fourth answered “moderate,” leaving only small percentages who felt awareness of local services was “widespread.” Mental health professionals, followed by human service professionals and then community leaders, rated awareness levels lowest. Various reasons were put forth to explain the lack of awareness. One worker said, “. . .there’s not a great deal of visibility of some of the needed resources like mental health, and I think there’s a reluctance on the part of people to understand all they do. . .so they tend to be somewhat ignorant of what they do.” Others said that the poor were too busy just surviving and the mid— dle class too busy evading their emotional problems to attend to infor- mation on available services. More than one professional recognized that many people were not getting help, nor would they unless out- reach was built in as a component of mental health programs. Following the pattern observed in measuring adequacy levels, we found awareness to be rated generally lower in disaster as opposed to control towns, with the exception of mental health professionals who seemed to feel that half of the population in their communities had at least a moderate awareness of local mental health services. In order to explain both the somewhat low resource scores and per- ceptions of service and awareness levels, as well as to identify those strengths which might be built upon in planning crisis intervention and emergency mental health services, we tallied the frequencies with which specific services were provided by mental health resources, par- ticularly the clinics and counseling centers. It seems that all com- munity mental health centers, private clinics, and college health facilities devote the major part of their resources to direct services to 71 CRISIS INTERVENTION FOR DISASTER VICTIMS meet the ongoing and emergent needs of clients. If a person has a cur- rent mental health problem and goes to one of these agencies, he will be helped in some fashion, since almost every single agency offers out- patient and emergency counseling services. In the event of a disaster, these agencies have the expertise and manpower to mobilize and supervise a mental health relief effort. Generally, fewer efforts are made on behalf of prevention. Com- munity mental health centers are required to provide, or to be working toward, provision of the 12 essential services, many of which are pre- ventive in nature.2 Unfortunately, ever-present shortages in funding and in trained personnel, as well as an understandable tendency to give priority to ongoing programs, severely restrict those efforts and activities. Most of the mental health programs we observed were experienced in providing the consultation and education that can be helpful in an advanced planning process. Through such consultation and educa- tion, agencies can build community knowledge about mental health and related problems that might arise in the wake of disaster, and can urge support for the planning and provision of crisis intervention and emergency mental health services that will be ready as the need arises. Most mental health centers also have the capacity for training volun- teers and paraprofessionals for crisis intervention. Such auxiliaries are not only necessary in mass emergencies, given the shortages in professional staffs, but have been shown to be among the most effec- tive providers of emergency counseling in both disaster and everyday situations. The frequency with which we observed the existence of hotlines, especially of the 24-hour, crisis-oriented variety, was encouraging.3 In disaster, there is need for a well-known, easily accessible source of in- formation and short—term intervention that can channel affected peo- ple toward that part of the system which best meets their needs. The relatively low cost and simplicity of operations make hotlines feasible in communities with limited financial resources. However, orientation and supervision of hotline volunteers should be requirements in set- ting up any such resource. Zln 1975, legislation was introduced amending the Community Mental Health Centers Act, increas- ing the number of services termed “essential.“ 3Such 24-hour emergency services have been one of the long-mandated requirements for federally supported community mental health centers. 72 NEEDS AND RESOURCES IN 12 US. TOWNS Mental Health vs. Other Groups as Caregivers; Common Patterns of Human Service Resources The configurations of human service resources are similar across the entire sample. Each town has, to some degree, almost all of the items specified on our inventory list. Physicians and the Red Cross were found throughout. Eleven towns have a welfare department, a family service agency, a senior citizens agency, agricultural extension agents, a ministerial association, and a law enforcement agency. Ten towns have a public health department, a public recreation depart- ment, group work agencies for children (usually scouting and “Y” programs), and a probation officer. Nine towns have a children’s serv- ice agency and an Alcoholics Anonymous group. This accounts for 14 of the 18 specified human service resources. Of the remaining four, school psychologists, the Salvation Army, and a United Fund plan- ning and fundraising agency are found in only six of the communities studied, while one lone town has the benefits of a mental health association. All communities but one have additional human service resources other than those we specifically looked for, the average num- ber of these “other” resources being about two per town. As with men— tal health resources, we found no significant difference on overall numbers of resources between disaster and control towns. All communities in the sample, then, are fairly similar in terms of number and configuration of human service resources, yet there is one slight variance. Those towns not having a welfare department do tend to have a private or public family and/or children’s service, sometimes combined, sometimes separate. Communities not having family or children’s service do tend to have public welfare and/or public health nurses. Moreover, as we shall see later, if one or more of these four ma— jor resources are missing, those that are present tend to be stronger and offer a wider variety of direct services. There also appears to be some relationship between absence of specified resources and presence of resources we designated as “other.” For example, the town having the fewest specified resources, lacking in eight of the inventory items, interestingly enough has seven “other” resources, far above the average number of two. The data on community resources may be easier to interpret if the community is conceptualized as a system, comprised of a number of subsystems which function to meet the community needs. Any com- munity system may be depicted as containing a health and welfare subsystem which exists with other systems operating to meet demands generated by various aspects of community life. Within the health and welfare subsystem are networks of community resources, e.g., 73 CRISIS INTERVENTION FOR DISASTER VICTIMS hospitals, clinics, community mental health centers, private social service agencies, public health and welfare organizations, which vary in number, strength, and degree of interdependence. The outlines and functioning of these kinds of caregiving subsystems can be seen to vary considerably from one community to another and within the same community over time. 4 Systems are conceptualized as responding to environmental de- mands. Therefore, existing subsystems—in this case, subsystems com— prised of health and welfare organizations—develop patterns of re— sponding to demands. Sudden increases in demands can lead to the emergence of new groups, which become integrated into subsystems; it has been noted, for instance, that this kind of emergence frequently oc- curs after disasters. However, it is also possible to identify patterns which have evolved over time in any community. It is these kinds of patterns that we have attempted to discover in the sample com- munities. On the basis of the data obtained, one or the other of the types of psychological support resources we have identified—either the mental health or the human services resources—is more abundant or more highly developed. Our hypothesis is that where there is a short- age of one type of resource, relative to demands, the other type is more fully elaborated. In other words, when inadequacy exists in one part of the caregiving system, other parts may compensate by doing more of the work. This hypothesis is helpful in explaining some of the differences we observed between mental health and human service resources as two separate components of the basic caregiving system. Evaluation of Human Service Resources Human service resources were scored in the same manner as mental health resources, except that the maximum possible score was 90. We then added both scores together for a combined community score. All scores were converted to percentages so comparisons could be made. As table 4 shows, human service scores were higher, falling in the up- per half of the range. 74 NEEDS AND RESOURCES IN 12 US. TOWNS Table 4 Distribution of communities, compared on scores for mental health and human service resources Sm Mental health Human services Combined 0- 10% 2 0 O 11- 20% 4 O O 21- 30% 3 O O 31- 40% O O 0 41- 50% 2 0 3 51— 60% 1 O 6 61- 70% 0 4 3 71— 80% 0 4 1 81- 90% 0 3 0 91-100% 0 1 0 There are a number of possible explanations for the discrepancy be- tween mental health and human service resource scores. Mental health resources, as we measured them, have a natural tendency to fall below the maximum possible because few communities have or need all the types of agencies we identified as potentially existing. The inventory list of mental health resources, in order to be inclusive, was somewhat redundant. Mental health, after all, is a relatively specialized field. Human service needs, on the other hand, are broader and more general, touching more people in more ways. Traditionally, different types of agencies have been developed and organized to ad— dress differential needs, or at least similar needs from different perspectives. For example, a family with multiple problems might go to a welfare department for financial help and a family service agency to learn better childrearing skills, while various members of the family are involved with other specialized resources—the mother in a job- training program, the father attending Alcoholics Anonymous meet- ings, and the children enjoying the recreation and character building services of an agency summer camp. It is likely that most of the human service resources identified in our inventory will be found in most com- munities. This was borne out in our research. Historically, human service resources, especially public welfare and child welfare programs, have been present in all States and in local political subdivisions since passage of the Social Security Act in the 75 CRISIS INTERVENTION FOR DISASTER VICTIMS 1930s. Taxes thus support, at least partially, the majority of the resources studied. Private volunteer groups and agencies concerned with special problem areas and/or interests assume financial respon- sibility for others. Are these reasons sufficient to explain the magnitude of the variance in service availability between mental health and human service resources in our sample communities? Measurement was based not only on sheer numbers of resources, but on quantity of direct serv- ice that has mental health functions. To obtain the maximum score, an agency must be providing a range of direct and indirect service which would prove useful in meeting crisis intervention and emergen- cy mental health needs in the event of a mass emergency. We tallied the frequency with which counseling, outreach, volun- teer/paraprofessional, and information and referral were offered by human service resources in order to determine which agencies tended to be most engaged in these critical services and would, therefore, be recognized by the community as sources of help in times of trouble. Logically, such agencies would be invaluable components of a crisis intervention or emergency mental health program. Being familiar to people, they would have a better chance of acceptance and utilization; having material and physical assistance to offer, they could provide tangible, immediate aid that would help to quickly establish the. trust and confidence essential to mental health counseling, and they would operate without the “mental health” label—a label which, as one of our informants succinctly stated, “does not help anybody in the men- tal health business.” Welfare departments, family and children’s service agencies, and public health departments, particularly their nurses, generally have a corps of experienced, familiar counselors. Much of the counseling done on mental health—related matters is informal, but this is not necessarily a weakness. They do possess the skills required for dealing with people in crisis. Some have had mental health training, while others are in a position to make excellent use of training programs conducted by local mental health professionals. Moreover, they are accustomed to providing outreach and home visiting, thought to be ap— propriate in disaster mental health efforts. The Red Cross, of course, is a natural source of help for people in disaster. Group work, senior citizens, and minority-oriented agencies already are tied in to these special populations and perhaps more directly address some of their particular needs. Ministers, doctors, policemen, and, in many cases, agricultural ex- tension agents are all familiar with the role of crisis counselor. Clergy and physicians especially have the advantage of being the ones often turned to first for emotional assistance. 76 NEEDS AND RESOURCES IN 12 US. TOWNS Each of the groups mentioned could perform well as emergency mental health workers, since in all communities each is currently pro- viding the kinds of direct service that would come into play. Indirect service (information and referral) is provided so commonly that it may be more of a hindrance than a help to a program where widespread disruption has occurred, making organization and coordination man— datory. It is desirable in most emergency situations to have only a few well-known and well-informed purveyors of information about availa- ble services. It is more feasible to widely publicize one or two informa- tion and referral centers and to keep them abreast of the services that are currently being provided and that may change rapidly in the postdisaster period. We also noted that some human service resources tend to satisfy themselves with information and referral rather than become more actively involved in direct service. This may be a func- tion of staff capacity and qualifications. Community Assessment of Human Service Resources Professionals and community leaders were asked to assess the ade- quacy and public awareness of social services in their communities, just as they were for mental health services. Overall, the level of social service is about the same as, or possibly slightly below, that of mental health. About half rate them “adequate,” 8.6 percent “superior,” and one-third judge them “below average” and “inadequate.” Averaging all communities, mental health and human service professionals were in general agreement regarding their assessments of social services, with human service workers being a bit more critical of their own agencies. Community leaders rated social services higher than either professional group did. When we compared assessment levels for mental health services in disaster as opposed to control towns, we found ratings generally were lower where disasters had occurred. The same pattern emerges for social services. Again, the members of the mental health profession most drastically revised their opinions downward. However, although overall ratings of social services decreased in disaster communities, they did not decrease as much as mental health services did. Whereas informants in control towns ranked mental health services slightly higher than social services, informants in disaster towns reversed the order. If, as we supposed earlier, differences in assessment between the two sets of communities are partially a result of how well agencies rise to the occasion of disaster, then social services apparently met the test a little better than mental health services did. 77 CRISIS INTERVENTION FOR DISASTER VICTIMS This is not to say that social services are better than mental health services. Most interviewees, including mental health professionals, simply feel that, in the aftermath of a disaster, the most immediate and pressing needs—certainly the most easily identified—stem from the widespread disruption of everyday living patterns. In the words of informants: “. . .after the tornado, people were concerned with their most basic needs: food, clothing, shelter. . .,” with “getting things back in shape.” Problems such as these bring people to social service agen- cies; thus, these agencies were given relatively more opportunity to help than mental health agencies were. This finding resembles that of Wright (1978) who found that, after disasters, social service agencies and other organizations active in the later phases of disaster response experience an increase in community prestige. Regarding emotional problems that might have otherwise taken people to mental health services, a respondent remarked that “. . .there was a lot of esprit de corps in the community. The community provided a lot of support that in other times the mental health center would be providing.” For whatever reasons, the public seems to be considerably more aware of social as opposed to mental health services. Over 60 percent of all informants saw community residents as having a “moderate” to “widespread” knowledge of social services. Human service profes- sionals ventured the highest assessments of awareness levels. Sizeable percentages of all informants, especially mental health professionals, nevertheless, feel more could be done to publicize or otherwise bring services within reach of people who need them. Our hypothesis stated that, as need arises, the system adjusts to meet it, and someone steps in to fill the gaps. In rural areas, desig- nated mental health resources are relatively scarce—more precisely, relatively inaccessible and understaffed; human service resources might well be meeting much of the need for day-to-day counseling of a mental health nature. This seems to hold true, particularly when we compare levels of service within each community. Table 5 suggests an inverse relationship between these two components of the caregiving system. Those communities that have lower scores for mental health tend to rate more highly on human services. As human service scores fall relative to maximum possible, mental health scores rise. Levels on mental health and human service scores tend to balance each other out. When scores in each community are combined for an overall rat- ing, all communities fall in the middle range. This finding enhances the potential for wider applicability of any emergency mental health program that has been found to be effective. We continue to endorse the notion that there is sufficient, indeed, ex- tensive, variety in rural communities and strongly recommend that 78 61. Table 5 The distribution of mental health and human service resources in 12 communities 100% 100% 90% . . 90% 80% . - 80% 70% - . 70% 60%- . 60% 50% . 50% 40% - 40% 30%- 30% 20%- — 20% 10% - 10% % Human Service (maximum possible score 90) Mental Health (maximum possible score 60) Combined Resources (maximum possible score 150) SNMOL 'S‘fl ZI NI SEIOHHOSEIH GNV SCIEIEIN CRISIS INTERVENTION FOR DISASTER VICTIMS each one tailor a program to its own particular case. Each community must assess its own needs in terms of its own typical problems, its own high-risk groups, its own configurations of resources and patterns of service delivery, and the many other factors we have discussed throughout this report. Yet, in light of this finding, certain basic strategies seem to work in most communities, obviating the need for program planners to start from rock bottom. In dealing with the problem of the variance that does exist in rural communities, as reflected in combined scores from one town to another and in disparate mental health and human service scores within towns, we analyzed certain of the social and economic charac- teristics of the communities. We related the following items on each community to its mental health, human service, and combined resource scores: Population 1975 Population change 1960-1975 Percent nonwhite population Median family income Economic base Though recognizing that some of these characteristics are related to each other, we decided to limit ourselves to comparing individually each characteristic to community scores, commenting on possible rela- tionships where possible. Table 6 Size of community population and resource scores Average Average Average Population mental health human service combined class score score score 0-10,000 13.8% 70.8% 47.8% 10-20,000 18.3% 86.0% 59.3% 20-30,000 30-40,000 44.3% 71 .0% 60.3% Without doubt, size of community is related to higher mental health scores. The larger the population, the better the supply of men- tal health resources and services. Middle-sized communities—those in the 10-20,000 class—tend to have the fullest array of human service resources and services, while the largest and smallest communities score almost equally. As we noted earlier, where mental health scores 80 NEEDS AND RESOURCES IN 12 US. TOWNS are highest, human service scores are lowest, explaining why the latter scores are lower in the largest communities. The smallest communities score lower on human services simply because they tend to have an overall poorer supply of both kinds of resources. Combined resource scores show only a partial relationship to size of community. The very smallest towns score lowest. Once beyond the 10,000 mark, scores are nearly equal. Percentage of Population Change and Resource Scores It was difficult to assess the impact of population increase or decrease on resource scores. For one thing, our population data are reliable only up to 1970, and onsite observation and data collection led us to suspect that the situation may have changed in some com- munities in recent years. In making what comparisons we could, only a few very general patterns emerged. Towns that are small and are los- ing population tend to have rather lower overall supplies of resources. Expanding towns, with “new” money to spend, tend to favor the con- struction and staffing of mental health facilities over human service agencies, perhaps because most of the expanding communities in our study are located in regions (North Dakota and Florida) that have been among the earliest supporters of mental health programing, at least at the State planning level. On the other hand, this finding may point to a trend of general growth of mental health resources. Table 7 Percentage of nonwhite population and resource scores Average Average Average Percentage of mental health human service combined nonwhite score score score 50-100% (majority nonwhite) 21.0% 82.7% 58.0% 10-49% (significant nonwhite minority) 22.0% 72.6% 52.4% 0-9% (small nonwhite minority) 32.0% 75.0% 58.0% Mental health scores are clearly highest in communities with few nonwhite citizens, while towns whose residents are largely nonwhite 81 CRISIS INTERVENTION FOR DISASTER VICTIMS have a greater supply of human service resources. Communities hav- ing definite racial majorities, either white or nonwhite, tend to have a better overall supply of resources than do towns that are largely mixed. Table 8 Median family income and resource scores Average Average Average mental health human service combined Income class score score score Upper third (8700-9800) 32.5% 73.5% 58.3% Middle third (5,800-7,300) 31 .8% 77.0% 58.8% Lower third (4300-5800) 1 2.0% 75.8% 50.3% As with a community size, which is related to medium income, there appears to be a definite relationship between higher income levels and presence of mental health resources. In our sample, the cutoff point falls around $6,000. Towns with low income levels scored relatively high on human service resources, but, in general, there is a slight ten- dency of combined resource levels to rise with income. Economic Base and Resource Scores We found no significant relationships in comparing resource scores to leading economic activity, be it manufacturing, retailing, education, or agriculture. Interestingly, our findings contradict earlier ones link- ing agriculturally based economies to low levels of resources. Not all agricultural areas are small or impoverished, and, as we have seen, resource levels are related to size and income. Informal Caregivers as Mental Health and Human Service Resources In the course of designing our research format, we took pains to in— sure that sufficient information was gathered to comment rather definitively on the supply of formal resources in rural communities, on the capacity for providing services in general crisis counseling in par- ticular, and on actual patterns of formal service delivery. Program planning is, or should be, a logical process, predicated on a need/supply ratio. The first step generally, perhaps because its 82 NEEDS AND RESOURCES IN 12 US. TOWNS relatively objective nature makes it easier, is the determination of sup- ply. However, we should point out that beginning with what one has and then proceeding to what one has not may not be the best way to plan a program, since problems or needs all too often tend to be defined in terms of what one can easily or immediately do, not what should be done. At any rate, the supply of mental health and human service resources in rural areas in the sample has been assessed. The matter of needs, both actual and perceived, in these same areas also has to be addressed. Now is an opportune time to interject a third factor in the planning ratio demand. Need does not directly equate with movement toward supply. Simply because an individual has a problem, par- ticularly a mental health problem, does not mean that it will be recog- nized and stated. If it is vocalized, the individual will not automatically turn for assistance to a formal agency simply because such agencies are supposed to be community caregivers. The value placed on self-reliance in rural areas is widely recognized by social scientists and by rural people themselves. “They tend to be really rugged individualists,” according to one resident. As noted pre- viously, stigma is attached to asking for formal services of any kind, particularly for emotional problems. Going to a mental health agency is not only socially difficult—“bad for your public image,” it is also a blow to one’s self-image—“a real admission of weakness.” “Mental illness has been looked down upon,” said one professional, “you’re supposed to have a stiff upper lip and get through it.” In view of these statements, all informants were asked to rank the prevalence of various kinds of need in their communities. Examples were given of some stress-producing situations, and informants were asked where, in their opinion, people generally went for help in such cases. (See tables 9 and 10.) While community acceptance and utilization of formal caregivers, including mental health agencies, are growing, a large number of peo- ple do not avail themselves of such services. “The whole lifestyle in these small towns is such that people are just not as prone to go to something like this (mental health center) . . . it’s not a normal part of their patterns of life.” We heard numerous references to the stronger religious orientation in rural communities and to the amount of pastoral counseling being done. As table 9 shows, nearly one-fourth (22.5 percent overall) prefer to take their troubles to a minister. In my estimation, they do not go to agencies for help—they are afraid—what will people think—so often they are reluctant to talk it over even with. . .(their) pastor: “If I told him all my 83 CRISIS INTERVENTION FOR DISASTER VICTIMS Table 9 Choice of caregiver by community Disaster Control All communities communities communities Clergy 24.3% 20.0% 22.5% Mental health centers 21.0% 13.8% 17.4% Physicians 16.2% 16.6% 16.4% Social service agencies 15.5% 15.9% 15.7% Friends and relatives 6.1% 12.5% 9.2% Legal— public safety organizations 4.1% 6.9% 5.4% Psychiatrist 2.0% 4.8% 3.4% School personnel 3.4% 3.4% 3.4% Hotlines 5.4% 1.4% 3.4% Hospital emergency room 3.4% 2.1% 2.7% Psychologist 1.4% 2.1% 1.7% problems I wouldn’t be able to face him in church.” People, therefore, often go to some other pastor. Encouraging for members of the mental health professions, mental health centers were cited often (17.4 percent overall) as the place where people go for help in dealing with stressful situations. There is a slight tendency for mental health professionals, more than the other groups, to assume that people come to them first, just as human serv— ice professionals assume regarding their own agencies. Utilization of mental health services seems to be a function of familiarity, par- ticularly among those who have traditionally attached most stigma to mental illness—the lower income and minorities. I think they are gradually getting to use the Center more and more. When we first opened, some in the black community would walk across the other block. They wouldn’t want to go by the “Crazy Place.” 84 NEEDS AND RESOURCES IN 12 US. TOWNS Table 10 Choice of caregiver by occupation Mental heanh professionals Clergy 25.3% Mental health centers 1 7.9% Physicians 16.4% Social service agencies 9.0% Friends and relatives 25.4% Legal— public safety organi— zations 1.5% Psychiatrist 4.5% School personnel 6.0% Hotlines 1.5% Hospital emergency room .0% Psychologist 3.0% Human service professionals 19.8% 15.6% 1 1 .5% 21.9% 17.7% 4.2% 2.1% 3.1% 5.2% 4.2% .0% Community leaders 23.8% 14.6% 20.0% 12.3% 14.6% 8.5% 4.6% 2.3% 3.1% 3.1% 2.3% Still, the tables show that the majority of people in rural areas con- tinue to seek help from a wide variety of resources. Sometimes these are formal human service resources such as social service agencies (16.4 percent), legal aid and the law enforcement officials (5.4 per—7 cent), and frequently the most informal of caregivers—family, friends, and the local bartender (9.2 percent). Perhaps the entire pattern of help seeking is best illustrated by the statement of a Legal Aid professional in one community: Most family counseling, unfortunately, is done by a neighbor or a friend who may or may not have gone through a similar ex- perience. . .it’s like legal advice. . .some people get more legal ad- vice in a tavern or a barber shop than they ever ask for in a law office; and they probably believe it more. 85 CRISIS INTERVENTION FOR DISASTER VICTIMS The direction that mental health agencies and those planning emergency mental health services might take is suggested by a veteran welfare worker in another community: “People stick with their families. They’ll go to the outside resources once in a while. In order for him to do that, someone close to him or a worker of that agency would have to give him the right approach and make him see the need of it. . . .” Disaster Related Agencies As various data were compared, it became evident that disaster communities are slightly better endowed with help giving resources of all kinds. While the number of resource agencies was about the same for both sets of towns, communities that have experienced large-scale emergencies tend to be organizationally richer, with their agencies offering more types of service more frequently, as measured by resource scores. Table 11 Resource scores for disaster and control towns Average Average Average mental health human service combined scores scores scores Disaster 25.7% 77.5% 56.8% Control 25.2% 74.3% 54.7% The difference is not striking, but it is consistent. Whether this will always be the case is a question for further study. However, this find- ing is consistent with the hypothesis advanced by many disaster researchers (Quarantelli and Dynes 1972; Fritz 1961) that disasters produce positive as well as negative consequences~in this case, an in- crease in the supply and complexity of human service resources. A more salient question for our immediate purpose is whether such variance has practical significance for planning and subsequent opera- tion of disaster relief efforts. Using the rationale that any prior knowledge is useful, it is well to look more closely at what happens to organizations in disaster. We know that disasters generate problems that are qualitatively and quantitatively different from those of the predisaster period. One simply expects that there will be new needs and demands calling for new tasks to be performed. As we have said, systems adapt in various ways to deal with changing situations. Adaptation within caregiving 86 NEEDS AND RESOURCES IN 12 US. TOWNS systems follows certain patterns, three of which are commonly found in smaller communities and are, therefore, important to recognize. Mental health and human service organizations in rural towns tend to either extend, expand, or emerge in response to disaster (Quarantelli and Dynes 1967). Extending organizations are those that have the greatest continuity with their predisaster status. Typical examples of these are the mental health and social service agencies which currently exist and function on a daily basis. While their helping behavior in disaster may be unplanned, or even unanticipated, they enter the emergency system pretty much as they are. Mobilizing from their own base of interrela- tionships, they direct their “old” activities toward new disaster-re— lated tasks. We found that mental health and human service agency activity was affected by disaster in the six towns that we studied. Human serv- ice agencies appeared to be significantly more affected (76.2 percent) than were mental health agencies (46.6 percent). The ways in which agencies were affected had to do with the types of client problems they encountered as a result of disaster and the efforts they made to deal with such problems. Human service personnel mentioned heavier workloads during and after the emergency period, increased stress in clients months afterward, the formation of new relationships with other agencies, new referral patterns, and the lack of proper programs for dealing with disaster victims. Mental health professionals also commented on seeing new kinds of client problems and new interagen- cy relationship and referral patterns. Two mental health agencies set up hotlines as a result of the disaster. At the time, both types of resources provided varying amounts of outreach, volun- teer/paraprofessional and, particularly, information and referral serv- 1ce. Years later, both mental health and human service resources con- tinue to have a richer supply of services than do similar resources in control towns. Mental health resources, for example, consistently offer more outpatient care, emergency service, and consultation and educa- tion. While we cannot say with certainty that such programs are a direct or an immediate response to disaster, they do seem to be an out- growth of the experience, indicating that towns that have gone through a large-scale emergency are more likely to perceive a need for these types of mental health services. Expanding organizations are best represented by the Red Cross, which, in normal times, tends to be a rather small agency in rural com- munities. Such organizations have a latent emergency function which is quite apart from their manifest activity in day-to-day life. When dis- aster occurs, groups like the Red Cross provide the well—known name 87 CRISIS INTERVENTION FOR DISASTER VICTIMS and regular employees as the core for a large influx of material and manpower from within and outside the disaster-affected area. The tasks they perform are ones for which they are trained and ready. However, the structure in which they work is new and somewhat un- wieldy, which may make for difficulties in coordinating their man- dated disaster responsibilities with other organizations involved in the relief effort, particularly with emergent groups. , Emergent organizations are those that are totally new in both structure and task. They arise in situations where obvious needs develop that do not become the immediate focus of attention of some existing organized effort. For example, in recent years communities suffering a disaster were increasingly likely to see the emergence of a type of interdenominational church-related group commonly named Interfaith Council or Interfaith Disaster Task Force, devoting itself to launching local disaster relief efforts. Such groups perceive themselves as “gap fillers,” commencing their work with an assessment of need and then addressing themselves to the provision of a broad variety of human services to those whom they feel are not receiving sufficient or appropriate help from the existing system. In another example, a group in Xenia perceived a need for mental health counseling for vic- tims of the 1974 tornado. In the months following the disaster, the ex- isting mental health caregivers were unable to mobilize any kind of relief program. Consequently, this group, calling itself Disaster Followup, organized an outreach effort, taking services door-to-door in an effort to insure that all possible victims and affected persons would be reached. The totality of disaster-related effort coalesces into an emergent subsystem arising to meet the variety of community needs and de- mands that can no longer be met through the regular caregiving system as it operated prior to disaster. This subsystem is comprised not only of emergent groups, but of existing agencies which extend or expand to adapt to the situation as it develops. New relationships form between agencies, work is shared, new tasks are performed by veterans, old tasks often by newcomers. Changes muSt be expected and, if incorporated into the long-range planning process, can be ad- vantageous. Coordination and cooperation among all parts of the system can help to avoid wasteful duplication, insure that needs are met adequately, and circumvent the creation of ill will that can work to the disadvantage of the entire community for years to come. 88 NEEDS AND RESOURCES IN 12 US. TOWNS Actual and Potential Crisis Needs in Sample Com- munities It is obvious that disasters create community needs by virtue of their occurrence. Few communities experience an intense need for community protection and security, for massive debris removal, or for wholesale business redevelopment on an everyday basis. However, dis- asters also do a great deal of their damage by intensifying, or making more prevalent, problems that were present in the community prior to the disaster. Examples of these kinds of problems might include the need for low-cost legal services and the need for consumer protection. This intensification of needs occurs in many areas of individual and community functioning, including the mental health area. Therefore, just as plans for the development of resources for launching a mental health disaster response must depend somewhat on the features of already existing resources, disaster—generated mental health needs can be seen as related to needs for services that already exist in the com- munity. For this reason, it was thought imperative to gather data on needs for communities which had not experienced disasters, as well as for those which had. How might disaster and nondisaster communities differ, or be similar, in terms of prevalent needs for services? The issue of community needs was approached in three ways in this study. First, in both disaster and control communities, all infor- mants——mental health professionals, human service professionals, and community leaders—were asked to rank in order of severity or commonality a list of over 20 problems or problem areas. The list was comprised of a wide variety of difficulties, ranging from problems in living and the need for “hard” services, through disturbances in inter- personal relations, deviance, and symptoms of emotional disorder, to actual symptoms of mental illness. Second, all informants in the 12 towns were asked to attempt to rank the need for material and/or financial support, the need for broad human or social services, and the need for mental health services, in terms of their relative significance for community residents. Third, in an attempt to discover what types of potential target groups exist in the designated areas, we asked informants to discuss whether there were groups or individuals living in their communities needing either social services or mental health services but not receiving them. Addi- tionally, an attempt was made to determine whether informants believe that disasters generate a need for mental health services and, if so, what kinds of services they think should be provided and by whom. Finally, in disaster communities informants were asked whether the disaster either created or intensified or, perhaps, even ameliorated community problems. 89 CRISIS INTERVENTION FOR DISASTER VICTIMS Prevalent Community Needs Housing, drinking, transportation, and family problems are seen by informants as presenting the most serious problems in all com- munities studied. These are followed in importance by the need for legal aid, medical problems, depression, loneliness, emotional problems, and finances. All problems in the latter group were chosen relatively infrequently (5 percent of the time or less) as among the “most serious” community problems. Housing is noted as the most serious problem in all communities, receiving a 14.8 percent share of the total responses in the “most serious” category. This is consistent with the research on non- metropolitan and rural areas, cited above, which stresses the shortage of quality housing and the high proportion of substandard housing in these areas even in nondisaster times. Housing seems to be a highly salient problem for informants. It is likely to be among the very first problems mentioned and almost always appears among the group of problems labeled “most serious.” Interestingly, informants in disaster communities seem no more likely to cite housing as a problem than do those in control communities. Transportation, another need often categorized as a problem in liv- ing, is cited as among the five most serious problems in both disaster and control communities. When not mentioned among the “most serious” problems, it is commonly placed in the next highest category. Like housing, transportation is mentioned as a particularly serious problem by informants, who are likely to add that the need for adequ- ate transportation is felt most acutely by the elderly and the poor and by those living in remote areas. Disaster community informants are only slightly more likely to mention transportation as a need than are their counterparts in control communities. Drinking and family problems are two personal and interpersonal stress situations that receive ranking as “most serious” in all sample communities. Overall, drinking receives the second highest ranking as a problem (11.6 percent of the “most serious” rankings), and family problems receive the fifth highest ranking. Many informants note that drinking constitutes a major community problem despite laws declar— ing their communities “dry.” Such laws, they state, merely reduce the incidence of public drunkenness and have no effect on residents’ pri- vate behavior. The high ranking accorded to drinking and family problems by community informants in the sample towns seems indica- tive of a significant need for some form of crisis intervention or emergency mental health service in these communities. Unemployment is cited as a very serious problem in a number of cases and is ranked overall among the “most serious” problems (9.9 90 NEEDS AND RESOURCES IN 12 US. TOWNS percent). However, informants also tend to state that unemployment is not a serious problem in their communities, and, thus, unemploy- ment appears on both the “most serious” and the “least serious” lists. Unemployment is more chronic and widespread in some sample com- munities than in others. Informants in some communities, therefore, rank unemployment very high, while those in others do not. Another factor appears to be the tendency to view unemployment as a relatively minor problem because of the existence of services to reduce its effects, e.g., unemployment compensation. Disaster and cOntrol communities do not appear to differ markedly in terms of the problems judged to be most serious. However, the need for legal aid is cited as among the most serious needs in disaster com- munities, while it is not mentioned at all in control communities. Ad- ditionally, while drinking averages overall among the “most serious” problems, it is not among the problems judged “most serious” in dis- aster communities. Symptoms of emotional disorder and examples of deviant behavior begin to appear more frequently in the ranking of the “next most serious” problems in all communities. Seen as serious in the com- munity, although perhaps not so widespread or severe as others pre- viously mentioned, are such problems as drugs, loneliness, depression, and emotional problems in general. While disaster and control com- munities do not differ greatly in terms of the problems placed in this category, depression is explicitly named as a problem in disaster- stricken communities, but not in others. Living conditions also appear with greater frequency in the “next most serious” category in disaster communities, as opposed to control towns. Although, in general, failure to take note of a problem mentioned on the list given to informants can be interpreted as a judgment that the problem is not salient, the data indicate some needs and problems that are explicitly mentioned as not serious or not important in the communities studied. These include the need for the most basic necessities of life—food and clothing—as well as one problem usually associated with severe personal crises—suicide. Regarding the lack of a need for food and clothing, many informants express the opinion that these needs are not pressing because public agencies such as welfare, together with private charities and social service organiza- tions, furnish aid to the most destitute community members. Thus, they indicate, no one goes without such basic life requirements. (See tables 12, 13, and 14 for lists of community problems and the percent- age of informants selecting them.) We expected the data to indicate differences among mental health professionals, human service agency professionals, and community leaders, where the ranking of problems was concerned. In other words, 91 CRISIS INTERVENTION FOR DISASTER VICTIMS Table 12 Disaster communities Problems receiving most frequent mention as “most serious” Percent of total responses Housing 14.8 Unemployment 11.3 Transportation 8.3 Family problems 8.3 Legal aid 5.2 Problems receiving most frequent mention as “next most serious” Percent of total responses Transportation 10 Legal aid 9 Drinking 8 Depression- 7 Living conditions 6 Family problems 6 Problems receiving most frequent mention as “least serious” Percent of total responses Clothing 1 7.9 Food 16.6 Unemployment 1 1.5 Insurance 8.9 Suicide 7.6 92 Table 13 Control communities Problems receiving most frequent mention as “most serious” Percent of . total responses Housing 14.8 Drinking 11.9 Unemployment 8.6 Transportation 7.4 Medical problems 6.6 Problems receiving most frequent mention as “next most serious” Percent of total responses Drugs 9.3 Loneliness 7.9 Emotional problems 7.9 Transportation 7.1 Family problems 7.1 Problems receiving most frequent mention as “least serious” Percent of total responses Clothing 20 Food 1 1 .6 Unemployment 8.4 Living conditions 8.4 Suicide 7.4 93 CRISIS INTERVENTION FOR DISASTER VICTIMS Table 14 All communities Problems receiving most frequent mention as “most serious” Percent of total responses Housing 14.8 Drinking 1 1 .6 Unemployment 9.9 Transportation 7.8 Family problems 6.8 Problems receiving most frequent mention as “next most serious” Percent of total responses Transportation 8.3 Drugs 7.1 Family problems 6.7 Legal aid 6.3 Loneliness 6.3 Emotional problems 6.3 Drinking 6.3 Problems receiving most frequent mention as “least serious” Percent of total responses Clothing 19.2 Food 14.0 Unemployment 10.5 Insurance 7.0 Suicide 7.0 94 NEEDS AND RESOURCES IN 12 U.S. TOWNS we expected that there might be a tendency for professionals in different fields to view community problems in terms of their particu- lar areas of expertise and perhaps to deemphasize the importance of needs outside their own realms of responsibility. Similarly, we ex- pected professionals and community leaders to “see the world” differently. No such differences appear in the data, however. There is, in fact, no marked tendency for any one group of informants to ignore, or downplay, needs believed to be important by another group. For ex- ample, mental health professionals rank housing, drinking, unemploy- ment, and transportation as the most serious community problems; this is consistent with the overall ranking of these problems for all communities. Human service agency personnel are as likely as others to cite mental health-related problems as important in their com- munities. Moreover, another encouraging finding is that community leaders seem quite sensitive to the emotional needs of residents and quite willing to offer opinions on these needs. Drinking, drugs, emo- tional problems, and family problems are all mentioned as problem areas as frequently—sometimes more frequently—by community leaders as they are by professionals in mental health and human serv- ice agencies. This agreement by professionals and community leaders indicates that, in general, the worst problems are probably more visi— ble and well known in small towns. It also seems to indicate that there is more homogeneity in attitudes about what kinds of services or programs these small towns need than exists in larger communities. One positive consequence of this common identification of problems, and this consensus on their ranking, may be the planning and development of social service and mental health areas where citizens and professionals may not see eye to eye on what problems are most severe and may not share common priorities about solving them. Relative Importance of Three Types of Needs Interviewees were asked to rank material/financial, mental health, and social or human service needs in terms of seriousness or urgency in their own communities. As with the identification of community problems, there was a marked degree of agreement among informants on this ranking. The most commonly chosen ranking of these needs, chosen by 30.7 percent of our informants, places material/financial needs first, followed by social service and mental health needs. Altogether, responses ranking material needs first, followed by either mental health or social service needs, comprise 37.6 percent of the responses. Informants in disaster communities are more likely than those in control communities to rank residents’ material needs first in 95 CRISIS INTERVENTION FOR DISASTER VICTIMS importance. Configurations in which material needs are ranked first- are chosen by 43.8 percent of informants in disaster communities, compared with 30.1 percent of informants in control communities. (See table 15 for a complete listing of informants’ choices.) Table 15 Percentage of informants choosing rankings of social services, mental health and material/financial needs Disaster Control All communities communities communities Social service Material/financial 8.3 7.5 7.9 Mental health Social service Mental health 12.5 15.0 9.9 Material/financial Mental health Social service 12.5 16.9 11.9 Material/financial Mental health Material/financial 10.4 3.8 9.9 Social service Material/financial Mental health 4.2 9.4 6.9 Social service Material/financial Social service 39.6 20.7 30.7 Mental health Unable to separate problems or unable 18.7 26.4 22.8 - to rank Of informants in all communities, 21.8 percent rate mental health as a serious community need. Those selecting mental health as most significant are also slightly more likely to emphasize social services as a need than they are to emphasize material and financial needs. Interview data indicate that, in general, informants feel that com- munity social service organizations are sufficient in number and 96 NEEDS AND RESOURCES IN 12 U.S. TOWNS quality to meet community needs. This feeling probably accounts for the relative lack of emphasis on social and human service needs, chosen as primary only by 17.8 percent of the informants. Do professionals perceive needs to be greatest in their own areas of expertise? Again, the data indicate that mental health professionals are very likely to cite a need for material or social service aid as cru- cial, and human service agency professionals seem just as likely as the other two groups to recognize the need for mental health services in their communities. As with the ranking of community problems, community influen- tials and agency professionals appear to have approximately the same priorities. However, the data do indicate that community leaders seem to make mental health needs a top community priority more often than do either mental health or human service professionals. The tendency to rank material/financial needs of residents first in disaster communities is particularly marked among agency profes- sionals: In disaster communities, 42.9 percent of the mental health professionals and 50 percent of the human service agency profes- sionals rank material needs first, followed by mental health and then social service needs; this ranking is selected by 0 percent and 28 per- cent of their professional counterparts in control communities. It seems paradoxical that informants asked to rank material, men- tal health, and social service needs rank material needs first, but, when asked the question a different way (as in the section above), they rate problems associated with the need for food and clothing as not serious in their communities. This apparent inconsistency seems due to several facts. One, of course, is the stress placed by informants on housing, which is a material need and which, as such, is logically in- cluded among material/financial needs. Another involves the inter- viewees’ tendency to see material needs as very pressing when they do occur, however infrequently. A third factor may be the informants’ tendency to equate the presence of agencies of a mental health or social service nature with the satisfaction of most needs for these serv- ices. However, another characteristic of informants’ responses to this question. should perhaps be noted: namely, their tendency to be unable to distinguish the three kinds of needs sufficiently to be able to then rank them in importance. In fact, 22.8 percent of the informants in all communities could not distinguish the problems sufficiently to rank them. This tendency is, we believe, at the root of the choice to place material needs before all others. Informants frequently describe the three kinds of needs as closely interrelated and often designate the lack of material and financial resources as the basic source of other needs, such as the need for mental health services. One interviewee, for 97 CRISIS INTERVENTION FOR DISASTER VICTIMS example, expressed the notion that so long as many clients must return to the same poor living conditions, the efforts of mental health agencies will be largely ineffective. Another stated that the various types of difficulties are interrelated and that family problems and drinking frequently stem from unemployment and financial need. Still another attributed depression to material factors such as poor housing and financial worries. Informants generally define material and fi- nancial needs as most pressing because they see these as the source of many other problems. Groups Needing Social and Mental Health Services In this portion of the interview, informants were asked open ended, general questions about whether or not there were groups or in- dividuals in the community needing social and mental health services and not receiving them. This was an attempt to probe for both poten- tial target groups and barriers to effective service delivery. It was anti- cipated that groups such as the elderly and minorities would be men- tioned frequently in answers to these questions, since both groups are often seen as receiving fewer services than they actually require. With regard to the need for social services, the two groups men- tioned above were designated as having unmet needs, but there was a great deal of variation in the responses made to the question, and neither group was the most frequently mentioned. Instead, many categories of individuals were specified, such as the poor, newcomers to the community, the uninformed, persons in physically isolated areas, and persons unable to afford transportation. Informants, in their comments, were raising the issue of accessibility of services. In- formants were indicating that many persons, rather than being mem— bers of an identifiable social class or ethnic group, have in common the fact that they do not or are not able to avail themselves of the services being offered in the community. This category, which we termed the “socially and geographically in- accessible,” is cited by 39.2 percent of the informants as needing social services and not receiving them. The elderly are the next most fre— quently mentioned group (22.5 percent of the informants), followed by children (9.8 percent), and minorities (7.8 percent). Other groups men- tioned as needing social services are the unemployed, those needing legal aid, alcoholics, and those who are too proud or too concerned about possible stigma to ask for help. It should be noted that, while the social service needs of minority group members are not among the most frequently mentioned needs in all communities, there are communities in the sample with relatively 98 NEEDS AND RESOURCES IN 12 US. TOWNS large nonwhite populations, and, in these communities, the needs of minority group members are emphasized. Additionally, interviewees in some community agencies stressed the needs of minority group members very strongly Informants in disaster-impacted and control communities do not differ markedly in terms of the groups they single out as needing social services. In both sets of towns, the socially and geographically “inac- cessible” and the elderly are singled out as the groups most needing such services. However, disaster community informants mentioned more needy groups, including those requiring legal aid, single parent families, drug users, alcoholics, and those afraid of stigma, among those needing and not receiving social and human services. When the question of the need for mental health services is ad- dressed, the socially and geographically inaccessible are again the most frequently cited group, mentioned by 29.3 percent of all infor- mants. Additionally, the interview data indicate that “the unin- formed,” which we included as part of the more general “inaccessi- ble” category in later analysis, are mentioned frequently in response to this question. Minorities are mentioned next most frequently as a group needing but not receiving mental health services, having been cited by 22.4 per- cent of the informants. This represents a much higher percentage than those judging minority group members as requiring more extensive social services. With regard to the mental health needs of minority group members, the notion is expressed in interviews that minority group persons not only may not feel comfortable using such services, but also may not be as aware of their availability as others in the com- munity. Another group, whose representation increases when the question of mental health needs is discussed, is the group comprised of those too proud or too afraid of stigma to ask for help; 17.2 percent of all informants mention pride and fear of stigma as barriers to use of men- tal health services by those needing them. Statements such as the following, made by both professionals and lay persons, were common in the interviews conducted: There is a stigma against going to a mental health agency, more than in metropolitan areas. In this community, it’s bad for your public image. Some people think if we changed our name to counseling center, anything except mental health, we might have more. Because of the stigma. . Stigma is attached to using mental health services. You can send them to any specialist except a psychiatrist. They put the brakes on then. 99 CRISIS INTERVENTION FOR DISASTER VICTIMS Clearly, in the communities we studied, reluctance to incur the label of mental illness is a factor which acts to reduce utilization of mental health resources. The elderly and children are also mentioned by informants (13.8 percent and 6.9 percent, respectively) as needing mental health serv- ices. In neither case, however, do informants judge this need to be as great as their need for social and human services. Drug users, alcoholics, the unemployed, and single parent families are also desig- nated by some informants as groups needing more or better mental health services than they are currently receiving. In summary, with regard to the mental health needs of particular target groups, informants displayed a great degree of variety in their opinions. Most did not single out socially identifiable groupings— blacks, Mexican-Americans, Indians, children, the elderly, lower-class individuals, and the like—but rather focused on problem areas and/or various categories of individuals for which programs might be tailored. This may mean that needy sociocultural groups are not pres- ent in the areas studied; or—more likely—it may mean that such groups are either ignored or are socially invisible by virtue of their lack of community influence. Impact of Disaster on Community Needs Most informants in disaster communities indicate that disasters both exacerbate existing community needs and create new ones. Problems associated with housing are, of course, mentioned most ‘often as both generated and intensified by disaster. The need for food and clothing is also mentioned as a need created by the disaster. Unemployment, transportation problems, and medical problems are also mentioned frequently as having been generated, or made more in- tense, by the disaster. Financial and insurance problems are likewise noted as having been evident during disaster times. Finally, some in- formants state that the disaster intensified emotional problems and depression in the community. As one interviewee remarked: It’s had the effect on the emotional part of the community. They do have anxieties about these things now. Most did not view disasters as creating emotional problems in and of themselves, however. The disaster was seen more as adding to exist- ing stress: I think you get some Surfacing of problems that are already there. I’m not sure that the tornado itself created new problems. 100 NEEDS AND RESOURCES IN 12 U.S. TOWNS Approximately one-half of the informants in disaster communities report either believing or hearing that mental health problems would increase after the disaster—citing depression, emotional upset, sleep disturbances, and children’s anxieties as among the symptoms which were anticipated. Some informants expressed disagreement with this notion, however; one declared himself “amazed that anyone would ever have suggested that mental health problems could possibly be re- lated to a disaster situation.” Not all our informants share the view that disasters are wholly negative in their effects or even have significant effects. Some ap- parently feel that the disaster impact was so light that it did little to increase community problems or that relief efforts solved them quickly, since some informants could not cite any specific problems they found to be more pressing after the disaster. Additionally, we did ask whether anyone in the community may have been better off in some respects as a result of the disaster, and about one-half of the in- terviewees answered“ affirmatively. Several mentioned the spirit of cooperation and togetherness that emerged after the disaster as a posi- tive community force. One said simply, “Crisis brings people closer to one another.” Those who were furnished with new housing were also viewed as better off in many cases. In general, then, disasters are seen as having mixed effects. They are viewed as both creating and increasing community problems and as affecting psychological as well as physical well-being. They are also seen as generating a sense of esprit de corps in the community which may have salutory effects for some. Perceived Need for Mental Health Counseling in the Dis- aster Setting Informants in all communities were asked whether they consider natural disaster to be a crisis situation requiring the provision of coun- seling services to victims; whether people had ever thought about this kind of need; and whether a disaster experience affected the attitudes of informants in disaster towns, making the issue of counseling serv- ices in disaster more clear or salient. Interviewees in disaster communities do appear to have considered these questions more than their counterparts in control communities have. About one-half the informants in control towns had not thought about the question previously and would not venture their opinions, but this was not found in disaster communities. In both disaster and control communities, however, among those who had considered the question sufficiently to feel able to express an 101 CRISIS INTERVENTION FOR DISASTER VICTIMS opinion, the responses indicate a strong belief that some sort of coun- seling effort should be directed toward disaster victims. Overall, less than 10 percent of our informants stated that an effort of this nature is not necessary. Of all groups interviewed, mental health and human service agency professionals in disaster communities seem to endorse the notion of counseling the disaster victims most strongly. Apparently, witnessing the effects of disaster on their clients created in them the impression that these clients might have benefited from psychological support, at least at some point in the disaster experience. Community leaders in control towns were most likely to see a need for disaster-related coun- seling services. Community leaders in disaster communities, while still endorsing the notion of counseling, do not support it as strongly as do community professionals. When asked what forms of assistance would provide the most psy- chological support for disaster victims, the great majority of inform- ants in control communities did not venture a reply and indicated substantial confusion on this point. In disaster-stricken communities, however, while many informants mentioned that traditional kinds of mental health services might have a place in disasters, there was much more support expressed for the use of nontraditional, informal, or in- novative forms of counseling. In most cases, informants in disaster communities stressed the notion that informal counseling, together with the provision of material aid, would be most helpful to disaster victims. When informants were asked who should provide mental health services to disaster victims—traditional disaster relief agencies, men- tal health professionals, mental health volunteers—responses dwindled to a thread. It is apparent that, even in communities with re- cent disaster experience, few individuals feel able to offer opinions or suggestions on this important point. However, some isolated inform- ants did have thoughts on this question: 0 that after a disaster people will turn to those with whom they have already established a relationship, and they will not want to accept help offered from outside the community 0 that mental health should be a formal part of any disaster relief effort and should be a part of community-wide planning 0 that the most useful role of mental health professionals after dis- asters is the provision of information and referral 0 that whoever becomes involved in providing emergency mental health services should seek and receive legitimacy from members of local government and from influential individuals in the com- munity 102 NEEDS AND RESOURCES IN 12 US. TOWNS 0 that after a disaster, ministers, social workers, friends, and “any- one willing to listen” might play a very large mental health role 0 that the swiftness of the move to help people in disaster is perhaps essential Conclusion A few points need to be highlighted before leaving the discussion on mental health needs in the communities studied and moving on to the discussion of strategies for meeting disaster-related needs. First, the data indicate substantial agreement among informants in all com- munities on the need for better housing and transportation. There is also apparent agreement that disturbed interpersonal relations—evi- denced by problem drinking and family difficulties—are quite com- mon. Similarly, all informants seem aware that various other problems associated with emotional stress are present in their com- munities. When asked to identify groups needing and not receiving services, or, in other words, when asked to speculate on the characteristics of potential target groups for mental health and social services, infor- mants show less agreement, and the consensus which was evident earlier among professionals and community influentials is not as ap- parent. There appear to be two different sets of criteria influencing the informants’ responses: On the one hand, there is the tendency to con- ceptualize those needing services as identifiable, visible sociocultural groupings; on the other, there is the more pronounced tendency to think of target groups in terms of specific problems that may be manifested or in terms of programs which already exist. We have sug- gested that, due to their low community influence, some sociocultural groups may have been ignored in these communities. As noted previously, little solid evidence exists to indicate that groups such as children and the elderly do, in fact, become worse off psychologically after disasters. Some researchers argue, for example, that older individuals, having experienced and coped with hard times in the past, are better equipped than many others to withstand dis- aster-related stresses. This is what Huerta, Horton, and Winters (1977, p. 8) conclude in their study of the elderly Victims of the 1976 Grand Teton Dam break: It does not appear that the more elderly victims express higher levels of alienation, feelings of depression, or hardship than others. Although the elderly suffered high losses in this disaster, this would not be their first major hardship or adversity. 103 CRISIS INTERVENTION FOR DISASTER VICTIMS On the other hand, however, if the concept of disaster as a stressful life event is kept in mind, an unequal share of the negative psychologi- cal effects of disasters may be borne by those members of the com- munity already bearing life stresses, e.g., the poor, nonwhites, and both young and old who must live on fixed incomes. This was found to be the case among the victims of the Rapid City flash flood studied by Hall and Landreth ( 1975, p. 59), who state that social and psychologi- cal stress was “felt primarily among a segment of the lower socioeconomic categories.” In the population studied, this category, which included transients in the community, minorities, and persons relocated in trailer camps, evidenced a higher level of stress and a higher rate of maladaptive behavior than did other groups. Thus, we believe that while efforts on behalf of children and the elderly are necessary, a special effort needs to be put forth to insure that groups are not overlooked in the disaster-recovery period. Regarding disaster and its impact on community needs, we ob- served a marked tendency for disaster community informants to focus on disaster-related needs which are both dramatic and relatively short lived. For example, many emphasized the creation of the need for food and clothing as an important disaster effect; however, these are the kinds of needs which are almost always ameliorated within days after the disaster event. Few mentioned subtle, long-lasting disaster effects. While informants stated that there had been an expectation that the disaster might result in psychological problems for some victims, and while disaster was seen as leading to an increase in some symptoms of disturbance, including depression, almost no one expressed the notion that disasters might place more stress on some segments of the com- munity than on others. The idea that disaster itself is a stressful life event that calls for supportive actions to sustain the coping abilities of victims seemed reasonable to most people we interviewed; they appear more than willing to support the notion that disaster victims need mental health counseling of some sort—but only in the abstract. Other than to stress the therapeutic effects of the provision of tangible aid and informal counseling, few seem to have ideas on what kinds of supportive serv- ices might work best or on what groups in the community might be best suited to provide such service. Even among agency professionals in disaster-stricken communities, disaster experience apparently has not resulted in increased emphasis on disaster mental health or in- creased interest in the psychological effects of disasters. Clearly, a need exists for public education in these areas. Before meaningful planning can occur, community residents must cease view— ing disasters as events so uncommon—indeed, so nearly unique—that 104 NEEDS AND RESOURCES IN 12 US. TOWNS planning is useless. Many rationales are commonly expressed by com- munity members in an effort to minimize perceptions of hazards and to justify their failure to plan. The notion that “lightning never strikes the same place twice, the idea that disasters come in cycles—the er- roneous belief expressed by residents of flood-prone localities that “100-year floods” actually occur no more than once in 100 years and that having experienced one renders a community immune to serious flooding for at least 99 years, and the notion that mortals cannot and should not attempt to intervene in the working of “God’s will” are but a few examples of such thinking. All ideas of this nature have been repeatedly and tragically demonstrated to be defeating, both on an in- dividual and community level. It is recognized that, had disaster victims themselves been surveyed in addition to community informants, other sets of needs and a more comprehensive picture might have been obtained. Nevertheless, with the survey data at hand, it is possible to outline approaches on how to match needs and resources in a rural disaster-stricken community. 105 Chapter VI MATCHING NEEDS AND RESOURCES Strategies for Planning and Implementing a Mental Health Disaster Response in the Smaller Community So far, we have discussed a number of topics. Special characteristics of the rural and small town setting, as treated in the literature on mental health needs of rural populations, have been highlighted. We stated that, while rural and urban lifestyles and problems should be thought of as on a continuum rather than as contrasting with one another, and while the attitudes of small town residents may in- creasingly resemble those of urban dwellers, nevertheless, there are features of small town life that are distinctive. Even more important for this discussion, we have suggested that the mental health needs of people in the nonurban setting may differ in some respects from those commonly associated with urban living; such problems may require different modes of service delivery than are employed in the tradi- tional clinic-centered urban arrangement. Turning to the question of mental health needs following disasters, we noted that evidence indicates that disasters do not appear to cause severe, long-lasting psychological disturbances in victims. However, disasters can be Viewed as stressful life events which can create acute problems in living, emotional upset, and transient symptoms of psy- chological disturbance in some of the individuals who suffer their im- pact. This fact and the fact that disasters may also result in mental health problems of longer duration for a smaller percentage of Victims have led us to emphasize the importance of psychological first aid for disaster victims. We have reported the findings of some research and the conclusions, reached by mental health practitioners involved in disaster response, which support the use of crisis intervention methods to reduce symptoms of stress in victims and to quickly restore them to positive social functioning so that the longrun consequences of con- tinued stress can be avoided. Following the discussion of mental health needs in disasters, we again turned to a discussion of the small town setting, this time to describe the research we conducted on emergency mental health needs and capabilities in small U.S. towns and to report our findings, paying 106 MATCHING NEEDS AND RESOURCES close attention to how the resources in smaller communities might contain the potential for being mobilized to launch a crisis interven- tion response to disaster. We tound that the need for emergency mental health resources is by no means confined to urban settings. According to informants, some portion of the residents of the small towns we studied experience problems in living on a day—to-day basis, exhibit behaviors which are indicative of disturbed interpersonal relations, and manifest symptoms of stress—all of which indicate that a need for crisis inter- vention services exists, even outside the disaster context. Informants in disaster-stricken towns believe that disaster generally increases stress and adds to community problems. Additionally, informants en- dorse the notion that counseling assistance of some sort should be given to disaster victims to mitigate the stress they experience. However, beyond stating that such counseling should be informal, short—term, and oriented to solving problems, few had any specific ob- servations about how a disaster mental health program should be car- ried out. In sum, we found a low degree of awareness about issues of disaster. We also found that smaller communities are not as lacking in resources as sometimes depicted. While services can undoubtedly be upgraded in each of the areas we studied, there is apparently not as great a shortage of mental health and human resources in these com- munities as may have been anticipated, given such factors as popula- tion size and distance from large urban centers. We were able to locate a number of both formal and informal resources which typically func- tion in response to demands for psychological first aid. Communities were found to vary in terms of the extent to which such demands are routinely met by formally designated mental health agencies. In fact, communities rich in mental health resources tended to be poorer in human service resources, and vice versa. Regardless of the picture on the agency level, in every town we studied we identified a sector of informal caregivers who are also engaged in performing crisis intervention functions. These traditional sources of psychological support—the family physician, the pastor, the friend—are perhaps more significant in smaller communities than in today’s big cities. On the basis of our research, we concluded that those interested in planning and carrying out a mental health program to meet the needs of disaster victims already have sufficient resources available to at least begin that work on the local level. This chapter covers those fac- tors which need to be considered by mental health planners and prac- titioners on both the local and the State level. The recommendations for program planning and implementation follow in chronological 107 CRISIS INTERVENTION FOR DISASTER VICTIMS order: the predisaster period, the immediate postimpact period, and the postdisaster recovery period. Discussion focuses on the steps organizations may take to insure disaster readiness and effective response, the relatively simple principles which should be followed, some approaches to avoid, and sources of various technical informa- tion and assistance which are available to mental health and human service practitioners. Preimpact Phase: Planning for Service Delivery The Role of the State Although disaster planning should orginate and be carried out on the local level, there are several things that mental health personnel on the State and regional level can do to provide impetus for local planning efforts and to support efforts that are already underway: 1. Create an awareness among local mental health professionals that the delivery of disaster-related mental health services is primarily a local responsibility. Make available to local organizations informa- tion on resources from Federal, State, and regional sources to be used in training and planning for mental health disaster service delivery. 2. Provide information about how communities and individuals respond to disasters, with specific emphasis on the role and problems to be met by the mental health system in disasters. Take appropriate steps to assure that local personnel are aware of the procedures for ap- plying for supplemental Federal funds under Section 413 of the Dis- aster Assistance Act, as well as for other funds for which their com- munities might be eligible. 3. Set disaster preparedness standards for mental health delivery systems on the local level. Appoint a coordinator of disaster mental health, who will work with local personnel in disaster planning and operations and who will act as liaison among various levels of Govern- ment and disaster-relevant agencies. 4. Sponsor legislation specifying the rights and responsibilities of local mental health systems in the disaster response. 5. Establish criteria for the monitoring and expenditure of dis- aster-related funds. Review and function as approval and forwarding agency through appropriate channels for Section 413 disaster counsel- ing proposals. Local personnel can be sensitized to issues of disaster mental health by a variety of means including: sponsoring seminars, workshops, and meetings; attending conferences covering disasters and disaster men- tal health; distributing books, pamphlets, and manuals; and setting 108 MATCHING NEEDS AND RESOURCES formal requirements for local agencies wishing to apply for funding for disaster-related programs. The Role of Personnel at the Local Level As stated, disaster planning in the mental health area should be conducted primarily by local personnel, taking into account needs and resources which exist in the community. The following are the kinds of activities which, if performed, will assure that a state of disaster pre- paredness is achieved on the local level: 1. Be aware of disaster-relevant legislation. This should be on both the Federal and the State levels and include sources of information and assistance which are available to the local community. As noted earlier, the Disaster Relief Act of 1974, Public Law 93-288, includes provisions for the granting of aid and assistance to disaster-stricken States. Section 413 of the law states that the Presi- dent, through the National Institute of Mental Health (NIMH), is authorized to provide counseling services to victims experiencing dis- aster—induced mental health problems by giving financial aid and assistance to State or local agencies and groups, including both public and private mental health agencies. Such funds may be used for train- ing personnel to render counseling services as well as for the actual delivery of services. This means that in large-scale, federally declared disasters resources are available from national agencies to assist local efforts in the event that local resources are judged inadequate to meet increased demands for mental health—related services. (See appendix I for the text of Section 413 of the Disaster Relief Act of 1974.) Many States now have in effect legislation specifying the rights and obligations of various local agencies and jurisdictions during times of disaster. Local mental health personnel need to be aware of such laws and support State agency efforts to assure adequate mental health in— put in State disaster preparedness plans. The Disaster Assistance and Emergency Mental Health Section is the Section of NIMH which is specifically responsible for programs relating to disaster mental health. This Section disburses funds made available through the Federal Disaster Assistance Administration (FDAA), in the form of contracts, where there is a demonstrated need for the provision of disaster-related emergency mental health programs. Financial aid can be given to appropriate agencies in federally declared disaster areas. Technical consultation is available via a site visit to the stricken area by a representative of the Disaster Assistance and Emergency Mental Health Section. This visit may in- clude an initial assessment of the extent of local needs and resources, delineation of procedures and requirements for a proposal, and iden- tification of a lead agency for delivery of postdisaster counseling serv- 109 CRISIS INTERVENTION FOR DISASTER VICTIMS ices. Documentation of need for such services is required; thus, every local mental health agency should have knowledge of the regulations which apply in the disaster assistance area. (See appendix II for the outlines of NIMH disaster assistance regulations.) 2. Become involved in local disaster-planning activities. Many communities have community-wide committees devoted to problems of disaster preparedness. Such committees typically include representatives from such organizations as the Red Cross, the police, the fire department, city and county government, Civil Defense, and the local general hospital. Mental health personnel will find it very difficult to integrate their efforts with those of other disaster-relevant organizations following disaster, if they do not work with these organizations during the planning phase. Thus, the mental health sec- tor of the community should also have its representative on this com- mittee. Mental health should be a formal part of the local disaster plan if the efforts of mental health professionals are to be effective. In communities where disaster planning has not yet begun, mental health personnel have an opportunity to initiate these kinds of efforts. In fact, this activity—originating and participating in local disaster planning—can help the local mental health organization even outside disaster times by publicizing the important role of mental health in the community and is an unanticipated benefit of mental health involve- ment in disaster planning. 3. Develop a mental health disaster plan. This plan should include provisions for the services the organiza- tion will deliver, as well as when, how, and by whom these services will be provided. Backup staff and resources should also be part of the plan, in the event the first responders are not available or are im- mobilized by the disaster. A division of labor and lines of authority and responsibility should be clearly specified and understood during the planning phase, so they can operate effectively in the disaster con- text. Planning should occur not merely within organizations, but also among organizations; interorganizational planning and working agreements will contribute immeasurably to efficient disaster opera- tions. 4. Know your community. Communities are not static entities, and, as is the case with many other local organizations and institutional sectors—business, educa- tional, and others—the organizational picture in the health and welfare realm is an everchanging one. For any number of reasons, social service organizations frequently expand and contract their task domains, offering new services or cutting back old ones. At the same time, various kinds of voluntary organizations, some having specialized functions or target clientele, may expand or disappear. 110 MATCHING NEEDS AND RESOURCES Because of the dynamic nature of interorganizational activities and relationships, in order to be prepared to mount a crisis intervention response to disaster, the mental health professional needs to have complete, accurate, up-to-date knowledge about local, social and human service resources. This knowledge should include information about organizations which become very important following dis- asters—the Red Cross, for example—as well as information about local agencies which offer material and financial aid. Additionally, the mental health professional should have a thorough understanding of what informal networks exist in the community that routinely meet the urgent needs of residents. The composition of these informal net— works varies from community to community, but may include local neighborhood organizations or friendship groups, clubs, church groups, clergy, and labor union organizations. Finally, the mental health practitioner should be aware of the identity and location of high-risk groups in the population, since these are groups upon which disasters might have a particularly marked impact. In short, one’s knowledge of the community should be such that it will be possible to function very effectively in providing immediate psychological support and information, in referral during the emergency period, and in per- forming fast, accurate needs assessment following disaster impact. 5. Educate mental health personnel about human behavior in dis- aster and about disaster mental health. Before mental health professionals can act effectively in t e dis- aster setting, they must learn what to expect; that is, they must be en- couraged to understand how people typically react. Contained in the annotated bibliography of the report are a number of publications on various aspects of disaster response; local mental health agencies may wish to obtain some of these and devise workshops, seminars, or programs based on their findings. Some of the information that can be stressed in staff training for disaster operations includes the fact that many organizations, including mental health organizations, may be performing activities which they do not perform on an everyday basis, and that they themselves may not be called upon to provide services in the same fashion provided during routine times. Mental health per- sonnel should also be prepared to work with new agencies and groups from both outside and within the community, some of which may be performing an implicit mental health function. In general, then, flex- ibility and sensitivity to new organizational arrangements and tasks should be emphasized. Mental health and other crisis response organizations and groups in several communities have recognized the advantage of receiving technical assistance in training workers in the delivery of disaster—re- lated crisis intervention and emergency mental health services. 111 CRISIS INTERVENTION FOR DISASTER VICTIMS Resources now exist for organizing this kind of training program which would assure that communities will have a trained cadre of workers ready to begin activities as soon as disaster strikes. Recently, a publication, Training Manual for Human Service Workers in Major Disasters, was prepared by the Los Angeles Suicide Prevention Center, under contract with NIMH, to use in the training of mental health professionals, paraprofessionals, and volunteers in disaster mental health techniques. The Manual, which focuses on training individuals in the rudiments of crisis intervention as performed in the disaster set- ting, may be particularly helpful in a rural area or small town because the programs for which it serves as a basis may be conducted on any scale, large or small, and do not require a large supply of highly trained personnel. (See appendix III for the table of contents of this Manual and for information on how to obtain copies.) Low-budget training programs can be devised using such resources as the Manual on crisis intervention in disasters, some of the publications contained in the annotated bibliography of this report, and films on community- wide disasters available from local Red Cross chapters and Civil Defense organizations. 6. Assign responsibility for agency disaster planning to specific in- dividuals. Disaster planning and response are frequently given low priority in organizations. It is essential that mental health organizations have disaster committees and formal disaster plans similar to those that function in hospitals and other community organizations. In short, disaster preparedness should be a formal organizational priority. (The chairperson of the mental health disaster committee may be the repre- sentative to the community planning body. This person should have the authority to commit the resources of the organization in the over- all community response.) ‘ 7. Exercise crisis intervention and psychological first-aid skills in small localized emergencies. What is being advocated here is nothing more than a mental health disaster drill. Local personnel do not have to wait for the occurrence of a massive community-wide disaster to exercise their newly learned skills. A mass casualty event, such as a large automobile crash, a train collision, or a nursing home fire, may provide a setting in which men- tal health personnel can deliver supportive services on a limited basis to a few victims. When events such as these occur, a mental health organization should activate its disaster plan, dispatching personnel to the site or to the local hospital emergency department, thus provid- ing these workers with experience that may prove invaluable at some later time when a community-wide disaster strikes. 112 MATCHING NEEDS AND RESOURCES 8. Upgrade agency recordkeeping procedures. It was noted in chapter IV that our researchers experienced con- siderable difficulty in obtaining statistics in the communities studied and that this difficulty was quite marked in the case of agency statistics of various kinds. Postdisaster needs assessment, as well as the application for funding from the Federal or State level, will be based, in part, on statistical data, including baseline data on mental health problems, number and nature of cases treated, etc. Thus, we wish to emphasize the importance of keeping accurate, comprehensive, and current records on a day-to-day basis. Like involvement in com- munity-wide planning, this is an aspect of disaster mental health pre- paredness that will benefit the local agency even if disaster never oc- curs. In summary, the goals of State and local predisaster plannings are: to insure that existing resources can be mobilized quickly, efficiently, and effectively if disaster strikes; to integrate mental health-related efforts with overall community efforts; to ensure that mental health personnel will be prepared to act efficiently to improve the morale of community residents; and to set up methods of recordkeeping and evaluation which can provide useful feedback to organizations that become involved in the postdisaster delivery of mental health services. Impact and Emergency Period: The Provision of Psy- chological First Aid State and local agencies that have engaged in predisaster planning will not be overwhelmed when disaster strikes. The benefits of plan- ning will be apparent immediately as organizations activate their dis- aster plans and begin emergency operations. However, even if plan- ning has not occurred, it is still not too late for organizations to mount an effective response in the immediate postimpact period. The Role of the State 1. Become involved in the local response. Should a request for assistance come from local individuals, State level personnel should be prepared to offer needed resources and per- sonnel. Even in the absence of a formal request, a State official should initiate contact with local personnel to begin a joint assessment of the need for services. 2. Assure that information on laws, regulations, and programs of relevance to local mental health organizations will be quickly dissemi- nated. 113 CRISIS INTERVENTION FOR DISASTER VICTIMS 3. Urge official disaster declaration so that support can be made available on the local level. Provide information on mental health needs status to the State Disaster Coordinator through State chan- nels. 4. In cases where need has been established, make emergency fund- ing available to whatever local group is engaging in needs assessment or the delivery of counseling services to disaster victims. 5. Act as a liaison between the Federal and the local levels of Government, as well as between different catchment areas, if more than one is involved in disaster response. The Role of Personnel at the Local Level At the community level, three main tasks must be performed simultaneously when disaster strikes: integration with the emergent community system delivering services during the emergency period; delivery of direct and indirect services to victims; and postdisaster needs assessment. All phases of these tasks will have been made im- measurably easier if predisaster planning has occurred. Where there has been prior planning, the responsible individual activates the dis- aster plan to put the mental health response in motion. If there has been no predisaster planning, local personnel will have to engage in swift planning as soon as possible after impact, focusing on the most immediate things that can be done to alleviate victims’ distress. The recommendations below are intended to be applicable both in situa- tions where preplanning has occurred and those where it has not. 1. Conduct an initial meeting with other deliverers of emergency health care services. If preplanning has occurred, this meeting will be routine. If not, it will be even more necessary. At this time, groups and organizations in- volved in providing supportive services to victims should devise a clear division of labor so that task responsibilities are well understood and duplication of effort is avoided. Information about such topics as the severity of the disaster, damage and injury reports, the number and location of the injured, the location of the emergency operations center, and the availability of resources should be exchanged. Organizations may also decide to exchange personnel, share resources, or merge their efforts. Some briefing or training of volunteers or paraprofessional staff may also be necessary at this time. 2. Integrate with the emergent caregiving system. The emergency period will be marked by changes in the everyday operations of a number of organizations and by the emergence of new groups; it may also see the arrival on the local scene of representatives of State and local disaster-relevant organizations. Part of the task of the providers of emergency mental health services during this period 114 MATCHING NEEDS AND RESOURCES will be to coordinate mental health efforts with the efforts of these and other groups involved in the emergency response. The new community system will consist of agencies such as the Red Cross and the Salva— tion Army, city and county officials, a well-fortified police and fire department, the Civil Defense organization, and personnel from the community’s health care subsystem—public health officials, doctors, nurses, paramedics, emergency medical technicians—as well as emergent groups, some of which may already be engaged in providing counseling to disaster victims. If there is a Federal disaster declara- tion, these local caregivers may also be joined within hours or days by representatives of State and Federal agencies such as State depart— ments of health and mental health, the Federal Disaster Assistance Administration (FDAA), the Small Business Administration (SBA), the Department of Housing and Urban Development (HUD), the Na- tional Institute of Mental Health (NIMH), the National Guard, and the Army Corps of Engineers. It is important that local mental health personnel be aware of the function of these agencies and that represen- tatives of mental health and human service organizations participate in their coordinating meetings. In disasters where there has been a Federal declaration, a One- Stop Center is usually set up to aid victims. Organizations involved in disaster recovery ordinarily station representatives at the One-Stop Center so that victims can file for all types of available aid in a single Visit. This kind of center makes integration and coordination of agency efforts easier. The mental health staff should also be represented at this center. It provides for an opportunity for initial screening and in- formal counseling to victims, as well as referrals for later outreach efforts. 3. Provide direct services to disaster victims. . As previously noted, there is evidence that the most common kinds of services required following disaster are those of a crisis intervention nature, rather than more traditional forms of therapy. Crisis intervention, as discussed by Caplan (1964), is a technique for ~-_.-;. dealing with psychological disturbance which is characterized by: (1) frequent contacts with the person being aided over a short period of time; (2) emphasis on the present problem of crisis, rather than on the earlier causes of disturbance; (3) rapid problem assessment, rather than long-range diagnosis; (4) use of trained paraprofessionals instead of exclusive use of highly trained professionals; and (5) emphasis on helping persons receiving services to deal positively with the current situation, rather than on seeking complete personality reorganization. This problemsolving model contrasts markedly with the medical model, which emphasizes “treatment” of the “patient” by a qualified professional, usually by means of long-term psychotherapy. The object 115 CRISIS INTERVENTION FOR DISASTER VICTIMS of crisis intervention is not personality change, but rather the reduc- tion of the state of crisis so that the individual can once again deal with his or her environment and the prevention of future maladaptive behavior. Assuming that the overall mental health emphasis is on the provi- sion of crisis intervention services, of what should these services con- sist? The focus should be on providing broad human services. In terms of the meeting of needs, the mental health worker should begin where the victim is; frequently the provision of tangible aid is the best and only way to reduce the symptoms of emotional disturbance. As one mental health professional who provided services to victims of the Xenia tornado stated: Sometimes, maybe giving them a stove, or giving them a week’s worth of food, was the best way to handle the emotional problems. Sometimes being overwhelmed by a financial problem or a material assistance kind of problem puts you over the limit and things get blown out of proportion . . . a lot of times if you go on to meet the material assistance kind of problem or the infor- mation kind of problem, you solve what’s bothering them. If you go in with the attitude that everybody needs counseling or everybody has a defect in decisionmaking or coping, I think it will take too long to get at what they really need (Taylor, Ross, and Quarantelli 1976, p. 74). i. Information and referral services are among the most valuable services that can be given during the immediate postimpact period. Workers should be knowledgeable enough about the emergent caregiv- ing system to be able to assist victims in solving their practical problems, even to the point of actually taking them to the appropriate agency. Providing information and referral services may seem simple at first glance; many mental health centers do this routinely. However, it is important to note a number of ways in which the caregiving system in the postimpact period may differ from the system as it exists on an everyday basis. Agencies may be located in new quar- ters due to destruction of their facilities. They may have new and different telephone numbers. They may even be offering new, different, or expanded services. Additionally, as has been noted repeatedly, dis- aster-relevant organizations, outside agencies, and emergent groups may all be on the scene to offer various forms of needed aid. All these factors mean that a large amount of effort in the postimpact period \1 may be devoted simply to gathering complete and accurate informa- tion on the capabilities of the emergent caregiving system. When such information is obtained, it should be made available to victims as 116 MATCHING NEEDS AND RESOURCES quickly as possible. One of the most important services that can be ren- dered by a mental health organization is to provide a master list stat- ing who is providing what services and where, within the first 24-48 hours after disaster. A second point is that services given should not carry the mental if"? health label. Disaster victims are normal individuals reacting in a nor- i mal fashion to a trying situation. These individuals need and deserve psychological support, but there is a possibility that they will not avail themselves of it if doing so means accepting the mentally ill label. This is particularly true in the smaller community, where little, if any, dis- tinction is made between “mental health” and “mental illness.” How should services be provided to victims? Crisis intervention can be performed through any number of imaginative means. In the dis- aster setting, simply sitting with someone in the hospital or at the One- Stop Center and listening to the story of the disaster, or helping a per- son with cleanup, may be therapeutic—although the same individuals who gratefully accept this kind of help may never have accepted “therapy.” An outreaching stance should be adopted; help should be offered on the mere evidence that a need exists, not only on the basis of a formal request from a victim. It is difficult to predict in advance where services will be given ,_ V following a disaster. In general, however, we recommend extensiveJ community outreach efforts. Workers should go where the people are who may be experiencing problems. We advise that workers become active in shelters set up for disaster victims; but it must be remem- bered that, when possible, relatively few people use official shelters even one night after the disaster, since most are able to stay with rela- tives or friends. The nature of community housing available can change this picture, of course. Thus, persons in shelters may constitute only a small portion of those a mental health program should be at- tempting to reach. Other sites where victims may gather include tem- porary morgues (when large numbers of deaths have occurred), hospital emergency rooms, sections of the community which have been destroyed or badly damaged, food canteens, first aid stations, and One—Stop Centers. The hospital, the shelter(s), the morgue, and the One-Stop Center are worthwhile sites for beginning the counseling effort, since many of the hardest hit victims will be found in these loca- tions. It is possible to be both unobtrusive and effective in these kinds of settings. For example, following a recent disaster in a rural Ap- palachian community, personnel from the local community mental health center volunteered to staff the exit desk at the One-Stop Center. In the course of helping victims fill out applications for possible forms of aid correctly and completely, these workers were able to assess vic- tims’ psychological states, listen to complaints, give reassurance and 117 CRISIS INTERVENTION FOR DISASTER VICTIMS encouragement, offer information, and keep a record of cases appear- ing to need followup. Similarly, a mental health paraprofessional can volunteer in a Red Cross shelter and dispense blankets, food, and toys,while talking with mothers about the reactions of their children. After the first few days, service can, and should, be delivered in vic— tims’ homes, in the schools, and in other places where people typically go as part of their daily routine. These may even include such settings as bars, beauty shops, church functions, and neighborhood and com- munity gatherings. Again, the magnitude and the location of the dis- aster and number of victims requiring temporary shelter govern the extent of the outreach effort. By whom should services be provided? We have tended to speak of mental health service delivery in disasters as a function of designated mental health organizations, and this is accurate, particularly where planning, training, and supervision are concerned. However, most communities—particularly smaller communities—will probably not contain a sufficient number of trained professionals to launch a large emergency mental health response. Moreover, such staff members are concerned with their regular clients, some or many of whom may ac— tually be victims. For these reasons, we have emphasized human serv- ice resources and informal caregiving networks in the communities we studied, as resources that can be built upon. Agencies that already per- form outreach and informal counseling—the Agricultural Extension Office, the Public Health Service, a school home—visiting program— can provide both material resources and personnel during disaster . ~. ‘ "times. Agency personnel who typically play helping roles in the com- munity, together with traditionally recognized community caregivers, can be used in a paraprofessional capacity in disaster outreach and counseling work. While older, established groups, with prestige in the community, should be responsible for the leadership, training, and supervision of the mental health recovery effort, it is conceivable that the majority of those involved in service delivery might be community volunteers. —”‘ More important than the level of training of the person delivering counseling services is the fact that services should be delivered by peo- ple from the community, rather than from the outside. Virtually every mental health professional who has been involved in the provision of disaster-related mental health services stresses the benefits that can be obtained from the use of indigenous personnel: They are familiar with the local scene and can offer information about where different services can be obtained; they know the local neighborhoods and the people who inhabit them; they are knowledgeable about local problems; and they are known by the people. In short, they are per- ceived as belonging. Use of local personnel is particularly important in // 118 MATCHING NEEDS AND RESOURCES the immediate postdisaster period because this is a time that is often marked not only by increased community morale, but also by its ob- verse—hostility to the outsider. For whom should services be provided? This question can be ultimately answered only by the individual community and only after a thorough needs assessment (see 4 below). The latter provides useful information about which individuals and groups are most severely im— pacted and which persons are experiencing the most difficulty. In the—\ immediate postimpact period, however, the best strategy is to assume I that all the people in the stricken area are potential clients and to ; begin to identify and to make contact with persons who logically can\ be assumed to be most in need of psychological support—those who i have lost one or more family members, those whose homes have been i destroyed, the seriously injured, the institutionalized, and those who are or have been under psychiatric care. A priority should be placed on delivering services to neglected segments of the population (the poor, racial and cultural minorities), as well as to those who are geographically isolated and/0r without transportation. The question of when services should be delivered can be divided into two parts: how soon services should begin, and how long they should continue. Obviously, the provision of services should begin as soon as possible after disaster impact. The sooner psychological first aid is provided, the less total stress victims will experience, and the greater the probability that long-term emotional problems will be avoided. The swift provision of supportive services can also contribute to improved community morale, essential for successful disaster recovery. How long services should continue depends upon the number, nature, and duration of the problems encountered by the population during the postdisaster period. This is one reason why we encourage needs assessment as a part of effective mental health service delivery. Although supplemental Federal funding for disaster mental health programs is intended to extend for a 6-month period, the ideal length of a given program cannot be known in advance, because each disaster and each community is different. Because of the importance of con- tinuity of client care, we urge that those involved in planning for and. delivering of disaster-related counseling services be mindful of the time dimension as it relates to their programs. Planning and program- ing should include consideration of how the small percentage of more serious problem cases discovered through “outreach” will be inte- grated into the regular mental health system. 4. Offer services to the community in addition to those provided directly to victims. \/ . 119 CRISIS INTERVENTION FOR DISASTER VICTIMS ‘ ‘ Besides offering counseling to Victims on an individual basis, dis- \ aster-related mental health programs can engage in community ', education, even during the immediate postimpact period. These i educational efforts should be designed to reach as many people as ; possible in the stricken area and should express a few simple themes -' relating to problems of disaster mental health. The notion should be conveyed, for example, that it is normal to feel upset, discouraged, and emotionally drained after a disaster experience. Forms of catharsis, such as the expression of grief over loss and the retelling of upsetting experiences, should be encouraged. Information about available sources of mental health counseling Should be provided and should in- clude specific directions on how to go about finding someone to listen or to help with concrete problems. The idea that it is quite common for normal people experiencing stress to use such services should be \\\gmphasized. A number of means can be employed for disseminating this infor- mation. Mental health professionals can take part in discussions devoted to the topic of psychological reactions to disasters on radio or television talk shows; public service time is usually available on the local media for the purpose of publicizing the availability of helping services, again playing down any possible connotations of mental ill- ness or breakdown. A series of articles or advertisements can be run in the local newspaper. Pamphlets can be printed quickly and distributed at the One-Stop Center and at other places where people gather. Eye- catching posters can be printed and placed in hospitals, shelters, first aid stations, churches, senior centers, and similar locations, as well as in informal neighborhood gathering places. Mental health-oriented groups should make their presence widely known and be sure that their services are outlined in directories listing and describing disaster-related agencies. Workers should be present at ' assemblies and planning meetings attended by local officials and com- munity residents to offer support, information, and suggestions. 5. Engage in needs assessment in order to obtain information for use in planning and future service delivery. Effective services are always those which are delivered on the basis of known needs, rather than on the basis of anticipated or predicted needs or on the basis of Visible demands. Thus, those involved in men- tal health service delivery following disaster must begin to employ various needs-assessment procedures as soon as possible after impact. The assessment of the mental health needs of a population is often performed by means of surveys on members of that population. In the period following disaster, however, population surveys are not likely to be the most appropriate method of needs assessment. First of all, they take time to devise and analyze, and the actual delivery of 120 MATCHING NEEDS AND RESOURCES emergency mental health services must begin as soon as possible after disaster strikes. Second, surveys are usually quite expensive to under- take. Third, common needs—assessment instruments such as the Health Opinion Survey (HOS), while excellent for a number of pur- poses, are not comprehensive enough to be applicable in the disaster situation. Of equal importance, of course, is that those making up the population whose needs are to be gauged, i.e., those who were in the community at the time of the disaster, may be scattered throughout the region in new and different locations, having left the area entirely, or having moved to places in the community other than their pre- disaster residences. For these reasons, methods of needs assessment other than formal surveys should be employed in the immediate postdisaster period. This does not, however, rule out the use of surveys for a variety of purposes in the long-term disaster period; nor does it mean that other forms of quantitative data cannot be gathered in the days immediately pre— ceeding the disaster event. Three methods of assessing victims’ dis- aster-related mental health needs will be discussed briefly: the use of indirect indicators of emotional stress; the use of informants; and the use of clinical evaluation. Indirect indicators include official statistics or records which, taken singly or together, provide data on the incidence of what can logically be construed to be stressful life events for those experiencing them. The indicators listed below have in common the fact that they point to the prevalence of disaster-generated situations which can be very stressful events in people’s lives—death, injury, loss, change of resi- dence, and the like. The following are some examples of indirect in- dicators that can supply information concerning the nature, range, and extensiveness of the community’s postdisaster mental health-re- lated problems, as well as information on potential target groups for services. From health care Number of dead (hospitals) organizations: Number of disaster-related admis- sions (hospitals) Number evacuated (hospitals) Number receiving first aid (first aid stations) F r o m m e n t a 1 Number of persons currently institu- hospitals: tionalized, and former patients liv— ing in the community Number evacuated or relocated (where applicable) 121 CRISIS INTERVENTION FOR DISASTER VICTIMS From mental health facilities: From nursing homes: From disaster relief organizations: From disaster relief organizations: From social welfare organizations: From other com- munity groups assessing needs: Number of persons currently receiv- ing a service who experienced dis- aster losses Number of persons in residence Number evacuated or relocated (where applicable) Families receiving financial subsidies (Red Cross) Residences destroyed (Red Cross) Residences with major damage (Red Cross) Number of persons sheltered (Red Cross) Average length of stay in shelters Number of persons applying for low- interest loans (SBA) Number of families requesting hous- ing assistance (HUD) Number of applications for in- dividual and family grants (FDAA) Number of applications for rural housing disaster loans (FHA) Number of applications for crop loss assistance (US. Department of Agriculture) Number of new food stamp applica- tions Number of new applications for Aid to Families with Dependent Children Agricultural and livestock losses Number of applications for unemployment assistance Number and nature of cases found Other information on the number, identity, and location of high- risk groups can be obtained in a variety of ways. For example, workers may overhear people in shelters discussing problems that are known to them, or serious cases of need may be reported in the local newspaper. 122 MATCHING NEEDS AND RESOURCES Workers should get out and circulate in the community during the emergency period. Visits to low-income areas or to nursing homes may reveal the existence of unrecognized and unreported needs. In short, mental health personnel may be able to obtain a great deal of useful data on the mental health status of community members by being in the stricken area, listening and observing carefully, and being sensitive to problems that become apparent. Going about actively in the impacted area also provides an oppor- tunity for contacting community informants capable of supplying in- ' formation on the mental health needs of the victim population. Volun- teers who work in search and rescue operations, hospital emergency department personnel, community officials, religious leaders, and per- sons who staff both official agencies and emergent groups may all prove to be valuable sources of data about victims’ emergency mental health needs. Contacts with informal caregivers in the community will also provide useful inputs into postdisaster needs-assessment efforts. Such contacts are encouraged to insure that the information obtained is complete and representative of the needs of all community sectors, including those not usually tied into formal caregiving networks. Needs assessment can also be performed through the use of clinical evaluation techniques. In this case, trained personnel judge the preva- lence of stress on the basis of contacts with members of the victim population. Although not performed until many months after the dis- aster, this method was employed to estimate the prevalence of symptoms of psychological disturbance among the survivors of the Buffalo Creek flood. Lengthy interviews were conducted with victims by individuals possessing expertise in the diagnosis of psychological complaints, primarily psychiatrists. Clinical evaluation is frequently conducted on at least an implicit basis by mental health professionals working in the disaster setting. Such persons are typically highly sensitive to symptoms of emotional distress exhibited by persons with whom they come in contact. For valid needs assessment this kind of evaluation should be performed sensitively, uniformly, and systematically by mental health caregivers. Additionally, evaluation should be performed as quickly as possible. Because highly trained personnel will be in relatively short supply in the emergency period and because their skills may be needed for other tasks, it is advisable that all mental health personnel, including volunteers, be trained in simple methods of clinical assessment, based on gross categories and Visible symptoms, which can be employed in the course of delivering supportive services. Examples of these types of evaluation, together with recommendations for various referral op- tions, are contained in the disaster training manual written by the staff of the Los Angeles Suicide Prevention Center (See appendix III). 123 CRISIS INTERVENTION FOR DISASTER VICTIMS Use of any combination of the three methods of needs assessment discussed above—ideally, of course, all three should be used together—should result in relatively accurate and complete informa- tion on the incidence of mental health-related community needs, at least as they manifest themselves in the first few days. Needs assess- ment in the emergency period should lead to knowledge of the approx- imate number of potential clients in the stricken area; what groups in the community are most heavily represented; how pronounced the need is for various kinds of services, e.g., help with transportation, assistance with family decisionmaking, information, and referral; and how many staff persons will be required to meet disaster-generated needs during the next few months. At this point—say, 10-14 days after the disaster, although the time period will vary from community to community—local personnel should be in a position to determine whether the magnitude of the community’s need for disaster-related mental health services is great enough to necessitate either the creation of new services or the expan- sion of existing services by some local caregiving group. If a decision is made to begin delivering new or expanded services, this group may decide to apply for supplementary funding from either State, local, or Federal sources. Data from the initial needs assessment will be needed to serve as a basis for this request, as will certain State and Federal disaster declarations. , In order for a local community to qualify for Federal funding, the community must be within a federally declared disaster area. Most severe community-wide disasters do become subject to Federal declarations, often within a day or two after impact. In such cases, no barriers exist to requests for Federal assistance in delivering mental health services. However, some disasters, even those resulting ‘in relatively large amounts of loss, are not federally declared. This may be particularly true in rural areas, where losses may seem small on an absolute scale, but may be great relative to the local resources. Table 16 1975 Incidence of federally declared and nondeclared disasters in the continental us. by size of largest community in impacted area. Population Declared Nondeclared Total 25,000 and over 54 81 135 15,000 to 25,000 12 32 44 Under 15,000 17 22 39 124 MATCHING NEEDS AND RESOURCES Table 16 illustrates the frequency of this type of situation; it shows the incidence of disasters in the continental United States in which the Red Cross gave aid to stricken families during the year 1975. Disaster events are further classified in terms of population size of the largest community in the impacted county and in terms of whether a Federal state of disaster was subsequently declared. Of the total of 218 disaster events, 83, or less than 40 percent, were federally declared disasters. Of these 39 disasters occurring in counties in which the largest town has a population of 15,000 or less, only 17 were subject to Federal declaration; of the 44 disasters striking counties in which the largest city has a population of 15,000 to 25,000, 12 were officially declared; (The map illustrates the geographical distribution of 1975 disaster events.) Thus, local mental health personnel should be mindful of the fact that, while it is almost certain that various forms of Federal aid will be made available to communities experiencing dire need, “bor- derline” cases can also exist, which may be considered disasters from the local perspective, but not from the Federal perspective. In such cases, local mental health programs may have to practice considerable budgetary flexibility in program planning and implementation, using existing capabilities as efficiently and effectively as possible, and seek- ing financial assistance from a variety of local, State, and regional sources. The Postdisaster Period: Long-Run Program Options The length of the emergency period will vary from disaster to dis- aster, depending onthe severity of the impact, the extensiveness of the disruption experienced by various community sectors, and the com- munity’s capability for coping with disaster. For discussion purposes, however, we will assume that the postdisaster period begins approx- imately 2 weeks after the disaster event. Instead of discussing the role of agencies on the State and local levels, as in the previous two sec- tions, we will simply note that the role of the State during this time re- mains what it has been previously—that of resource, sponsor, and facilitator—and will move directly to a discussion of disaster-related mental health activities on the local level. Within a relatively short time, then, the initial period of emergency is over. Operations at the One-Stop Center may be gearing down, as one by one various disaster-related agencies begin to see their tasks nearing completion. Crisis intervention, in the form of immediate material assistance and psychological first aid, has been given to those who are known to have needed it, usually as they were encountered in the hospital, the morgue, the One—Stop Center, or any other disaster relief center their community may have operated. 125 981 STATE OUTLINE '3 UNITED STATES ‘- kt c4 Ih \ a m :w m 5“: In- sum Size of largest Communi‘y in County: Federal Disas‘er Daclaration . under 15.000 V a“ cities/counties statewide o 15,000-25,000 W seleued cities/coumies within a over 25,000 A state SWILOIA HELSVSICI 80.21 NOLLNEIAHELLNI SISIHO MATCHING NEEDS AND RESOURCES Search and rescue are over, the major traffic routes have been cleared of debris, communications systems—telephone service, radio, and television—are once again functioning. People are gone from emergency shelters, having been placed in temporary housing by some governmental agency or having placed themselves with relatives or friends. Planning alternatives have been explored by local authorities, and the long, slow process of rebuilding has begun. Now is the time to reassess the situation. If the disaster suffered by the community was relatively minor, it may seem that the com- munity’s main task revolves around problems of physical reconstruc- tion. However, individuals affected by the disaster may still be ex- periencing subtle life changes, with a potential for leading to emo- tional crisis. Those who have been faced with a life-threatening situa- tion, loss of property, or interruptions of everyday social support mechanism—family life, work, the neighborhood—and who have not resolved the attending stress in a positive manner, may still be feeling stress which could result in mental health problems of a more serious nature. At One-Stop Centers, workers are being taught to be aware of per- sons with emotional discomfort. Those who are upset seem to benefit sufficiently from the intervention of crisis workers to begin to cope with their own rebuilding tasks. What should be remembered now is that much of the emotional strain on victims and affected people may not surface immediately because people do not have the time or ability to feel their losses. They may be rationally aware of what they and others have suffered, but—often through hard work, sometimes through withdrawing—many people may also be insulating them- selves from overreacting until they are ready to recognize and deal with the problems of loss, anger, etc. It may take anywhere from a few weeks to several months after the disaster to reach this point. Indeed, as studies have shown (Penick, Larcen, and Powell 1974), not only the experience of the disaster agent itself but the frustrations ensuing from the snarl of red tape and delay surrounding the procuring of assistance are conducive to poor mental health. In light of this knowledge and based on needs assessment con- ducted in the impact-emergency period, local personnel involved in the mental health effort may wish to provide the community with a long-range disaster mental health program. Funding, of course, would optimize any such program. Groups or organizations in a federally declared disaster area may wish to apply to the Regional Director of the Federal Disaster Assis- tance Administration (FDAA) for operating money, if initial needs assessment (see above: Impact/Emergency Period) indicates that a program would be beneficial. There are nearly 100 Federal programs, 127 CRISIS INTERVENTION FOR DISASTER VICTIMS covering a wide range of disaster-related economic, health, and physi- cal reconstruction problems available to supplement State and local efforts. The FDAA has published a digest, here included in the bibliography, which details programs that require a Presidential declaration of major disaster and those that do not. Of interest here are the provisions for assistance to proVide crisis counseling to victims of a major disaster to relieve mental health problems caused or aggra- vated by the disaster or its aftermath. This assistance may include funds for the training of disaster workers. Although a proposal for this funding must be submitted within 60 days after the Presidential dis- aster declaration, preparing this kind of document is not as onerous a task as it may seem. Typically, the National Institute of Mental Health will provide technical assistance in the preparation of the pro- posal, if so requested. The funding process, of course, is considerably facilitated if communities have worked on local coordination and con- tingency planning before the disaster occurs, and if they make contact with State and Federal agencies during the emergency period. Where there has been a formal disaster declaration on the State level, other funding options might be available. Local groups should have familiarized themselves with these at an earlier planning stage. If neither Federal nor State funds are available, there are a number of strategies that can be employed with expertise and manpower volun- tarily contributed from the community or perhaps from nearby towns. One final note should be made before going to specific strategies. The literature mentions frequently that disaster mental health programs are unique in that they deal with essentially “normal” populations that are undergoing severe but understandable stress. Manifestations of tension, worry, or depression are seen as acceptable responses to personal and community catastrophe. Unfortunately, many of these people do not feel they need counseling, since they do not want to identify their problems as mental illness. If these problems continue, however, they may worsen without treatment. If this is typi- cal for general populations in disaster, it is still more so for rural populations that, even in normal times, have a tendency to resist men- tal health labeling as applied to either agencies or problems. What is really quite fortuitous is that methods found to be effective for reach- ing disaster victims should be especially effective in reaching rural dis- aster victims. In fact, if a good mental health and human service deliv- ery system is currently functioning in the smaller, relatively isolated community, chances are excellent that at least the basic elements of good disaster mental health service delivery exist. Below are some recommended program options that can be tailored to local needs and available personnel and financial resources. Ideally, all of these options should operate in conjunction with each 128 MATCHING NEEDS AND RESOURCES other. If this is impossible, presence of even one or two will go far toward meeting acute and chronic mental health needs, contributing to the prevention of further need and facilitating the overall recovery effort. 1. Perform Needs-Assessment This has been stressed before in the discussion of the preplanning stage and again in the treatment of the postimpact period. We cannot emphasize too strongly that this should be an ongoing process. Par- ticularly in a situation as fluid as that following disaster, an evalua- tion of what is needed at a given time is no indication of what may be needed later. At the very outset, program personnel should realize and keep in mind that a disaster mental health program is intended to be temporary. The length of the postdisaster period varies from place to place, depending on the degree of severity of the disaster, and there is nothing magic in the 6-12 month timespan stipulated by some fund- ing agencies; however, an end point will inevitably come for any dis- aster program. This must be taken into account from program incep- tion. A periodic assessment of disaster-related mental health needs, as they change over time, helps in the phasing out of components of the program as they outlive their usefulness and in the incorporation of other components that have continued value for community mental health into the existing system of the community’s caregiving resources. The same four methods of needs assessment outlined above (see Impact/Emergency period) can be used at this time. Clinical assess- ments made by professionals and other crisis interveners, in working with individuals, can give an idea of the specific types of problems being encountered. Statistical information from agency caseloads and various kinds of public records can objectively indicate the extent of community, social, and economic disruption and can indirectly sug- gest the nature, range, and scope of problems that have bearing on mental health needs. A number of these indirect indicators were listed earlier. Others that can be collected over a longer time are: police records on family disputes; child abuse and neglect; juvenile delin- quency; school attendance records; marriage and divorce records; number of days closed for schools, hospitals, churches, workplaces; hospital admissions; welfare assistance applications, including food stamps; unemployment numbers and costs; housing losses, including minor and major damage as well as complete loss; and disruption of public transportation, service. Data gathered by helping organiza- tions—the Information and Referral Center, the Red Cross, Inter- faith, etc.—can provide leads on particular neighborhoods and population groups that have been hardest hit and seem to be most affected. Of particular worth in longrunneeds assessment, and more 129 CRISIS INTERVENTION FOR DISASTER VICTIMS feasible than during the immediate postimpact period because there is more time, is the gathering of direct indicators of needs through survey data, i.e., going straight to the people of the community, to the victims themselves, and asking them about what they need and want. If groups, such as a local interfaith organization or any other social agency, plan to do any kind of survey, they might be asked to include some questions relating to mental health on their questionnaire. Another possibility is to recruit the services of a nearby college sociology, psychology, or community medical department to conduct such a survey. One other means for gathering direct indicators is to conduct a survey in conjunction with performing outreach, since this would spare victims too many knocks on the door and improve chances for gaining entry. 2. Offer Crisis Intervention and Information and Referral Services We have defined crisis intervention and information and referral and their rationale as service tactics and have particularly endorsed their use during the postimpact phase. While the need for such services is not as pronounced once the initial period is over, it still exists. Crisis is an individual as well as a community experience. As stated above, many people do not allow themselves to feel loss, tension, or any other kind of emotional disturbance right away and, thus, put off coming to a One-Stop or Disaster Center. If such a problem is felt and it becomes more than the person can deal with, crisis can occur. To be useful, crisis intervention must offer practical as well as emo- tional assistance, hence the tie in with information and referral. To be truly helpful on a practical level, one must know what resources are available from day to day in a disaster-stricken community and must be prepared to help people secure the aid they need. Information and referral involve coordination with other agencies to insure that the work is shared and distributed, rather than duplicated, and to keep abreast of who is doing what during the somewhat confused recovery period. A limited number of information and referral points are desirable in order to facilitate coordination and the exchange of in- formation. Information and referral that become too specialized lose. their effectiveness as a disaster strategy; crisis workers must be capa- ble of providing assistance with all kinds of problems. Service is not complete when information is merely conveyed verbally. It may also be necessary to provide transportation, an interpreter or advocate, child care, and other services in order to insure that the victim ac- tually gains access to the resources to which he or she has been re- ferred. Finally, followup on referrals is essential. Such aid, which helps meet many needs, is good not only in itself, but also in that it opens doors for disclosure of psychological needs. If, in the course of giving help on such practical matters, a crisis worker 130 MATCHING NEEDS AND RESOURCES finds evidence of, or is taken into confidence regarding emotional problems, the worker is then in a position to better exercise skills of a more direct mental health nature. For most disaster victims a few ses- sions emphasizing what the victim can do to cope are more effective than extended therapy. For the relatively few cases where a pre-exist- ing emotional problem is exacerbated by disaster, it is better for the crisis worker, personally, to get the victim involved with a regular community mental health agency. Such an agency is more appropriate and has the required skills for long—term counseling so that continuity of care of the victim does not become a problem when the disaster mental health program is phased out. In the case of children who are experiencing adverse effects from the disaster, crisis workers can best intervene through the parents, in- structing them to give their children the opportunity to ventilate their problems and to make a special attempt to give them more time and attention, even though the adults may be busy rebuilding and reorganizing their lives. Again, for more severe problems, parents should be assisted in seeking help from a regular mental health or child welfare agency. 3. Conduct Outreach and Casefinding Activities A basic question in disaster mental health, generally, and in rural mental health, disaster or otherwise, is, not so much, what to deliver, but how, when, and where to deliver it. A disaster mental health program certainly needs a home base from which to operate; yet, those who have experience in these matters say it is a mistake to assume that people will come to a stationary facility, in great numbers, requesting counseling. Disaster victims have been found to welcome the oppor- tunity to share their experiences and feelings and to exchange infor- mation, but they will not necessarily seek out such opportunity. As the postdisaster period lengthens and patterns of life settle back to nor- mal, people may become increasingly reluctant to go to formal caregivers for help with disaster-related problems. A strategy that has been found to be effective during this phase is that of outreach. Some things to consider in establishing an outreach program are personnel selection, training and program goals, and philosophy. Outreach personnel can be quite diverse—professionals from out- side the community or from local agencies, trained paraprofessionals, and indigenous volunteers. The selection of outreach workers merits considerable attention. One program (Heffron 1975) used the criteria that workers be indigenous to the disaster-affected area and/or be directly, personally affected by the disaster and/or have experience in the delivery of human services to disaster victims. Usually workers who are in some way known to victims have the greatest chance of 131 CRISIS INTERVENTION FOR DISASTER VICTIMS being accepted. Familiarity alone is not enough, however. Effective- ness of outreach workers is dependent, as well, on possession of a num— ber of personal traits which Collins and Pancoast (1976) summarized in the concept of “freedom from drain.” The person who undertakes to, help others in times of trouble must possess sufficient emotional and physical resources and must be receiving sufficient personal rewards to be truly capable of helping. Some specific qualities required in an outreach worker would be a high level of energy in order to remain ac- tive and resourceful in the face of shared stresses, a strong personality capable of showing a wide range of emotions, and experience in living, manifested by the capacity to negotiate with others and the ability to establish rapport with outside sources of power (other agencies) as well as with victims. In one community that mounted an outreach effort (Bowman 1975), it was felt that selection of workers was critical to the success of the program. Since only about 15-20 people were needed, about the number most smaller towns would find adequate, they decided not to advertise widely or go through a lengthy and perhaps faulty screening process, but to directly recruit “natural helpers”—typically, women and some men from the community who were known to one or another of the program committee as “good with people.” Training in generic disaster relief and crisis intervention techniques is necessary where volunteers are used and is recommended even for professionals. Money for training is available where there is an ap- proved Section 413 project in federally declared disasters. There are a number of tested programs that local mental health agencies can ob- tain and conduct for very little money, even prior to a disaster or in disasters where Federal funds are not available. Several of these are cited in the bibliography. Generally, for most outreach programs, training has been given in two phases. The first is usually a 1-2 week intensive workshop which orients workers to the disaster context and provides information on specific problem areas and specific resources for dealing with them.1 After workers are already functioning in assigned roles, they attend a series of meetings designed to enhance natural helping skills and to help them respond to changing needs of community and client. Another factor which has been found to relate to the success of out- reach programs concerns how the workers see themselves and their jobs. The professional specialist who is accustomed to sitting in an office offering service for a relatively circumscribed range of problems 1More recent Section 413 project experience indicates that an initial 243 day orientation session, sup- plemented by regular meetings and workshops during the 6-month program, more nearly fits the project time parameters and still allows for adequate staff training. 132 MATCHING NEEDS AND RESOURCES may have trouble stepping into the role of outreach worker. Actually, mental health professionals in small town agencies tend to function in a broader context than their counterparts in urban centers, seeing the mental health center more as a social agency (Jones, Wagenfield, and Robin 1976) and would, therefore, probably work well in an outreach capacity. Shortages of professional expertise and a need to keep the regular caregiving system functioning at an adequate level for the regular patient load, however, preclude professionals providing much more than training, diagnosis, and supervision to a disaster outreach effort. A role that we find particularly appropriate to rural mental health and disaster mental health programs is that of the Service Guide (Raft, Coley, and Miller 1976). The term itself is a good one, implying as it does a level of expertise somewhere between that of the profes- sional and the typical volunteer. It is also neutral with regard to the mental health label. The Service Guide visits people in their homes, even those in isolated areas, and is prepared intellectually and at- titudinally to provide help on all problems—material, physical, and emotional. While trained in crisis intervention techniques, he is ready to provide needed information and referral to the point of transporting and accompanying individuals to needed resources and following up on the case by providing support and encouragement to continue necessary treatment or helpseeking. In a study where Service Guides worked for a year and were then discontinued (Raft, Coley, and Miller 1976), it was found that the percentages of blacks, nursing home resi- dents, the elderly, and children under 12 who had previously used for- mal mental health services significantly seriously decreased. A truism often heard in small towns and elsewhere is that “those who need most, don’t get.” The use of Service Guides to reach out to people ap- pears to help overcome the imbalance of need and service in rural communities. One problem frequently mentioned in connection with outreach is that people sometimes resent “agency” people knocking on their doors offering help, i.e., “charity.” Workers themselves have a normal fear of rejection. Yet it is clear that a community mental health program, as a disaster mental health program so emphatically is, must be a real part of the community. Workers cannot simply sit behind desks at a center and expect to help a town that has been torn apart. In some Nebraska communities (Omaha Tornado Report 1976), this dilemma was resolved as workers developed and expressed a sin- cere interest in how‘ people coped with disaster. Going from house to house asking not how badly people were doing, but how well, and stressing that what Victims had to say would be helpful to others, workers overcame resistance in themselves and the people they visited. 133 CRISIS INTERVENTION FOR DISASTER VICTIMS One method for opening doors that the Nebraska workers used, which as we suggested earlier would be an invaluable tool for needs assess— ment, was to take a survey. In the process of gaining‘direct informa- tion on community needs, workers used the survey as a tool for emo- tional support, providing those they visited with an opportunity to vent feelings and to be reassured about the normality of those feelings. 4. Provide Consultation and Education Services to the Entire Community As an alternative to direct service methods such as outreach, or as a supplement that serves the community as a whole, while outreach and crisis intervention deal with individuals, consultation, and education, it is a way of fortifying existing helping resources to meet mental health needs. Parallel to the crisis intervention framework of focusing on strengths rather than on weaknesses, consultation and education emphasize what the community can do and reinforce the feeling that the collective citizenry is already doing well to meet the challenge of disaster. The strategy is simply one of investing scarce mental health resources into areas where the returns will be greatest. In one noteworthy application of community-wide consultation and educa- tion (Hollister et a1. 1973), the phrase “effective parsimony” was coined to describe how limited funds and relatively few clinicians can be committed to an extensive program of consultations, agency staff training, and citizen education, to meet the needs of people who seek help for their emotional problems somewhere other than formal men- tal health agencies. To do so as efficiently and effectively as possible, mental health consultation and education programs must be coordinated with other existing resources, both formal and informal. This coordination must be done in a way that requires the least disruption of the individual victim’s life, uses the least effort that is reasonably effective, and employs the least expenditure of time and effort. This is achieved by meeting with people where they are—on the job, in schools, and in neighborhoods. The use of other agencies that most nearly fit in with normal living patterns is encouraged, as is the use of services that re- quire the least time and training first, such as crisis intervention, sav- ing highly educated professionals and sophisticated clinical pro- cedures for more difficult cases (Hollister et al. 1973). As we have often noted, a number of human service agencies and formal caregivers have a preeminent mental health role in smaller and rural communities. Since these are the resources to which people typically turn for help, local mental health professionals can strengthen them in their roles by conducting workshops and training 134 MATCHING NEEDS AND RESOURCES sessions with informal community caregivers such as general practi- tioners and other physicians, ministers, public health nurses and local hospital nurses, and the staffs of residential facilities such as nursing homes and children’s villages. Lay people who are motivated to learn more about mental health may be reached through meetings at churches, schools, and the wait- ing rooms of agencies. Groups of parents and teachers are primary targets for consultation and education, since they would be the first to notice any manifestations of disaster-related emotional problems in children and are in an excellent position to help such children. Even if nothing is done in terms of mental health programing in a town ex- periencing disaster, adults involved in recovery efforts have at least some opportunity to tell their stories and share their feelings with others. Children may not have this opportunity, since schools are often closed and play groups disrupted in the disaster’s aftermath. Moreover, parents often feel that it is beneficial for their children to “try to forget it” and, therefore, avoid talking about the disaster when the children are present. This attitude, while well intentioned, has been found to hinder rather than help the child in dealing with his fears. Several disaster programs have been concerned with the effects that tornadoes, floods, and earthquakes, etc., have had on children. The Omaha Tornado Project (1976), among others, developed ex- cellent techniques for alleviating fear, confusion, and discomfort, in- cluding a coloring book for children and fliers for parents and teachers explaining what children may be feeling and what action to take. Consultation and education can reach the general public via radio and TV spots and longer programs, fliers, pamphlets, displays at shop- ping centers and grocery stores, and newspaper articles. Mental health is not hard to sell, even to those who traditionally resist the label and formal services, if it is couched in terms that can be easily understood and applied to daily life and that show that everybody has a part to play. A positive, self-help approach, rather than a sickness-focused, psychiatry-centered one, seems tailormade for communities and peo- ple whose ethos places high value on self-reliance. A program of this scope does not spring up full blown. Leadership is required to win community support, to share joint planning with! other agencies, to share decisionmaking with other disciplines, and to work toward interagency participation in the implementation of the con- sultation and education strategy. In disaster, leadership tends to be emergent, often falling to whomever is willing to assume it. The result of the mental health profession taking an active role in coordinating a program designed to spread mental health knowledge and skills throughout the community is increased visibility of the whole field, which can have positive ramifications long after recovery. 135 CRISIS INTERVENTION FOR DISASTER VICTIMS The assumption of a leadership role, however, requires an increased sensitivity to the needs of those led. In any community, particularly a close-knit one, the rise of one segment, such as the mental health profession, into a position of relative power or centrality can result in conflict and/or ineffectiveness without the guidance of an operating philosophy that is truly community oriented. ' Eisdorfer, Altrocchi, and Young (1968), in years of experience with establishing consultation and education programs in rural com- munities, have elucidated certain principles that seem highly opera— tive. 0 Certain of these have relevance to the postdisaster context. The support of community leaders is crucial for the development of a mental health program. While a key individual may play the central role in starting a program, he must depend upon the sup- port of other community figures for long-range development. An accurate appraisal of community needs, supported by data, is extremely helpful in approaching community agencies, especially those with fiscal responsibilities. Flexibility in meeting needs is extremely important. Although a consultation and education program needs protection against in- undation by clinical services, it should, nevertheless, be recog- nized that in selected instances direct clinical intervention is an important aspect of program development. A new consultation and education program will increase the community’s awareness of mental health problems, and the de- mand for clinical services will rise. Plans should be made for meeting such demands. In dealing with different professionals, it should be understood that each profession has its own way of doing things, and such patterns should be respected. Existence over time is most helpful for consultation and educa- tion. Offering aid a little at a time over a year is far more effec- tive than an intensive effort lasting a few weeks. One of the foremost functions of consultation and education is to help the community recognize widespread mental health problems and assist the proper agents in the community in deal- ing with them. The most appropriate attitude of consultants, especially those from outside the community, is one of eagerness to learn from the community. 5. Maintain the Existing Caregiving System Although we have been primarily concerned here with developing new strategies for meeting disaster-related mental health needs, we in 136 MATCHING NEEDS AND RESOURCES no way mean to imply that the existing caregiving system is unimpor- tant or should be neglected. We are emphatic about the notion that a disaster service delivery system is not an entity that will replace the existing system, but is rather one to be built into and integrally linked with what has gone before. Those caregivers who have long been active in the community can be an invaluable source of support in terms of manpower and administrative structure and can lend credibility and acceptance to disaster programs. They are, moreover, important in and of themselves. ' Even in a major catastrophe, a significant number, perhaps ama— jority, of people will be either unaffected or only marginally affected. They will continue to need the services they have been accustomed to receiving. As the postdisaster period lengthens and disaster-related needs are met, some of those who have been victims will reassume status as normal agency consumers. In addition, it is highly likely that, as an outcome of receiving mental health services from disaster crisis workers, many previous victims who had not before been con— sumers of mental health services will be more aware of ongoing men- tal health needs and will thus increase the demand for such services. One of the basic rationales for crisis intervention, used here in the generic rather than the technical sense, is that those who are given both practical and emotional support at a time when their own coping mechanisms are inadequate can come through the crisis stronger than before—better able to handle whatever emergencies present them- selves in the future. As this applies to individuals, it likewise applies to systems as a whole. If the existing caregiving system is linked with the disaster response effort and, at the same time, is given the necessary community support to keep its nondisaster services at a high level, it can emerge at the end of the recovery period more comprehensive and more effective than before. Such enhanced capabilities are important in relation to the final strategy to be considered. 6. Make All Necessary Arrangements for Phaseout and Evaluation of the Work As a part of the overall disaster recovery effort, the purpose of a dis- aster mental health program is to “work itself out of business.” Fund- ing, if it has been obtained, will run out at a specified time. Those programs mounted with local resources have more flexibility as to ter— mination date, but eventually it will become apparent that disaster-re- lated needs have largely been satisfied, and the program itself will have reached a point of diminishing returns. The primary object of the phaseout period is continuity of care for those whose needs are still manifest. Here is where a strengthened ongoing caregiving system becomes essential, since services to these people will have to be ab- sorbed by local community resources. This process will be facilitated if 137 CRISIS INTERVENTION FOR DISASTER VICTIMS victims recognized as having need for long—term care are referred to other agencies as early as possible. In the case of people who are hav— ing an unusually difficult time resolving disaster-related problems, there should be discussions with, and referrals to, the appropriate ongoing organizations. Finally, communities which have received State or Federal funds for disaster mental health programs are required to submit a final evaluation to their funding sources. Even where a final report is not mandatory, a program will benefit tremendously by virtue of ongoing evaluation, conducted in conjunction with needs assessment. Program planners need to assess the strengths and weaknesses, and the ac- complishments and failures of their programs in order to upgrade ongoing services. Once this has been done, they should consider dis- seminating their experiences and program assessments by means of seminars, conferences, media reports, or published articles. Ex- periences and recommendations shared in this fashion would be of positive value to other communities which may suffer a disaster, as well as to the whole field of disaster research. Throughout the foregoing chapter we have attempted to provide those interested in planning for and delivering emergency mental health services in disasters with a series of practical, detailed sugges- tions for developing programs suitable for use at the local level. In ad- dition to attempting to convey a sense of what it is like to try to con- duct mental health work in the turbulent physical and social environ- ment of the postdisaster setting, we have sought to emphasize a num- ber of points that should probably be briefly reiterated. In general, these are some of the more important ideas: 1. It is possible to organize an efficient and effective mental health-oriented response to disaster even in areas which are relatively lacking in resources. In order to do this, however, preplanning is necessary. Sources of information and expertise exist to help with this planning. 2. Planning for the delivery of counseling services in disasters, as well as for the actual provision of services, is, in the last analysis, a local responsibility. Nevertheless, the States bear a large share of the responsibility for stimulating, coordinating, and assisting local communities in developing mental health disaster plans. 3. In the event of a communitywide disaster, logistic and finan- cial assistance is available from Federal sources and, in many cases, from the State level, explicitly designated for use in the provision of counseling and other needed services to disaster victims. 138 MATCHING NEEDS AND RESOURCES . Individuals who have experienced disaster impact are, in the main, normal, healthy individuals who may be experiencing an unprecedented degree of stress. The therapeutic stance that should be taken toward most victims, at least 1n the short run, is one that offers counseling and broad human services that deemphasize the intensive psychotherapeutic and treatment aspects of mental health care. . Programs work best that deliver services “where the client is.” This is the case both with reference to the client’s physical location (in a hospital, in a shelter, at a work site) and to the client’s wants and needs. . In the event that an expanded mental health program is judged to be necessary, the use of volunteers and paraprofes- sionals is highly appropriate in the postdisaster situation, par- ticularly in such important areas as outreach and information and referral. Those organizing a postdisaster mental health program should recruit volunteers from among traditional, informal community caregivers. . Needs assessment is an integral part of the delivery of dis- aster-related mental health services at all phases of operation. . In order to insure continuity of care for all community mem- bers requiring mental health services, it is important to: (a) maintain predisaster levels of service for clients already receiving mental health services; and (b) work throughout the period with the regular agencies to arrange for the phasing out of special disaster mental health programs at the end of the postdisaster period. 139 APPENDIX l Public Law 93—288 May 22, 1974 Title IV—Federal Disaster Assistance Programs 42 USC 5171. FEDERAL FACILITIES SEC. 401. (a) The President may authorize any Federal agency to repair, reconstruct, restore, or replace any facility owned by the United States and under the jurisdiction of such agency which is damaged or destroyed by any major disaster if he determines that such repair, reconstruction, restoration, or replacement is of such importance and urgency that it cannot reasonably be deferred pending the enactment of specific authorizing legislation or the making of an appropriation for such purposes, or the ob- taining of congressional committee approval. (b) In order to carry out the provisions of this section, such repair, reconstruction, restoration, or replacement may be begun notwithstanding a lack or an insufficiency of funds appropriated for such purpose, where such lack or insufficiency can be remedied by the transfer in accordance with law, of funds appropriated to that agency for another purpose. (c) In implementing this section, Federal agencies shall evaluate the natural hazards to which these facilities are exposed and shall take appropriate action to mitigate such hazards, in- cluding safe land—use and construction practices, in accordance with standards prescribed by the President. 140 42 USC 5172. “Public facility.” Limitation. APPENDIXES REPAIR AND RESTORATION OF DAMAGED FACILITIES SEC. 402. (a) The President is authorized to make contributions to State or local govern- ments to help repair, restore, reconstruct, or replace public facilities belonging to such State or local governments which were damaged or destroyed by a major disaster. (b) The President is also authorized to make grants to help repair, restore, reconstruct, or replace private nonprofit educational, utility, emergency, medical, and custodial care facilities, including those for the aged or dis- abled, and facilities on Indian reservations as defined by the President, which were damaged or destroyed by a major disaster. (c) For those facilities eligible under this sec— tion which were in the process of construction when damaged or destroyed by a major disaster, the grant shall be based on the net costs of restoring such facilities substantially to their predisaster condition. (d) For the purposes of this section, “public facility” includes any publicly owned flood con- trol, navigation, irrigation, reclamation, public power, sewage treatment and collection, water supply and distribution, watershed develop- ment, or airport facility, any non-Federal-aid street, road, or highway, any other public build- ing, structure, or system including those used for educational or recreational purposes, and any park. (e) The Federal contribution for grants made under this section shall not exceed 100 per cen- tum of the net cost of repairing, restoring, reconstructing, or replacing any such facility on the basis of the design of such facility as it ex- isted immediately prior to such disaster and in conformity with current applicable codes, specifications, and standards. (f) In those cases where a State or local government determines that public welfare would not be best served by repairing, restoring, 141 42 USC 5173. APPENDIXES reconstructing, or replacing particular public facilities owned or controlled by that State or that local government which have been damaged or destroyed in a major disaster, it may elect to receive, in lieu of the contribution described in subsection (e) of this section, a con- tribution based on 90 per centum of the Federal estimate of the total cost of repairing, restoring, reconstructing, or replacing all damaged facilities owned by it within its jurisdiction. The cost of repairing, restoring, reconstructing, or replacing damaged or destroyed public facilities shall be estimated on the basis of the design of each such facility as it existed immediately prior to such disaster and in conformity with current applicable codes, specifications and standards. Funds contributed under this subsection may be expended either to repair or restore certain selected damaged public facilities or to construct new public facilities which the State or local government determines to be necessary to meet its needs for governmental services and func- tions in the disaster-affected area. DE BRIS REMOVAL SEC. 403. (a) The President, whenever he determines it to be in the public interest, is authorized— (1) through the use of Federal depart- ments, agencies, and instrumentalities, to clear debris and wreckage resulting from a major disaster from publicly and privately owned lands and waters; and (2) to make grants to any State or local government for the purpose of removing debris or wreckage resulting from a major disaster from publicly or privately owned lands and waters. (b) No authority under this section shall be exercised unless the affected State or local goverment shall first arrange an unconditional authorization for removal of such debris or wreckage from public and private property, and, in the case of removal of debris or wreckage from 142 42 USC 5174. APPENDIXES private property, shall first agree to indemnify the Federal Government against any claim aris- ing from such removal. TEMPORARY HOUSING ASSISTANCE SEC. 404. (a) The President is authorized to provide, either by purchase or lease, temporary housing, including, but not limited to, unoccu- pied habitable dwellings, suitable rental hous- ing, mobile homes or other readily fabricated dwellings for those who, as a result of a major disaster, require temporary housing. During the first twelve months of occupancy no rentals shall be established for any such accommodations, and thereafter rentals shall be established, based upon fair market value of the accom- modations being furnished, adjusted to take into consideration the financial ability of the occu- pant. Any mobile home or readily fabricated dwelling shall be placed on a site complete with utilities prOvided either by the State or local government, or by the owner or occupant of the site who was displaced by the major disaster, without charge to the United States. The Presi- dent may authorize installation of essential utilities at Federal expense and he may elect to provide other more economical or accessible sites when he determines such action to be in the public interest. (b) The President is authorized to provide assistance on a temporary basis in the form of mortgage or rental payments to or on behalf of individuals and families who, as a result of fi- nancial hardship caused by a major disaster, have received written notice of dispossession or eviction from a residence by reason of foreclosure of any mortgage or lien, cancellation of any contract of sale, or termination of any lease, entered into prior to such disaster. Such assistance shall be provided for a period of not to exceed one year or for the duration of the period of financial hardship, whichever is the lesser. (c) In lieu of providing other types of tempor- ary housing after a major disaster, the President 143 Nondiscrimination. 42 USC 5175. 43 USC 4321 note. APPENDIXES is authorized to make expenditures for the pur- pose of repairing or restoring to a habitable con- dition owner-occupied private residential struc- tures made uninhabitable by a major disaster which are capable of being restored quickly to a habitable condition with minimal repairs. No assistance provided under this section may be used for major reconstruction or rehabilitation of damaged property. (d )( 1) Notwithstanding any other provision of law, any temporary housing acquired by purchase may be sold directly to individuals and families who are occupants of temporary hous- ing at prices that are fair and equitable, as deter- mined by the President. (2) The President may sell or otherwise make available temporary housing units directly to States, other governmental entities, and volun- tary organizations. The President shall impose as a condition of transfer under this paragraph a covenant toxcomply with the provisions of sec- tion 31 1 of this Act requiring nondiscrimination in occupancy of such temporary housing units. Such disposition shall be limited to units purchased under the provisions of subsection (a) of this section and to the purposes of providing temporary housing for disaster victims in emergencies or in major disasters. PROTECTION OF ENVIRONMENT SEC. 405. No action taken or assistance pro- vided pursuant to sections 305, 306, or 403 of this Act, or any assistance provided pursuant to section 402 or 419 of this Act that has the effect of restoring facilities substantially as they ex- isted prior to the disaster, shall be deemed a ma- jor Federal action significantly affecting the quality of the human environment within the meaning of the National Environmental Policy Act of 1969 (83 Stat. 852). Nothing in this sec- tion shall alter or affect the applicability of the National Environmental Policy Act of 1969 (83 Stat. 852) to other Federal actions taken under this Act or under any other provision of law. 144 42 USC 5176. Natural hazards, evaluation. 42 USC 5177. Time limitation. . .- - a. .u-.-~w MINIMUM STANDARDS FOR PUBLIC AND PRIVATE STRUCTURES SEC. 406. As a condition of any disaster loan or grant made under the provisions of this Act, the recipient shall agree that any repair or con- struction to be financed therewith shall be in‘ac- cordance with applicable standards of safety, de- cency, and sanitation and in conformity with ap— plicable codes, specifications, and standards, and shall furnish such evidence of compliance with this section as may be required by regula- tion. As a further condition of any loan or grant made under the provisions of this Act, the State or local government shall agree that the natural hazards in the areas in which the proceeds of the grants or loans are to be used shall be evaluated and appropriate action shall be taken to miti- gate such hazards, including safe land-use and construction practices, in accordance with standards prescribed or approved by the Presi- dent after adequate consultation with the ap- propriate elected officials of general purpose local governments, and the State shall furnish such evidence of compliance with this section as may be required by regulation. UNEMPLOYMENT ASSISTANCE SEC. 407. (a) The President is authorized to provide to any individual unemployed as a result of a major disaster such benefit assistance as he deems appropriate while such individual is unemployed. Such assistance as the President shall provide shall be available to an individual as long as the individual’s unemployment caused by the major disaster continues or until the individual is reemployed in a suitable posi- tion, but no longer than one year after the major disaster is declared. Such assistance for a week of unemployment shall not exceed the maximum weekly amount authorized under the unemploy- ment compensation law of the State in which the disaster occurred, and the amount of assistance under this section to any such individual for a week of unemployment shall be reduced by any 145 Agreement with State agencies. Reemployment assistance services. 42 USC 5178. Federal share. Advances. Limitation. APPENDIXES amount of unemployment compensation or of private income protection insurance compensa- tion available to such individual for such week of unemployment. The President is directed to provide such assistance through agreements with States which, in his judgment, have an ade- quate system for administering such assistance through existing State agencies. (b) The President is further authorized for the purposes of this Act to provide reemployment assistance services under other laws to in- dividuals who are unemployed as a result of a major disaster. INDIVIDUAL AND FAMILY GRANT PROGRAMS SEC. 408. (a) The President is authorized to make a grant to a State for the purpose of such State making grants to meet disaster-related necessary expenses or serious needs of in- dividuals or families adversely affected by a ma- jor disaster in those cases where such in- dividuals or families are unable to meet such ex- penses or needs through assistance under other provisions of this Act, or from other means. The Governor of a State shall administer the grant program authorized by this section. (b) The Federal share of a grant to an in- dividual or a family under this section shall be equal to 75 per centum of the actual cost of meeting such an expense or need and shall be made only on condition that the remaining 25 per centum of such cost is paid to such in— dividual or family from funds made available by a State. Where a State is unable immediately to pay its share, the President is authorized to ad- vance to such State such 25 per centum share, and any such advance is to be repaid to the United States when such State is able to do so. No individual and no family shall receive any grant or grants under this section aggregating more than $5,000 with respect to any one major disaster. 146 APPENDIXES Regulations. (c) The President shall promulgate regula- tions to carry out this section and such regula- tions shall include national criteria, standards, and procedures for the determination of eligibility for grants and the administration of grants made under this section. Administration ex- ((1) A State may expend not to exceed 3 per penses, limitation. centum of any grant made by the President to it under subsection (a) of this section for expenses of administering grants to individuals and families under this section. Effective data. (e) This section shall take effect as of April 20, 1973. FOOD COUPONS AND DISTRIBUTION 42 USC 5179. SEC. 409. (a) Whenever the President deter- mines that, as a result of a major disaster, low- income households are unable to purchase ade- quate amounts of nutritious food, he is authorized, under such terms and conditions as he may prescribe, to distribute through the Secretary of Agriculture or other appropriate agencies coupon allotments to such households pursuant to the provisions of the Food Stamp 78 Stat. 703. Act of 1964 (PL. 91-671; 84 Stat. 2048) and to 7 USC 2011 note. make surplus commodities available pursuant to the provisions of this Act. (b) The President, through the Secretary of Agriculture or other appropriate agencies, is authorized to continue to make such coupon allotments and surplus commodities available to such households for so long as he determines necessary, taking into consideration such factors as he deems appropriate, including the conse- quences of the major disaster on the earning power of the households, to which assistance is made available under this section. (0) Nothing in this section shall be construed as amending or otherwise changing the provi- sions of the Food Stamp Act of 1964 except as they relate to the availability of food stamps in an area affected by a major disaster. 147 Emergency mass feeding. 42 USC 5180. 49 Stat. 774. 42 USC 5181. 84 Stat. 1894. 42 USC 4601 note. 42 USC 5182. 42 USC 5183. APPENDIXES FOOD COMMODITIES SEC. 410. (a) The President is authorized and directed to assure that adequate stocks of food will be ready and conveniently available for emergency mass feeding or distribution in any area of the United States which suffers a major disaster or emergency. (b) The Secretary of Agriculture shall utilize funds appropriated under section 32 of the Act of August 24, 1935 (7 USC. 612C), to purchase food commodities necessary to provide adequate supplies for use in any area of the United States in the event of a major disaster or emergency in such area. RELOCATION ASSISTANCE SEC. 411. Notwithstanding any other provi- sion of law, no person otherwise eligible for any kind of replacement housing payment under the Uniform Relocation Assistance and Real Prop- erty Acquisition Policies Act of 1970 (PL. 91-646) shall be denied such eligibility as a result of his being unable, because of a major disaster as determined by the President, to meet the occupancy requirements set by such Act. LEGAL SERVICES SEC. 412. Whenever the President determines that low-income individuals are unable to secure legal services adequate to meet their needs as a consequence of a major disaster, consistent with the goals of the programs authorized by this Act, the President shall assure that such programs are conducted with the advice and assistance of appropriate Federal agencies and State and local bar associations. CRISIS COUNSELING ASSISTANCE AND TRAINING SEC. 413. The President is. authorized (through the National Institute of Mental Health) to provide professional counseling serv- ices, including financial assistance to State or local agencies or private mental health 148 Loans to local governments. 42 USC 5184. Repayment. 31 USC 1261 and note. APPENDIXES organizations to provide such services or train- ing of disaster workers, to victims of major dis— asters in order to relieve mental health problems ' caused or aggravated by such major disaster or its aftermath. COMMUNITY DISASTER LOANS SEC. 414. (a) The President is authorized to make loans to any local government which may suffer a substantial loss of tax and other revenues as a result of a major disaster, and has demonstrated a need for financial assistance in order to perform its governmental functions. The amount of any such loan shall be based on need, and shall not exceed 25 per centum of the annual operating budget of that local govern- ment for the fiscal year in which the major dis- aster occurs. Repayment of all or any part of such loan to the extent that revenues of the local government during the three full fiscal year period following the major disaster are insuffi- cient to meet the operating budget of the local government, including additional disaster-re- lated expenses of a municipal operation character shall be cancelled. (b) Any loans made under this section shall not reduce or otherwise affect any grants or other assistance under this Act. (c)(1) Subtitle C of title I of the State and Local Fiscal Assistance Act of 1972 (PL. 92-512; 86 Stat. 919) is amended by adding at the end thereof the following new section: “SEC. 145. ENTITLEMENT FACTORS AFFECTED BY MAJOR DISASTERS. “In the administration of this title the Secretary shall disregard any change in data used in determin— ing the entitlement of a State government or a unit of local government for a period of 60 months if that change— “(1) results from a major disaster deter- mined by the President under section 301 of the Disaster Relief Act of 1974, and “(2) reduces the amount of the entitle- ment of that State government or unit of local government.” 149 Effective date. 42 USC 5185. 42 USC 5186. 42 USC 5187. Cost-sharing. 42 USC 5188. APPENDIXES (2) The amendment made by this section takes effect on April 1, 1974. EMERGENCY COMMUNICATIONS SEC. 415. The President is authorized during, or in anticipation of, an emergency or major dis- aster to establish temporary communications systems and to make such communications available to State and local government officials and other persons as he deems appropriate. EMERGENCY PUBLIC TRANSPORTATION SEC. 416. The President is authorized to pro- vide temporary public transportation service in an area affected by a major disaster to meet emergency needs and to provide transportation to governmental offices, supply centers, stores, post offices, schools, major employment centers, and such other places as may be necessary in order to enable the community to resume its nor- mal pattern of life as soon as possible. FIRE SUPPRESSION GRANTS SEC. 417. The President is authorized to pro- vide assistance, including grants, equipment, supplies, and personnel, to any State for the sup- pression of any fire on publicly or privately owned forest or grassland which threatens such destruction as would constitute a major disaster. TIMBER SALE CONTRACTS SEC. 418. (a) Where an existing timber sale contract between the Secretary of Agriculture or the Secretary of the Interior and a timber purchaser does not provide relief from major physical change not due to negligence of the purchaser prior to approval of construction of any section of specified road or of any other specified development facility and, as a result of a major disaster, a major physical change results ~ in additional construction work in connection with such road or facility by such purchaser with an estimated cost, as determined by the ap- propriate Secretary, (1) of more than $1,000 for sales under one million board feet, (2) of more 150 APPENDIXES than $1 per thousand board feet for sales of one to three million board feet, or (3) of more than $3,000 for sales over three million board feet, such increased construction cost shall be borne by the United States. Contract cancella- (b) If the appropriate Secretary determines tion. that damages are so great that restoration, reconstruction, or construction is not practical under the cost-sharing arrangement authorized by subsection (a) of this section, he may allow cancellation of a contract entered into by his Department notwithstanding contrary provi- sions therein. Sale of tim- (c) The Secretary of Agriculture is authorized ber, notice. to reduce to seven days the minimum period of 30 Stat. 35. advance public notice required by the first sec— tion ofthe Act of June 4, 1897 (16 U.S.C. 476), in connection with the sale of timber from national forests, whenever the Secretary determines that (1) the sale of such timber will assist in the con- struction of any area of a State damaged by a major disaster, (2) the sale of such timber will assist in sustaining the economyrof such area, or (3) the sale of 'such timber is necessary to salvage the value of timber damaged in such major dis- aster or to protect undamaged timber. (d) The President, when he determines it to be in the public interest, is authorized to make grants to any State or local government for the purpose of removing from privately owned lands timber damaged as a result of a major disaster, and such State or local government is authorized upon application, to make payments out of such grants to any person for reimburse- ment of expenses actually incurred by such per- son in the removal of damaged timber, not to ex- ceed the amount that such expenses/exceed the salvage value of such timber. IN-LIEU CONTRIBUTION 42 USC 5189. SEC. 419. In any case in which the Federal estimate of the total cost of (1) repairing, restor- ing, reconstructing, or replacing, under section 402, all damaged or destroyed public facilities 151 APPENDIXES owned by a State or local government within its jurisdiction, and (2) emergency assistance under section 306 and debris removed under section 403, is less than $25,000, then on application of a State or local government, the President is authorized to make a contribution to such State or local government under the provisions of this section in lieu of any contribution to such State or local government under section 306, 402, or 403. Such contribution shall be based on 100 per centum of such total estimated cost, which may be expended either to repair, restore, reconstruct, or replace all such damaged or destroyed public facilities, to repair, restore, reconstruct, or replace certain selected damaged or destroyed public facilities, to construct new public facilities which the State or local govern- ment determines to be necessary to meet its needs for governmental services and functions in the disaster—affected area, or to undertake dis- , aster work as authorized in section 306 or 403. The cost of repairing, restoring, reconstructing, or replacing damaged or destroyed public facilities shall be estimated on the basis of the design of each such facility as it existed im- mediately prior to such disaster and in conform- ity with current applicable codes, specifications and standards. 152 APPENDIX II Rules and regulations for implementation of Section 413 of the Disaster Relief Act of 1974 (as taken from the Federal Register, Vol. 41, No. 229, November 26, 1976) Title 42—Public Health Chapter 1—Public Health Service, Department of Health, Education, and Welfare Part 38—Disaster Assistance for Crisis Counseling and Training On April 16, 1976, there was published in the Federal Register (41 FR 16169) a notice of proposed rulemaking setting forth procedures to implement section 413 of Pub. L. 93-288, the Disaster Relief Act of 1974 (42 U.S.C. 5183), which authorizes the President, through the National Institute of Mental Health, “to provide professional counsel— ing services, including financial assistance to States or local agencies or private mental health organizations to provide such services or training of disaster workers, to victims of major disasters in order to alleviate mental health problems caused or aggravated by major dis- asters or their aftermath.” On July 11, 1974, the President delegated his authority under Sec- tion 413 and other provisions of the Disaster Relief Act of 1974 to the Secretary of Housing and Urban Development (Executive Order No. 11795, 39 FR 25939, as amended by Executive Order No. 11910, 41 FR 15681). The authority to promulgate regulations for the implementa- tion of Section 413 of Pub. L. 93-288 was delegated to the Secretary of Health, Education, and Welfare by the Secretary of Housing and Ur- ban Development on March 7, 1975 (40 FR 10705). The citation of authority in the regulations has been amended to include these delega- tions. In addition, 38.3(d) has been amended to clarify that the recom- mendation of the Secretary of Health, Education, and Welfare is a prerequisite to an extension of the 180-day time limitation on grants and contracts by either the Regional Director or the Administrator. As set forth in 38.1(b), the activities to be carried out under the regulations are subject to all applicable provisions of the Disaster 153 APPENDIXES Relief Act of 1974 and the implementing regulations, 24 CFR Part 2205, promulgated by the Administrator of the Federal Disaster Assis- tance Administration and are subject to the general policy guidance and coordination of the Administrator. The regulations do not change the existing Federal Disaster Assistance Administration (FDAA) and Department of Health, Education, and Welfare (HEW) policies which provide for the involvement and assistance of FDAA and HEW regional health officers in the implementation of the crisis counseling and training program. Ten responses were received within the 30-day period following publication of the notice of proposed rulemaking in the Federal Register. All comments with respect to the proposed revision were given due consideration. Six of the respondents suggested an extension of the program to encompass pre-disaster or pre-crisis training; one asked that public notices be provided by way of newspaper advertise- ments to alert communities to available services; one emphasized the need for program accountability, requesting that State agencies be designated to conduct ongoing monitoring of programs; one suggested that training take place through mental health programs in the com- munity to meet local needs and provide continuity of care; and another stated complete support for the program. These comments have not required any changes in the proposed rules for the reasons set forth below. 1. With respect to pre-crisis training, it has been determined that priority must be given to the adequate operation of essential disaster and post-disaster programs. If experience indicates that available funds exceed the needs of these programs, this determination will be reconsidered. 2. Contained within some of the comments which stressed the need for pre-crisis training were statements regarding the engagement of experienced professionals and the use of universities to provide a continuing base of qualified counsellors. The regulations do encom- pass the utilization of such skills. Public agencies and private mental health organizations which receive assistance under the regulations for the provision of the professional mental health counseling services or mental health training of disaster workers needed as a result of a major disaster may enlist and employ experienced community and university professionals to supplement their staff as necessary to meet the needs resulting from the major disaster. 3. Similarly, the substance of the comment suggesting the use of local mental health programs for training and service delivery is already incorporated within the terms of 38.4(b) and 38.5(c) of the regulations. It is a long-standing policy of the Federal Disaster Assis- tance Administration (FDAA) that preference be given to the extent 154 APPENDIXES feasible and practicable to the use of local agencies and organizations in providing disaster relief, including the provision of training and service delivery. 4. With regard to the comment about public notices, the Depart- ment of Health, Education, and Welfare will follow the policy of the Federal Disaster Assistance Administration by using paid advertising as needed for disaster situations, while reserving the right to deter- mine its frequency. The need for paid advertising varies according to the type of disaster, geographic area, duration, and cultural popula- tion; thus, it has been determined not to promulgate a specific regula- tion on this point. 5. With respect to the suggestion for State supervision, adequate provision for program accountability is made by the regulations. See in particular 38.4, 38.5, and 38.9. Characteristically, this program involves the expenditure of relatively small amounts of money over short time periods. It does not involve the additional employment of large numbers of persons for its implementation. Accordingly, with the addition of the foregoing minor technical and clarifying changes, the regulations proposing to amend Subchapter C, Chapter I of Title 42 Code of Federal Regulations by adding a new Part 38 are hereby adopted and are set forth below. Effective date: This amendment becomes effective on November 26, 1976. It is hereby certified that this proposal has been screened pursuant to Executive Order No. 11821, and does not require an inflation im- pact evaluation. Dated: October 6, 1976. James F. Dickson, Acting Assistant Secretary for Health. Approved: November 12, 1976. Marjorie Lynch, Acting Secretary. Sec. 38.1 Purpose; coordination 38.2 Definitions 38.3 Assistance; procedures, limitations 38.4 Contracts 38.5 Grant assistance 38.6 Nondiscrimination 38.7 Nonliability 155 APPENDIXES 38.8 Criminal and civil penalties 38.9 Federal audits Authority: Sec. 413, Pub. L. 93-288. The Disaster Relief Act of 1974, 88 Stat. 157, 42 U.S.C. 5183, E0 11795, 39 FR 25939, as amended by EC 11910, 41 FR 15681. 38.1 Purpose; coordination (a) Purpose. This part establishes standards and procedures for the implementation of Section 413 of Pub. L. 93-288, the Disaster Relief Act of 1974 (42 U.S.C. 5183) which authorizes the provision, either directly or through financial assistance to State or local agencies or private mental health organizations, of: (1) Professional counseling services to victims of a major disaster in order to relieve mental health problems caused or aggravated by such a major disaster or its aftermath; and (2) Training of disaster workers to provide or assist in providing those professional counseling services. (b) Coordination. The Secretary, acting through the National In- stitute of Mental Health, will, as provided in 24 CFR 2205.51, carry out Section 413 of the Act and this part in coordination with, and under the general policy guidance of the Administrator of the Federal Disaster Assistance Administration. Contracts and grants awarded under this part are subject to all applicable provisions of the Act and the implementing regulations promulgated by the Administrator (24 CFR Part 2205). 38.2 Definitions All terms not defined herein shall have the same meaning as given them in the Act. As used in this part: (a) “Act” means the Disaster Relief Act of 1974 (42 U.S.C. 5121 et seq.). (b) “Administrator” means the Administrator, Federal Disaster Assistance Administration (FDAA), Department of Housing and Ur- ban Development, and any other person to whom he delegates the authority. (0) “Contractor” means any public agency or private mental health organization which, pursuant to this part, contracts with the Secretary to provide professional mental health crisis counseling services or to provide mental health training for disaster workers. (d) “Crisis" means the existence of any life situation resulting from a major disaster or its aftermath which so effects the emotional and mental equilibrium of a disaster victim that professional mental health counseling services should be provided to help preclude possi- ble damaging physical or psychological effects. 156 APPENDIXES (e) “Disaster workers” means mental health specialists such as psychiatrists, psychologists, psychiatric nurses, social workers, or qualified agents thereof. (f) “Federal Coordinating Officer” means the person appointed by the Administrator to coordinate Federal assistance in a major dis- aster. (g) “Governor” means the chief executive of a State. (h) “Grantee” means any public agency or private nonprofit men- tal health organization which, pursuant to this part, is awarded a grant for the purpose of providing professional mental health crisis counseling services or mental health training for disaster workers. (i) “Major disaster” means any hurricane, tornado, storm, flood, highwater, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, drought, fire, ex- plosion, or other catastrophe in any part of the United States which, in the determination of the President, causes damage of sufficient severity and magnitude to warrant major disaster assistance under the Act above and beyond emergency services by the Federal Govern- ment, to supplement the efforts and available resources of the States, local governments, and disaster relief organizations, in alleviating the damage, loss, hardship, or suffering caused thereby. (j) “Regional Director” means a director of a regional office of the Federal Disaster Assistance Administration (FDAA). (k) “Secretary” means the Secretary of Health, Education, and Welfare and any other officer or employee of the Department of Health, Education and Welfare to whom the authority involved has been delegated. (1) “State” means any of the fifty States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Canal Zone, or the Trust Territory of the Pacific Islands. (m) “State Coordinating Officer” means the person appointed by the Governor to act in cooperation with the appointed Federal Coor- dinating Officer. (11) “Training” means the specific instruction which may be re- quired to enable disaster workers to provide professional mental health crisis counseling to victims of a major disaster or its aftermath. 38.3 Assistance; procedures, limitations (a) Application. In order to obtain assistance under this part, the Governor or his State Coordinating Officer must, not later than 60 days following a major disaster declaration by the President, file with the appropriate Regional Director a request which includes: 157 APPENDIXES (1) An estimate of the number of disaster victims who may need professional mental health crisis counseling services and of the num— ber of disaster workers who may need training in the provision of such services; (2) Identification of the geographical areas in which the need exists; (3) An estimate of the period during which assistance under this part will be required and of the total funds which will be required to pro— vide such assistance; (4) A description of the types of mental health problems caused or aggravated by the major disaster or its aftermath; and (5) Identification of the State and local agencies and private mental health organizations capable of providing professional mental health crisis counseling to disaster victims or training of disaster workers. (b) Review, approval. The Secretary, upon notification by the Ad- ministrator of a State request for assistance under this part, will con- duct a review to determine the extent to which such assistance is needed to supplement assistance programs provided by State and local governments and private organizations and, on the basis of that review, prepare and submit a recommendation and report for con- sideration by the Administrator. Upon approval by the Administrator and his advancement of funds for carrying out the approved assis- tance, the Secretary may, within the limits of the funds advanced, pro- vide the approved services either directly or through a grant or con- tract. (c) Eligibility for services. (1) In order to be eligible for the profes- sional mental health crisis counseling services available under this part an individual must: (i) Have been located within the designated major disaster area or have been a resident of such area at the time of the major disaster or its aftermath; and (ii) Have a mental health problem which was caused or aggra- vated by the major disaster or its aftermath. (2) Disaster workers who are available on short notice to provide professional mental health crisis counseling services in a major dis- aster area are eligible for training under this part. (d) Time Limitation. Contracts and grants awarded under this part will not continue beyond 180 days after the first day services are pro— vided pursuant to such contracts and grants, except that upon the recommendation of the Secretary (1) the Regional Director may ex- tend the 180 day period for up to 30 days or (2) the Administrator may extend the 180 day period for more than 30 days. 158 APPENDIXES 38.4 Contracts (a) Eligibility. Public agencies and private mental health organiza- tions which are determined by the Secretary to be capable of providing the professional mental health crisis counseling services or mental health training of disaster workers needed as a result of a major dis- aster are eligible for the award of a contract under this part. (b) Use of local agencies. Preference will be given, to the extent feasible and practicable, to those agencies and organizations which are located or do business primarily in the area affected by the major disaster. (c) General Requirements. Contracts under this part shall be en- tered into and carried out in accordance with the provisions of Chap- ters 1 and 3 of Title 41 of the Code of Federal Regulations and all other applicable laws and regulations. (d) Payments. The Secretary shall from time to time make pay- ments to the contractor of all or a portion of the contract award, either by way of reimbursement for expenses incurred or in advance for ex- penses to be incurred, to the extent he determines such payments are necessary to promote prompt initiation and advancement of the serv- ices to be provided under the contract. All payments not expended by the contractor within the period of the contract shall be returned to the Secretary. (e) Reports. Contractors shall submit the following reports to the Secretary: (1) Progress reports, to be submitted at the end of the first 30 days of the contract period and every 30 days thereafter; (2) A final report to be submitted within 60 days of the date upon which the contract terminates; and (3) Such additional reports as the Secretary may prescribe including those which may be required to enable the Federal Coordinating Officer to carry out his functions. 38.5 Grant Assistance (a) Eligibility. Public agencies and private nonprofit mental health organizations which are determined by the Secretary to be capable of providing the professional mental health crisis counseling services or mental health training of disaster workers needed as a result of a ma- jor disaster are eligible for a grant award under this part. (b) Application. (1) In order to receive a grant award under this part an eligible en- tity must submit an application in such form and at such time as the Secretary may prescribe. 159 APPENDIXES (2) The application shall be executed by an individual authorized to act for. the applicant and to assume on behalf of the applicant the obligations imposed by the Act, the regulations of this part, and the terms and conditions of any grant award. (3) The application shall contain: (i) A proposed plan for the provision of the services for which grant assistance is requested; (ii) A proposed budget for the expenditure of the requested grant funds; and (iii) Such other pertinent information and assurances as the Secre- tary may require. (c) Grant awards. (1) Within the limits of the funds advanced by the Administrator, the Secretary may award grants to cover all or part of the cost of the project to those applicants whose projects will in his judgment best promote the purposes of section 413 of the Act and the regulations of this part. Preference will be given, to the extent feasible and practica- ble, to those public and private nonprofit agencies and organizations which are located or do business primarily in the area affected by the major disaster. p (2) A grant award under this part shall be in writing and shall specify the amount of the award, the period of support, and the ap- proved budget for that period. (3) A grant award shall not commit or obligate the United States in any way to make any additional, supplemental, continuation, or other grant award. (4) Within the limits of the funds advanced by the Administrator, the amount of any grant award shall be determined by the Secretary on the basis of his estimate of the sum necessary to carry out the grant purpose. (d) Applicability of 45 CFR Part 74. (1) The provisions of 45 CFR Part 74, establishing uniform ad- ministrative requirements and cost principles, shall apply to all grants under this part to State and local governments as those terms, are defined in Subpart A of that Part 74. The relevant provisions of the following subparts of Part 74 shall also apply to grants to all other grantee organizations under this part; 45 CFR Part 74 Subpart A~——General B—Cash Depositories C—Bonding and Insurance D—Retention and Custodial Requirements for Records 160 APPENDIXES F—Grant—Related Income G—Matching and Cost Sharing K—Grant Payment Requirements L—Budget Revision Procedures M—Grant Closeout, Suspension, and Termination O—Property Q—Cost Principles (2) Additional conditions. The Secretary may at the time of any grant award impose such conditions as in his judgment are necessary to assure or protect advancement of the supported activity, the in- terests of the public health, or the conservation of grant funds. (e) Payment. The Secretary shall from time to time make payments to a grantee of all or a portion of any grant award, either in advance or by way of reimbursement for expenses incurred or to be incurred in ac— cordance with the terms and conditions of the grant award. (f) Grantee accountability. All payments made by the Secretary shall be recorded by the grantee in accounting records separate from the records of all other grant funds, including funds derived from other grant awards. With respect to each approved project the grantee shall account for the sum total of all amounts paid by presenting, or otherwise making available to the Secretary, satisfactory evidence of expenditures for direct and indirect costs meeting the requirements of this part. (g) Expenditure ofgrant funds. (1) Any funds awarded pursuant to this part shall be expended solely for the purposes for which the funds were granted in accordance with the approved budget, the regulations of this part, the terms and conditions of the grant award, and the applicable cost principles prescribed by Subpart Q of 45 CFR Part 74. (2) At the end of the period of support any unobligated grant funds remaining in the grant account must be refunded to the United States. (h) Reports. Grantees shall submit the following reports to the Secretary: (1) Quarterly progress reports, to be submitted within 30 days of the end of each quarterly period within the grant period; (2) A final report to be submitted within 90 days of the date upon which the grant period ends; and (3) Such additional reports as the Secretary may prescribe, including those which may be required to enable the Federal Coordinating Officer to carry out his functions. 161 APPENDIXES 38.6 Nondiscrimination Attention is called to the requirements of 24 CFR 2205.13 relating to nondiscrimination on the grounds of race, religion, sex, color, age, economic status, or national origin in the provision of disaster assis- tance. 38.7 Nonliability Attention is called to section 308 of the Act (42 U.S.C. 5148) which provides that the Federal Government shall not be liable for any claim based upon the exercise or performance of or the failure to exer— cise or perform a discretionary function or duty ’on the part of a Federal agency or an employee of the Federal Government in carrying out the provisions of the Act. 38.8 Criminal and Civil Penalties Attention is called to section 317 of the Act (42 U.S.C. 5157) which provides: (a) Any individual who fraudulently or willfully misstates any fact in connection with a request for assistance under this Act shall be fined not more than $10,000 or imprisoned for not more than one year or both for each violation. (b) Any individual who knowingly violates any order or regulation under this Act shall be subject to a civil penalty of not more than $5,000 for each violation. (c) Whoever knowingly misapplies the proceeds of a loan or other cash benefit obtained under any section of this Act shall be subject to a fine in an amount equal to one and one half times the original prin- cipal amount of the loan or cash benefit. 38.9 Federal Audits The Secretary, the Administrator, and the Comptroller General of the United States, or their duly authorized representatives shall have access to any books, documents, papers, and records that pertain to Federal funds, equipment, and supplies received under this part for the purpose of audit and examination. (FR Doc. 76—34805 Filed 11-24-76; 8:45 am) 162 APPENDIX III Training Manual for Human Service Workers in Major Disasters—Table of Contents This manual was prepared by the Institute for the Studies of Destructive Behaviors and the Los Angeles Suicide Prevention Center, under Contract No. 278-75-0018(SM) from the National Institute of Mental Health. The manual can be obtained from: US. Department of Health, Education, & Welfare Public Health Service ADAMHA 5600 Fishers Lane Rockville, MD 20857 PREFACE SECTION I. INTRODUCTION I. Background 11. Need for Intervention III. Phases of Disaster A. Heroic phase B. Honeymoon phase C. Disillusionment phase D. Reconstruction phase IV. Key Concepts A. The target population is primarily normal B. Avoid mental health labels C. Be innovative in offering help D. Fit the program into the community V. Manual A. When? B. Who? C. What? SECTION II. BEFORE THE TRAINING BEGINS 1. Community Acceptance Gaining entry and sanction 163 II. III. IV. V. VI. VII. APPENDIXES Initial Entry A. Civic leaders B. Disaster intervention agencies Appraisal of the Community A. Resources for human services B. Locations for observing the relief efforts C. Sources for selecting Trainers and Trainees D. Community organizations as recipients of human service support Selection of Personnel A. Director B. Assistant director C. Secretary D. Trainers E. Selecting Trainees Establishment of Headquarters and Field Sites Headquarters Information and Rumor Control Summary SECTION III. TRAINING THE TRAINERS I. II. Outline Preparation A. Selection of Trainers B. Information C. Insurance Program A. First day B. Second day C. Debriefing SECTION IV. TRAINING THE HUMAN SERVICE WORKERS Outline 1. Introduction Suggested 5-day curriculum II. Introduction of Training Program to Trainees A. Distribution of materials B. Introduction of Staff and Trainees C. Director opens program III. Course Content A. Sharing of personal disaster experiences B. Information on the status of the disaster C. Background phases of disaster and accompanying behavior 164 APPENDIXES Task concept—definition of the role of the Trainee The helping process Empathy Problems of living Help and seek-help behaviors Types of mental health problems following disasters Role playing Tapping strengths in the individual and the community Groups—therapy and community . Reports and debriefing Governmental and non-governmental disaster relief agencies ZZVFP-HFEPT‘F‘JU SECTION V. SPECIAL RISK GROUPS I. II. III. IV. VI. VII. VIII. Outline Introduction A. Common needs and reactions B. Special needs groups Age Groups Pre-school (1-5) Early childhood (ages 5-11) Preadolescent (ages 11-14) Adolescent (ages 14-18) Middle-age Older adults Socioeconomic Classes Cultural and Racial Differences Institutionalized Persons People in Emotional Crises People Requiring Emergency Medical Care Human Services and Disaster Relief Workers A. Symptoms B. Management 74.51.3053”? SECTION VI. SELF-AWARENESS SESSION I. II. Overview General Format Exploring motivations for helping Helping self to help others Exploring self Where do we go from here? Evaluations snow? 165 SECTION VII. APPENDIXES APPENDIXES Appendix A. Health Service Workers Information Form B. Training Program Evaluation Form C. Client Information Form D. Examples of Disaster-Related Emotional Problems 1. P®fl¢9FPN Depression Grief Anger Guilt Apathy Fears The “burn—out” syndrome Bizarre behavior Suicide 166 SELECTED ANNOTATED BIBLIOGRAPHY This bibliography is designed to supply persons interested in the planning and delivery of disaster-related crisis intervention services with up-to-date, useful information on three general topics: individual and organizational behavior in disasters; identification and treatment of mental illness in small communities; and disaster mental health. It would be a monumental task to assemble and annotate all the material relating to these three topics. Thus, we were somewhat selec- tive in our judgment of what works to include. Section I, on human reactions in disaster, is intended to introduce the reader to some general works mainly of a social-scientific nature, on various types of individual and community responses to a variety of disaster agents. Section 11, “Recent Literature on Rural Mental Health and Selected Works in Community Mental Health and Crisis Interven- tion,” contains references on current and recent research findings con- cerning the incidence of mental illness in rural areas and innovative rural mental health programs. Works having a more general scope are also included in this section, as are some widely recognized writings on crisis intervention practice. In section III, we attempt to be somewhat more comprehensive and include references for a large proportion of what has been written about mental health consequences of disasters, as well as for writings dealing with the delivery of mental health services to victims. I. General Social-Scientific Writings on Disaster and Disaster Planning Barton, Allen H. Communities in Disasters: A Sociological Analysis of Collective Stress Situations. Garden City, New York: Doubleday, Anchor Books, 1970. A theoretical discussion and abstract summary of much of the dis- aster literature. Barton discusses individual behavior in emergen- cies, the coordination of organization behavior, and the altruistic responses that develop in disasters. Some attention is also given to factors influencing longrun recovery. 167 BIBLIOGRAPHY Bates, F.L., et al. The Social and Psychological Consequences of a Natural Disaster. Washington, D.C.: National Academy of Sc1ences-National Research Council, Publication 1081, 1963. This '1s 'a longitudinal study of Hurricane Audrey. Most of the description and analysis is about the rehabilitation and recovery act1v1t1es after the disaster and long-run social changes. Chapman, Dwight, ed. Human behavior in disaster: A new field of T905121 research. Specral 1ssue, Journal of Social Issues 10, No. 3, This collection of articles includes a description of the work of the Committee on Disaster Studies of the National Research Council and of the NORC Studies in disaster. Among the papers are “Problems of Theory in the Analysis of Stress Behavior” by Irving Janis and “Some Accomplishments and Some Needs in Disaster Study” by Lewis Killian. Drabek, Thomas E. Social processes in disaster: Family evacuation. Social Problems 16(3):336—349, Winter 1969. A study of family response to disaster warnings. Analysis of inter- views with families who were suddenly evacuated prior to a major flood revealed a series of distinct processes through which warning, confirmation, and evacuation occurred. Evacuation behavior followed four patters: by default, by invitation, by compromise, and by decision. Dynes, Russell R. The Functioning of Expanding Organizations in Community Disasters, Columbus: The Ohio State University, The Disaster Research Center Report Series No. 2, 1968. Expanding organizations are those which have latent disaster responsibilities but must develop a new group structure to achieve them. Case studies are presented of three kinds of expanding organizations—Red Cross, Salvation Army, and local civil defense. Dynes, Russell R. Organized Behavior in Disaster. Columbus: The Ohio State University, The Disaster Research Center Book and Monograph Series No. 3, 1973 new paperback printing. This book focuses on a theoretical discussion of community organizations and their activities in meeting problems created by disaster. Dynes draws on the existing literature and the work of the Disaster Research Center. The different meanings of “disaster” and the social implications of various types of disaster agents are dis- cussed, and four types of organized behavior are isolated. Dynes, Russell R.; Quarantelli, EL; and Kreps, Gary A. A Perspec- tive on Disaster Planning. Columbus: The Ohio State University, The Disaster Research Center Report Series No. 11, 1972. This report presents the characteristics of disaster agents and the kinds of demands they generate. A contrast is made between com- munity activities in normal times and during emergencies. The 168 BIBLIOGRAPHY basic elements involved in organized response of a community to disaster are set forth. The report concludes with a systematic dis- cussion of disaster planning, including weaknesses in typical dis- aster plans and strategies for planning. Form, William H., and Nosow, Sigmund. Community in Disaster. New York: Harper, 1958. An older study about the community response to a Michigan tor- nado. The major focus is on the rescue behavior by small groups after the disaster and problems of organizations in mobilizing for the emergency. There is also a discussion on planning for disasters. Fritz, Charles E. Disaster. Contemporary Social Problems, Merton and Nisbet, eds. New York: Harcourt, Brace & World, Inc., 1961. A classic apologia for the study of disasters, including the issues of definition and misconceptions. Discusses the many problems com- munities have in responding to the event as well as some of the adaptive or positive outcomes. Fritz, Charles E., and Mathewson, J .H. Convergence Behavior in Dis- asters: A Problem in Social Control. Washington, DC: National Academy of Sciences-National Research Council Publication 476, 1957. This report looks at the convergence, or the informal, spontaneous movement of people, messages, and supplies toward the disaster area. Methods and techniques for controlling such convergence behavior are detailed. Laffoon, Polk IV. Tornado. New York: Harper & Row, 1975. A reporter’s account of the 1974 Xenia tornado. Social, psychologi— cal, and economic consequences are presented through eye-witness accounts. Essentially descriptive and mostly accurate, it could be a useful supplement to more analytical treatments of the topic. Marks, Eli S., et al. Human Reactions in Disaster Situations. Chicago: The University of Chicago, National Opinion Research Center; available on microfile AD #107-594 from the Clearinghouse for Federal Scientific and Technical Information, National Bureau of Standards, Springfield, Virginia, 22151, 1954. This report summarizes a series of field studies conducted by the National Opinion Research Center in the early 1950s. The major study in the set is about a series of tornadoes in Arkansas. One of the few quantitative studies in the literature. Quarantelli, E.L., and Dynes, Russell R. Images of Disaster Behavior: Myths and Consequences. Columbus: The Ohio State University, The Disaster Research Center Preliminary Paper No. 5, 1972. 169 BIBLIOGRAPHY The authors argue that what are generally believed to be problems in the disaster setting are not the real ones organizations have to face. Erroneous beliefs about human behavior in disasters are com- pared with what is known through empirical research to actually occur in disasters. Planners are urged to base their preparations for disasters on a realistic picture of disaster behavior, rather than on myths. Quarantelli, EL, and Dynes, Russell R. Different types of organiza- tions in disaster responses and their operational problems. Colum- bus: The Ohio State University, The Disaster Research Center Preliminary Paper No. 41, 1977. Four different types of organized efforts to cope with community emergencies, especially natural disasters, are described. Some con- sequences of a disaster event for these organizations are delineated, including the problems of uncertainty, urgency, and lost authority. Problems of task assignment, communication, authority and deci- sionmaking are also reviewed. Quarantelli, EL, and Dynes, Russell R., eds. Organizational and group behavior in disasters. American Behavioral Scientist 13(3), January-February, 1970. This special issue focuses on disaster as a social disruption within communities. The pattern of social disruption is closely related to the various characteristics of the disaster agent; these determine the nature of disaster tasks to which emergency organizations have to respond. Taylor, James B.; Zurcher, Louis A.; and Key, William H. Tornado. Seattle: University of Washington Press, 1970. Using personalistic, case-centered data, the authors take a systematic interdisciplinary look at the Topeka tornado. The focus moves from the individual response, through midlevels of group and mass behavior and organizational response, to placement in the historical context, wtih comparisons and contrasts made be- tween this and other disasters. Warheit, George, and Dynes, Russell R. The Functioning of Established Organizations in Community Disasters. Columbus: The Ohio State University, The Disaster Research Center Report Series No. 1, 1968. Established organizations are defined as those which respond to disaster with their regular personnel engaged in familiar tasks. A theoretical framework is presented viewing established organiza- tions’ predisaster operations as a situation where capabilities ex- ceed demands. Operational problems in disaster and adaptations to these are discussed. 170 BIBLIOGRAPHY Wenger, Dennis E., and Parr, Arnold. Community Functions Under Disaster Conditions. Columbus: The Ohio State University, The Disaster Research Center Report Series No. 4, 1969. This report examines disaster-activated tasks at the community level of analysis. After theoretically describing the community in predisaster periods, the authors undertake an indepth analysis of community tasks and activities corresponding to the disaster stages from warning to rehabilitation. Specific inter- and intraorganiza- tional problems are described. ll. Recent Literature on Rural Mental Health Needs and Programs and Selected Works on Community Men- tal Health and Crisis Intervention Rural Mental Health Allerton, William S. Rural mental health in Virginia, Virginia Medi- cal Monthly, 99(1): 72-73, January 1972. Use of paramedicals and psychiatric nurses increases service coverage to remote areas. Allerton calls for more collaboration be- tween nurses, mental health clinics and hospitals, and for training programs for “mental health technicians.” Bloom, Joseph, and Richards, William. Mental health program development in rural Alaska. Alaska Medicine, 18(3):25-28, May 1976. While dealing specifically with the unique character of service delivery in Alaska, this paper may be suggestive to those concerned with providing MH services to extremely “backwoods” rural areas. It includes a useful scale for measuring the development and organization of such services and a discussion of the roles suitable to either the public or private practitioner. Bowden, Charles L., and Reeb, Arvil E. Community psychiatry: Scott County evaluation. Journal of the Kentucky State Medical Associa- tion, 70(2):106-108, February 1972. Bowden evaluates one once-weekly community psychiatric program as adequate for rural catchment areas. He finds distance less important a factor than convenience and attributes program success to its location within the familiar health department build- ing and to close liaison between the center and local medical per- sonnel. Clemente, Frank, ed. The new rural America. Special issue, The An- nals, Lambert and Heston, eds. Vol. 429, January 1977. 171 BIBLIOGRAPHY This issue of The Annals is devoted to the concerns and charac- teristics of today’s rural America. Titles of interest include: “Rural- Urban Differences in Attitudes and Behavior in the United States,” “Political Structure of Rural America,” “The Rural Aged,” “The Rural Church and Rural Religion,” and “The Quality of Life in Rural America.” Cohen, Julius. The effect of distance on the use of outpatient services in a rural mental health center. Hospital and Community Psychia- try, 23(1):27-28, March 1972. To offset the deterring effects of distance and adverse local at- titudes on service utilization, the author recommends various out- reach and consultation programs for greater visibility. Daniels, David N. The community mental health center in the rural area: Is the present model appropriate? American Journal of Psy- chiatry, 124(4):32-36, April 1967. Daniels believes that the direct clinical service CMHC model does not meet the needs of people in the large Western States. He pro- poses an alternative indirect service model emphasizing consulta- tion and education, preventive psychiatry, and community psychia- try as community organization. Dohrenwend, Bruce R, and Dohrenwend, Barbara S. Psychiatric dis- orders in urban settings. American Handbook ofPsychiatry, Vol. II, Arieti, ed. New York: Basic Books, 1974. pp. 424-447. An important analysis of epidemiologic data on mental illness. In- cluded here because it is one of the few such analyses to have com- parable data for both urban and rural segments of the populations studied and thus is able to make some definitive statements about rural mental illness rates as opposed to urban. Edgerton, J. Wilbert, and Bentz, W. Kenneth. Attitudes and opinions of rural people about mental illness and program services. American Journal of Public Health, 59(3):470-477, March 1969. The authors report results of a survey conducted in two counties. Findings showed an expressed need for mental health services, especially a clinic, yet low awareness of existing services. The CMHC concept was nearly unknown. Attitudes toward the men- tally ill were more positive than in the past, but still ambivalent. Respondents saw the role of psychiatrist as unique, but felt non- psychiatrists have important role as well. Edgerton, J. Wilbert, et a1. Demographic factors and responses to stress among rural people. American Journal of Public Health, 60(6):1065-1071, June 1970. An application of the Health Opinion Survey (HOS) is documented to show its usefulness as a tool for initially assessing prevalence of 172 BIBLIOGRAPHY mental disorder in rural populations. Referring to a previous study which reported that mental health clinics in the survey area were not used by the low-income and poorly educated, they call for special programing to meet the needs of these key target groups. Eisdorfer, Carl; Altrocchi, John; and Young, Robert F. Principles of community mental health in a rural setting: The Halifax County program. Community Mental Health Journal, 4(3):21 1-220, March 1968. The authors endorse the consultation and education approach as a temporary solution to the problems of scarce mental health resources in rural areas. Based upon a history of operating such a program, 20 principles focusing on community sanction, consulta— tion techniques, clinical services, and other aspects of CMHC programing are proposed. Garrett, Mary Louise; Miles, David L.; and LeBaron, Allan G. Rural areas pose special problems for providing social services. Hospitals, 50(22):77-79, November 1976. Like other writers, the authors endorse the notion that many of the problems of introducing and providing social and mental health services to rural communities are offset by using some established local institution as a base. Two cases where this has been tried—un- successfully through a doctor’s office and successfully through a hospital—are discussed. Both advantages and disadvantages of using indigenous paraprofessionals are described. Gertz, Boris; Meider, Jill; and Pluckhan, Margaret L. A survey of rural mental health needs and resources. Hospital and Community Psychiatry, 26(12):816—819, December 1975. The authors surveyed rural CMHCs across the United States to come up with the composite presented in this article. Description focuses on services offered, skills required, and problems in the delivery of care and of evaluation. Also analyzed were the extent of inservice training available, the support systems needed, and the functions a proposed national task force on rural mental health could perform. Guillozet, Noel. Community mental health—new approaches for rural areas using psychiatric social workers. Medical Care, 13(1):59-67, January 1975. Dealing with the problems of scarce resources, high need but low demand and/or acceptance for mental health services, the author recommends and cites his experiences with recruiting social workers into a medical group practice. 173 BIBLIOGRAPHY Hofstatter, L. et al. A modern psychiatric delivery system for urban and rural areas. Southern Medical Journal, 65(7):875-881, July 1972. Residency training programs within CMHCs have both short- and long-term advantages. Continuity of care in a CMHC is best achieved through the use of an interdisciplinary team. Working through existing networks helps workers gain better entry into tightly knit communities. Hollister, William G., et a1. Experiences in Rural Mental Health. Chapel Hill, North Carolina: University of North Carolina, School of Medicine, Division of Community Psychiatry of the Department of Psychiatry, 1973. A series of eight booklets describing what the authors did and learned about developing flexible, workable patterns for providing comprehensive mental health services to rural people. The ap- proach includes living within the realities of low funding capabilities, coping with the problems of scarce mental health per- sonnel, and avoiding the imposition of urban-type services by out- side professionals through local citizen involvement. Included in these booklets is a demography of the rural areas served. Recomg mended. Huessy, Hans R. Tactic and targets in the rural setting. Handbook of Community Mental Health, Golann and Eisdorfer, eds. New York: Appleton—Century-Crofts, 1972, pp. 699-710. Huessy is concerned here with the aspects of mental health programing which are peculiar to rural settings. Disadvantages— underestimates of mental health problems, scarcity of trained per- sonnel, social visibility of the professional, State imposition of programs more suitable to the city, and financing—are weighed against advantages—the need for reevaluation resulting in better methods, ease of interagency relations, research opportunities, feasibility of first-level management leading to better continuity of care, and others. Strategies designed to take advantage of the resources of each community are presented. Hunter, William F., and Ratcliffe, Allen W. The Range Mental Health Center: Evaluation of a community-oriented MH consultation program in northern Minnesota. Community Mental Health Jour- nal, 4(3):260-267, 1968. The basic content of this paper is described in its title. Initial find- ings suggest that consultation services assist community caretakers in managing emotionally disturbed clients, thus broadening signifi- cantly the impact of the MH center staff over a large geographic area. 174 BIBLIOGRAPHY Janzen, Sharon Ann. Psychiatric day care in a rural area. American Journal of Nursing, 74(12):2216-2217, December 1974. The author describes a successful lay mental health care group, nearly devoid of professional intervention. Such a volunteer group is necessarily limited in scope and depends upon the dedication of its members for its success. Johnson, Robert Jr., and Gandy, William F. Rural mental health care: A fourth year report. Journal of the Oklahoma State Medical Association, 65(8):336-338, August 1972. A description of the growth and development of a CMHC in rural Oklahoma. Equitable financing and staff compensation are cre— dited for operational efficiency. Jones, James D.; Wagenfeld, Morton; and Robin, Stanley S. A profile of the rural community mental health center. Community Mental Health Journal, 12(2):176-181, 1976. Jones et al. compared rural CMHCs with their counterparts in cities. Findings were that rural workers were most likely to view their centers as similar to social agencies and evidenced a signifi- cantly higher endorsement of CMH ideology. Rural workers also perceived their roles as one of higher organizational and personal activism, with less discrepancy between the two than did urban workers. Lee, Soong H., et al. Community mental health center accessibility—A survey of the rural poor. Archives of General Psychiatry, 31:335-339, September 1974. A statement of familiar findings: Ignorance of available services and stigma are as effective barriers as distance to the provision of mental health services. Recommendations include community education, use of indigenous workers to gain entry, and the provi- sion of backup MH services to local physicians. Leighton, D.C.; Leighton, A.H.; and Armstrong, R.A. Community psy- chiatry in a rural area: A social psychiatric approach. Handbook of Community Psychiatry and Community Mental Health, New York: Grune and Stratton, 1967, pp. 166-176. A classic and oft-cited work. Leighton et al. see overall community integration as well as socioeconomic status as causal factors in in- dividual mental health. Muhlberger, Esther V. Collaboration for community mental health. Social Work, 20(6):445-447, November 1975. Muhlberger sees collaboration as potentially more productive than consultation in the smaller community. The use of volunteers, part- time staff, and the strong interagency linkages often found in rural 175 BIBLIOGRAPHY areas are ways of extending traditional resources. Group workshops between the CMHC and other agency staffs are mutually beneficial. Naftulin, Donald; Donnelly, Frank; and O’Halloran, Patricia. Mental health courses as a facilitator for change in a rural community. Community Mental Health Journal, 10(3):359-365, 1974. This study documents a university effort to assist a rural com- munity in developing a mental health educational program for pri- mary interveners within the community, which resulted in signifi- cant positive change in groups taking the courses. Phillips, Donald F. Reaching out to rural communities. Hospitals, 46(6):53-57, 1972. An interesting and provocative discussion of the potential for hospital involvement in community mental health. Raft, David; Coley, Silas B.; and Miller, Francis T. Using a service guide to provide comprehensive care in a rural mental health clinic. Hospital and Community Psychiatry, 27(8):553 +, August 1976. The Service Guide (SG), a type of nonprofessional linking person between a rural mental health center and the less affluent com- munity, was found to be highly effective in maintaining continuity of care. The SG participated in all levels of MH care delivery and especially kept close contact with the poor and elderly. When the SG program was discontinued, it was found that clinic use decreased and referrals dropped among these segments of the population, while better off clients were relatively unaffected. Riggs, R. Thomas, and Kugel, Linda F. Transition from urban to rural mental health practice. Social Casework, November 1976, pp. 562-567. This article discusses the culture shock facing MH professionals who move to smaller towns as they realize that they are profes- sionally more isolated, that urban-oriented models of psy- chotherapy don’t apply in rural settings, and that the clinician— client relationship is less private, more visible, and subject to public evaluation. Some of the skills and personal qualities necessary to make the transition are described, as are the stages professionals new to rural communities commonly experience—euphoria, through depression, to adaptation. Roemer, Milton 1. Health needs and services of the rural poor. Rural Poverty in the United States, Washington, D.C.: US. National Ad- visory Commission on Rural Poverty, USGPO, 1968, pp. 311-332. Specific health needs of the rural poor are cited: susceptibility to various chronic diseases; inadequacies of rural physicians, both in numbers and specializations; deficiencies of and in treatment 176 BIBLIOGRAPHY facilities, public nonsupport for hospitalization costs; and social ad- justment problems particular to the rural poor. State hospital use is a last resort for many, which leads to energetic building programs by some low-income States, though the result may still be under- staffed and substandard facilities. Saltzman, Ben N. Mental health and the rural aging. Arkansas Medi- cal Society Journal, 68(4):131—135, September 1971. The isolated lifestyle of many older persons, coupled with the iso- lation of the rural setting, make the elderly a high-risk group for mental health problems. Saltzman suggests that psychiatrists may tend to ignore MH problems in the elderly and states that rates for mental illness are highest in older age groups. Segal, Julius, ed. The Mental Health of Rural America: The Rural Programs of the National Institute of Mental Health. Rockville, Maryland: Program Analysis and Reports Branch, Office of Program Planning and Evaluation, Alcohol, Drug Abuse, and Men- tal Health Administration, 5600 Fishers Lane 20857, DHEW (HSM) 78-9035, 1973. This book is a primer of sorts, coming from the viewpoint that men- tal health problems in rural areas are often proportionately worse than in urban settings, exacerbated by poverty and scarce resources. It provides a basic overview of epidemiologic, demographic, and at- titudinal studies and goes into considerable descriptive detail on how NIMH has helped various communities deal with different issues in mental health delivery. Shore, James H., et al. A Suicide Prevention Center on an Indian Reservation. American Journal of Psychiatry, 128(9):76-81, March 1972. The authors emphasize the importance of community involvement in a suicide prevention service, especially that of the reservation power structure. Characteristics of the patient population are analyzed, including attitudes relating to the development of the CMHC. Indigenous counselor-attendants were considered ex- tremely helpful. The author states suicide attempts may be related to a learned pattern of destructive behavior. Shupe, Anson Jr. Development of mental health services among exist- ing community institutions in rural areas: The case of the Japanese Kumiai. Community Mental Health Journal, 10(3):351-358, 1974. The Japanese Kumiai, essentially highly developed community service centers, are presented as an example of the use of an established community focal point and familiar personnel to in- troduce new ideas to a rural community. It is suggested that US. 177 BIBLIOGRAPHY farmer’s cooperatives might be similarly used by community men- tal health programers, as a bridge to the populace. Special problems encountered by mental health program developers in rural areas are mentioned, as well as the need for a “preventive perspective” in rural communities undergoing disintegrative social change and lacking mental health facilities. Thomas, Captane P., and Bell, Norman W. Evaluation of a rural com— munity mental health program. Archives of General Psychiatry, 20:448-456, April 1969. The CMHC examined here operates not on a walk-in basis, but as a source of specialist evaluation and treatment of the more seriously ill. Screening and referral are mandatory, which brings into ques- tion the label of “CMHC.” Community response to this policy gave rise to several volunteer crisis intervention groups. Veverka, Joseph F., and Goldman, James. Rural family counseling. Journal of the Iowa Medical Society, 63(8):395-398, August 1973. Description of a small-scale experiment wherein a social worker in a rural area worked with the local physician in an attempt to pro— vide family counseling. Continuity of care resulted, plus satisfaction with the teamwork approach. Wedel, Harold L. Characteristics of community mental health center operations in small communities. Community Mental Health Jour- nal, 5(6):437-444, 1969. The author discusses the peculiar aspects of rural communities as opposed to urban in some detail, stating, among other things, that human needs are different in areas of low population density. He discusses the fact that a community mental health program must adapt to these differentiations, and outlines specific recommenda- tions to MH personnel as to modes of conduct in the community and variations in patient-therapist relations. Williams, Michael. A rural mental health delivery system. Hospital and Community Psychiatry, 26(10):671-674, October 1975. This CMHC, in an extremely rural area of Utah, serves its geographically scattered and multi-ethnic population through the use of indigenous outreach workers and programs tailored to various ethnic needs Willie, Charles V. Health care needs of the disadvantaged in a rural- urban area. HSMHA Health Reports, 87(1):82-86, January 1972. A survey conducted with professionals and consumers showed basic health care needs for both urban and rural areas. Needs Were iden- tical but ranked differently in the two settings. Recommendations 178 BIBLIOGRAPHY are made in each category, including the general one that program planners should be fed information from consumers themselves. Withersty, David T. Psychiatric residents provide extra manpower for rural community agencies. Hospital and Community Psychiatry, 26(5):270-271, May 1975. Second-year residents from a nearby medical center were used as full-time workers for periods of 3 to 6 months, providing both direct and indirect service. Community Mental Health Bellin, Seymour 8.; Locke, Ben Z.; and New, Mary. One neighborhood health center as a mental health diagnostic service. Public Health Reports, 91(5):446-451, September/October 1976. Discusses the potential of a neighborhood health center as a case- finding and treatment service for a socially and economically disad- vantaged area. The authors conclude that being a comprehensive (physical and mental) care center encourages service utilization. Attention is paid to the epidemiology and demographics of the area. Cobb, Sidney. Social support as a moderator of life stress. Psy- chosomatic Medicine, 38(5):300-314, September/October 1976. This article contains an overview of significant research on the role of social support for the individual undergoing crisis. The belief that one is cared for and esteemed is seen as having a potential for protecting those in crisis from a variety of pathological conditions. A number of situations where social support can result in more positive psychosocial functioning are noted. The author urges further investigation on the effects of social support on the outcome of medical treatment and on individuals in chronic stress situa- tions. Collins, Alice H., and Pancoast, Diane L. Natural Helping Networks: A Strategy for Prevention. Washington, DC: NASW Pub. #CBC- O70-C, 1976. The authors argue strongly that “natural helpers” have a uniquely valuable role to play in the delivery of mental health and human services. The issues of identifying, recruiting, and coordinating the best possible indigenous workers are treated in depth. Fann, William E., and Goshen, Charles E. The Language of Mental Health. St. Louis: The CV. Mosby Co., 1973. A comprehensive easily usable guide to the vocabulary of the men- tal health and behavioral sciences. Includes categorical glossaries of diagnostic, treatment, and administrative and legal terminology. 179 BIBLIOGRAPHY Feild, Hubert S., and Gatewood, Robert. The paraprofessional and the organization: Some problems of mutual adjustment. Personnel and Guidance Journal, 55(4):181-185, December 1976. The authors detail some of the problems that can arise when paraprofessionals are employed by social service agencies. From the paraprofessionals’ viewpoint, these are the nature of their work, op- portunities for advancement, relationships with professional staff, and dealing with agency policies; from the agency perspective, the paraprofessional can overidentify with either the client or the agen— cy, may lack certain work skills, and may require more attention than the agency wants to give. Gill, Merton M. “The Two Models of the Mental Health Disciplines.” Paper presented at the graduation exercises of the Menninger School of Psychiatry, June 19, 1976. Gill attempts to clarify what is meant by the “medical” and the “psychological” or community mental health mode. He re-terms these two the “reactive” and the “proactive,” and maintains that the essential difference is how they view and utilize the concept of responsibility. Giordano, Joseph. Community mental health in a pluralistic society. International Journal of Mental Health 525-15, 1976. Problems of professionalism, ideological conflict, inequality, and inflexibility are discussed as factors which account for dissatisfac- tion with the community mental health movements. The author calls for a revision of the philosophy of community mental health to one which recognizes the ethnic and subcultural differences which exist in American society. Golann, Stuart E., and Eisdorfer, Carl. Mental health and the com- munity—The development of issues. In: Handbook of Community Mental Health, New York:Appleton-Century-Crofts, 1972. Golann and Eisdorfer discuss developing the role of the community in mental health clinic operations, in terms of location and availability of services, outreach to clients, and involvement with an increased variety of caregivers. Gomez, Angel Gregorio. Some considerations in structuring human services for the Spanish-speaking population of the United States. International Journal of Mental Health, 5(2):60-68, 1976. Gomez argues that few social action programs exist that actually meet the needs of Hispanic Americans, and that those which do ex- ist are token efforts. Several problems of social and mental health service delivery to these groups are noted, and recommendations are made for their amelioration. 180 BIBLIOGRAPHY Herbert, George K. Factors contributing to the successful use of in- digenous mental health workers. Hospital and Community Psy- chiatry 25(5):308-310, May 1974. In recognition of the unique contributions indigenous workers can make, one program allowed them flexibility in developing job skills, supplementing this with ongoing inservice training. Workers’ feel- ings of satisfaction and of being of worth to the center stemmed from the respect the agency accorded them. Hesse, Katherine F. The paraprofessional as a referral link in the mental health delivery system. Community Mental Health Journal 12(3):252-258, 1976. There are differing expectations on the part of clients, agency peo- ple, and the paraprofessionals themselves regarding qualifications, knowledge, and activities of the paraprofessional referral worker. This study suggests that as long as paraprofessional roles are am- biguously defined the workers will not be able to satisfy everyone involved. Howe, Louisa P. The concept of the community: Some implications for the development of community psychiatry. Handbook of Com- munity Psychiatry and Community Mental Health, New York: Grune and Stratton, 1976, pp. 16-46. The author discusses a number of theoretical conceptions of the “community,” citing as most salient one which deals with symbolic interactions between people in terms of common destiny and a shared history and which sees crisis as the fulcrum upon which sense of community is either heightened or diminished. Recommen- dations are made to the psychiatrist who would work at the com- munity as well as the individual patient level, including respect for the autonomy of people regardless of their status, a soft—pedal ap- proach to power structures, and the study of crisis and coping reac- tions so a crisis situation can be capitalized on to effect constructive change. Kaplan, Howard M., and Bohr, Ronald H. Change in the mental health field? Community Mental Health Journal 12(3):244-251, 1976. Reasons for nonutilizations of community mental health centers are discussed, as are several social, political, economic, and ideological factors which the authors consider to be barriers to change in the field of community mental health. Trends acting to promote needed changes are also noted. 181 BIBLIOGRAPHY Lorion, Raymond P. Ethnicity and mental health: An empirical obsta- cle course. International Journal of Mental Health 5(2):16-25, 1976. Lorion argues that innovative approaches to providing care, advo— cated in the community mental health movement, have not pro- duced intervention strategies suitable for use with those in our society who are part of ethnic-group subcultures. Noting that there are formidable methodological problems in assessing the relation- ship between ethnicity and mental health, the author argues for an inductive, pragmatic approach to the delivery of mental health services to members of ethnic subcultures. He concludes that the treatment of members of ethnic groups and other subcultures may have to be accompanied by a redefinition of role and a change in at- titude on the part of the mental health professional. Manis, Jerome G., et a1. Estimating the prevalence of mental illness. American Sociological Review 29(1):84-89, February 1964. This article discusses methods of locating and identifying cases of mental illness. Using a 22-item Mental Health Scale, the study found little variation in treated prevalence rates in three com- munities. The largest variation was found to occur in the rates of untreated cases, leading the authors to conclude, among other things, that differences in reported rates of untreated mental illness may arise from a lack of agreement in criteria used to establish mental health and mental illness categories. Mechanic, David. Community psychiatry: Some sociological perspec- tives and implications. Community Psychiatry. Madison, Wiscon- sin: University of Wisconsin Press, Symposium on Community Psy- chiatry, 1966, pp. 201-222. The author discusses trends and issues in community psychiatry from a sociological point of view. The notions of mental health and mental illness are discussed from a variety of perspectives: defini- tional, conceptual, practical, and ethical. Throughout his discus- sion, Mechanic focuses on the linkages, both obvious and subtle, be- tween the field of mental health and the larger society. Norris, Eleanor, and Larsen, Judith K. Critical issues in mental health service delivery: What are the priorities? Hospital and Com- munity Psychiatry, 27(8):561-566, August 1976. When caregivers were asked to rate 57 mental health issues in terms of present and future (5-year) importance, ratings varied con— siderably by professional role and educational attainment. The author is concerned that such difference be acknowledged if future MH programs are to be planned effectively. 182 BIBLIOGRAPHY Penn, Nolan E.; Baker, Frank; and Schulberg, Herbert C. Community mental health ideology scale: Social work norms. Community Men- tal Health Journal, 12(2):211-214, 1976. Using the 1967 CMH Ideology Scale, the authors surveyed social work professionals and graduate students to measure individual commitment to the tenets of community mental health. High scores, particularly on items relevant to treatment goals and total com- munity involvement, argue for an integral role for the profession in community psychiatry. Rabkin, Judith. Public attitudes toward mental illness: A review of the literature. Schizophrenia Bulletin, 10:9-33, Fall 1974. The author concludes, after reviewing the literature, that despite community education efforts, the label of mental illness continues to lead to irreversibly diminished community standing. Rabkin notes that the public seems to be more influenced by the social visibility of symptoms than by their actual severity and discusses various characteristics of the mentally ill that influence public ac- ceptance. The author believes more research is needed in order to understand what conditions foster both positive and negative at- titudes toward the mentally ill. Rabkin, Judith, and Struening, Elmer L. Life events, stress and ill- ness. Science, 194(426):1013-1020, December 1976. A review of the literature on stressful life events and their relation to illness. In addition to delineating research trends and critiquing methodological approaches, the authors consider definitions of social stressors, stress and the onset of illness, and mediating fac- tors, such as the various social support systems to which an in- dividual might belong. Noting the complexity of the relationships between life stress, events, and illness, they maintain that care must be taken to select life events relevant to the topic and population under study. Reed, Katherine. Mental Health and Social Services for Mexican- Americans: An Essay and Annotated Bibliography. Monticello, Il- linois: Council of Planning Librarians Exchange Bibliography #1023, Mary Vance, ed. PO. Box 229, 1976. Reissman, Frank. A neighborhood-based mental health approach. Emergent Approaches to Mental Health Problems, Cowan, Gardner, and Zax, eds. New York:Appleton-Century-Crofts, 1967, pp. 162-184. Presents a service strategy for reaching low-income populations, and, by implication, those who are otherwise isolated, geographically, socially, or emotionally. Reissman outlines goals, 183 BIBLIOGRAPHY objectives, and some of the reasons why traditional service programs often fail with these groups. A strong community action stance is advocated. Rome, Howard P. Barriers to the establishment of comprehensive community mental health centers. Community Psychiatry. Madison, Wisconsin: University of Wisconsin Press, Symposium on Community Psychiatry, 1966, pp. 31-55. Rome views the “frontier psychology,” i.e., rugged individualism and resistance to governmental control, as being a significant bar- rier to CMH programs, since today’s technology and complex operational structures make dealing with Government agencies a realistic necessity. A number of organizational conflicts within and between agencies are outlined, as well as social conflicts between professionals and clients, and professionals and the general public. Problems related to the ambiguous standing of psychiatry and to distance between professional and client are also discussed. A list of 15 specific barriers to the establishment of CMHCs is furnished. See, Joel J., and Mustian, R. David. The emerging role of sociological consultation in the field of community mental health. Community Mental Health Journal, 12(3):267—274, 1976. The authors discuss the use of sociologists both as researchers and as consultants in mental health planning and the design of services. Sociologists are seen as having skills which would aid in statewide planning; needs assessment; the setting of goals for community mental health centers; and the establishment of efficient and effec- tive organizational operating principles. Possible sources of role strain between the sociologist and the community mental health practitioner are also noted. Sheeley, William F. The general practitioners’ contribution to com- munity psychiatry. Handbook of Community Psychiatry and Com- munity Mental Health. New York: Grune & Stratton, 1964, pp. 269-279. Because he knows, and is known to, so many people, Sheeley sees the GP as a potential casefinder and community educator regarding mental health problems. This position is made more advantageous if the GP is willing to improve his own psychiatric skills and culti- vate ongoing relationships with referring colleagues and other suitable resources, such as the local clergy. By the same token, the GP who is ignorant or fearful of the mental health milieu is viewed as a hazard. 184 BIBLIOGRAPHY Snow, David L., and Newton, Peter M. The task, social structure, and social process in the community mental health center movement. American Psychologist, 31(8):582-594, August 1976. A discussion of the CMHC movement’s historical emphasis on direct (treatment) over indirect (preventive, social-action) services. The need for indirect services is cited, in terms of dealing with men- tal health needs in a social rather than medical framework. Sug- gested improvements are specified. Snyder, James D., and Engleman, Robert M. Ten social service programs that really work. Geriatrics 31(10):119-125, October 1976. Ten social service programs geared to the needs of the elderly are described in detail, including Federal nutrition and volunteer programs, discount merchandising, health activation, legal counsel, and job and program fairs. Sundel, Martin. “Establishing a Needs Assessment Program in a Human Service Organization: A Case Study.” Louisville, Ken- tucky: Paper presented at the National Conference on Needs Assessment in Health and Human Services, March 10, 1976. Needs assessment is becoming increasingly important as a result of pressures on service organizations to be truly responsive to the com- munity. Sundel here discusses the approach taken by one CMH program in assessing needs relevant to program planning and evaluation. As a case study on a program serving rural, suburban, and urban populations with varying levels of income and diverse ethnic backgrounds, this paper is descriptive, analytic, and some- what prescriptive and should therefore be of value to other organizations who are considering undertaking their own needs assessment programs. Vaughn, Warren T. Local mental health program administration. Handbook of Community Psychiatry and Community Mental Health. New York: Grune & Stratton, 1964, pp. 388-408. Vaughn deals with the complexities of community mental health administration. He furnishes an administrative job description, in terms of qualifications, responsibilities, and expectations, and ex— tensively discusses the need for communication and coordination with community groups, focusing particularly on various “partner- ship” axes: State-local, public-private, professional-lay, interagen- cy, and interdisciplinary. An appendix provides source materials relative to organizations involved in CMHC research, organizations of program administrators, and a general reference guide to com- munity mental health and social psychiatry. 185 BIBLIOGRAPHY Warheit, George I.; Holzer, Charles E.; and Schwab, John J. An analysis of social class and racial differences in depressive symptomatology: A community study. Journal of Health and Social Rehabilitation 14(4) 291-299, December 1973. This paper reports data from a random sample of adults in a Southeastern county, analyzing scores on a depression scale accord- ing to age, race, sex, annual family income, education, and a general socioeconomic status score. SES was found to be the most signifi- cant variable, with age and race not significant at the level studied. Crisis Intervention Caplan, Gerald. Principles of Preventive Psychiatry. New York: Basic Books, 1964 This is one of the earlier and clearest statements of the CMH ideology. Many of the terms found in the literature—primary, sec- ondary, and tertiary prevention, crisis intervention, high-risk populations—are defined, illustrated, and placed in a context of community organization and planning. Central to Caplan’s concep- tualization is the significance of crises in the life and mental health of an individual, hence his basic model for treatment and preven- tion is based on intervention at these times. Jacobson, Gerald F. Emergency services in community mental health. American Journal of Public Health, 64(2):124-128, 1974. Reporting on the inadequacies of emergency MH services in CMHCs, the author states that there is promise in this area that could be realized if clear definitions were developed for emergency services, coupled with the application of a consistent theoretical framework. A classification is proposed, differentiating between suicide prevention, emergency and referral, and crisis intervention. Crisis intervention is discussed in further detail in regard to theoretical framework and techniques. Kaslow, Florence. Crisis intervention theory and technique. Intellect Magazine, January 1976. A succinct explanation of the significance and potential of crisis for the individual, the theory behind crisis intervention, and the tech- niques for strengthening a person’s capacity to cope with stress. Litman, Robert E., and Wold, Carl 1. Beyond crisis intervention. Psy- chiatric Annals, 6(11):119-121, 1976. The authors see standard crisis intervention techniques as being in- effectual with some high suicide risks. They have developed a reaching out service, called “continuing relationships,” provided by 186 BIBLIOGRAPHY volunteers. The service is not considered therapy, clients are en- couraged to utilize other appropriate resources, and the emphasis is on rehabilitation rather than crisis. McGee, Richard K. Crisis Intervention in the Community. Baltimore: University Park Press, 1974. A basic text for those concerned with planning crisis intervention programs. McGee provides the historical and conceptual context of crisis intervention, describes characteristics of 10 actual programs, and develops a model for service delivery. Some of the topics dis- cussed are, among others, crisis center staffing, recordkeeping and statistics, planning guidelines, evaluation, and the use of nonprofes- sional volunteers. McGee, Thomas F. Some basic considerations in crisis intervention. Community Mental Health Journal, 4(4):319-325, 1968. To increase understanding of the concept of crisis intervention, it is proposed that emotional crises be placed on a continuum ranging from normal developmental crises to psychiatric emergencies. This clarifies the reasons behind using crisis intervention, as it does the roles of direct treatment and consultation. McGee also suggests that a variety of viewpoints be considered in assessing a crisis, resulting in a more pragmatic orientation for the CMHC. Parad, Howard J., ed. Crisis Intervention: Selected Readings. New York: Family Service Association of America, 44 East 23rd Street, 10010, 1965. The papers presented here delineate the range of formulations of crisis theory, the varieties of practical applications, and some of the research done on the subject. The underlying philosophy is that short-term treatment can be a matter of choice, not merely of expe- diency. Long a social work text, the book is treatment oriented, and thus has considerable value for those who deliver, as well as those who plan, services. Smith, Larry L. Crisis intervention theory and practice. Community Mental Health Review, 2:1, 1977. Smith reviews current and basic literature on crisis intervention, dealing particularly with the formulations of Caplan, Parad, and Rapoport. He concludes that, while crisis intervention is a popular model, it is still conceptually unclear because it is not opera- tionalized into clear treatment plans. An extensive bibliography is included. Spitz, Norris. The evolution of a pyschiatric emergency crisis interven- tion service in a medical emergency room setting. Comprehensive Psychiatry, 17(1):99-113, January/February 1976. 187 BIBLIOGRAPHY This article describes the emergency room at Cincinnati General Hospital, where a new type of psychiatric team has been imple- mented to provide better psychiatric emergency care. Yano, Brian, et a1. Crisis intervention: A guide for nurses. Journal of Rehabilitation, 42(5):23-26, September/October 1976. Three broad aspects f0 crisis intervention are examined in the con- text of one case study. Stages of crisis are identified, definitions of crisis are offered, and the effects of an individual’s (victim or caregiver) psychological conditioning on crisis response are dis- cussed. Mental Health Consequences of Disaster and the Delivery of Services to Victims Bates, F.L., et al. The Social and Psychological Consequences of a Natural Disaster: A Longitudinal Study of Hurricane Audrey, Washington, D.C.: National Academy of Sciences-National Research Council, 1963. Part of this book’s value is that it analyzes social and psychological changes in a disaster—stricken community over a long period. Noteworthy chapters are “Role Stress Associated with Rehabilita- tion,” “Mental Health Effects of Hurricane Audrey,” and “Social Changein Response to Hurricane Audrey.” The authors conducted a number of interviews, surveys, and analyses of records to deter- mine lasting changes in community and individual functioning. Regarding mental health, they found only minimal reporting of mental illness or emotional disturbance, but considerable evidence of “nervousness, somatic complaints and behavioral disturbance” that were not likely to be identified as emotionally related. Findings are supplemented with a discussion of various types of stress, at- tenuating factors, and behavioral responses within a temporal con- text. Birnbaum, Freda; Coplon, Jennifer; and Scharff, Ira. Crisis interven- tion after a natural disaster. Social Casework 54:545-551, Novem- ber, 1973. A descriptive account of social work crisis intervention services to the Jewish community affected by the 1972 Agnes flood. The authors explain the structures used and some of the strategies employed. Group work and outreach were particularly effective, while discontinuity of care and resentment of “outside inter- ference” were cited as serious problems. 188 BIBLIOGRAPHY Block, Donald A.', Silber, Earle; and Perry, Stewart. Some Factors in the Emotional Reaction of Children to Disaster. Bethesda, Mary- land: Laboratory of Child Research, National Institute of Mental Health, 1953. This 1953 study, investigating the results of a tornado that par- ticularly affected a theatre filled with children, explored two general areas of interest: the relationship between a child’s emo- tional disturbance and (1) the extent of his actual involvement in the disaster, and (2) the way in which parents handled the ex- perience with the child. Bowman, Sue. Disaster intervention: From the Inside. Paper pre— sented at the Annual Meeting of the American Psychological Association, Chicago, Illinois, August 31, 1975. Written by the coordinator of the Monticello Neighbor-to-Neighbor Team, this paper describes the organization of a mental health out- reach effort for tornado victims in a community previously without formally designated mental health agencies. Use of paraprofes- sionals indigenous to the community under the leadership of out- side professionals is discussed, and the importance of gaining legitimacy in the community is stressed. Other topics include: cri- teria for choice of mental health workers; the training of workers; problems posed by funding questions; and program evaluation. Brownstone, Jane, et al. Disaster-relief training and mental health. Hospital and Community Psychiatry 28:1, January 1977. Following a Mississippi River flood in 1973, a taskforce was created to merge mental health and disaster relief services. Recommenda- tions were: short-term emotional support to victims, ideally coupled with material aid, and the use of MH professionals as “backup” to frontline workers. A self-contained video- tape/workshop was developed to help workers improve listening skills, learn problemsolving techniques, become aware of behavioral clues to emotional disturbance, and familiarize them- selves with the work of other relief agencies. Church, June. The Buffalo Creek Disaster: Extent and Range of Emo- tional and/or Behavioral Problems. Paper for APA Symposium on Picking up the Pieces: Disaster Intervention and Human Ecology, Montreal, Canada, 1973. Church gives examples of the emotional disturbance found and the treatment provided. Based on his experience he suggestes that such emotional stress could be alleviated if natural social groupings of evacuees were preserved, if there was someone with a clearly defined ombudsman/advocate role, and if inservice mental health training was provided to members of disaster relief organizations. 189 BIBLIOGRAPHY Cohen, Raquel E. “Post-Disaster Mobilization of a Crisis Intervention Team: The Managua Experience.” Paper presented at the National Institute of Mental Health Continuing Education Seminar on Emergency Mental Health Services, Washington, DC, June 22-24, 1973. In this account of mental health activities following a major earth- quake, Cohen focuses on (1) the multilevel areas of activities of the team—direct services plus consultation and education within exist- ing services; (2) the dislocation of socioeconomic structures, com- munity services, and impact on the population; and (3) a descrip- tion of a series of crisis intervention projects, paying special atten— tion to procedures for entering and integrating with the existing system, defining objectives, detailing activities of workers and the outcomes, and suggesting future techniques and procedures. Drabek, Thomas E., and Boggs, Keith S. Families in disaster: Reac- tions and relatives. Journal of Marriage and the Family, 30:443-451, August 1968. In studying the response of families to disaster warnings, the authors interviewed a sample of over 3,700 families who were evacuated when a flood struck metropolitan Denver. They found initial response to be marked disbelief regardless of warning source and a strong tendency for families to take refuge with relatives rather than with centers. This tendency was significantly affected by social class and by the degree of interaction between relatives during the warning period. Drayer, Calvin 8.; Cameron, Dale C.; Woodward, Walter D.; and Glass, Albert J. Psychological first aid in community disasters. Journal of the American Medical Association, 156(1):36-41, Sep- tember 1954. This article, which makes reference to both natural disasters and combat situations, discusses five kinds of psychological reactions to disaster: “normal” reactions, panic, “depressed” reactions, “overly active” responses, and bodily reactions. Four principles for effective psychological first aid are outlined, most of which focus on the need for conveying acceptance of the kinds of feelings victims are ex- periencing. Strategies for dealing with each of the five types of reac- tions are also advanced. Farber, Irving J. Psychological aspects of mass disasters. Journal of the National Medical Association 59(5):.‘340-345, 1967. A psychoanalytically oriented discussion of what Farber terms the “disaster syndrome.” Drawn mostly from studies of war neuroses and from Freud, it would be of limited value to those concerned 190 BIBLIOGRAPHY with community wide disasters, requiring systematic intervention strategies. Frederick, Calvin J. Psychological first aid: Emergency mental health and disaster assistance. The Psychotherapy Bulletin, 10(1):15-20, Winter 1977. Recent findings on the negative psychological effects of disaster are reviewed briefly by the author, an NIMH official who recommends the use of crisis intervention techniques to reduce disaster-related psychological problems. The legal basis for the delivery of mental health services to disaster victims is reviewed, and the means by which funds may be obtained are outlined. Glass, Albert J. Psychological aspects of disaster. Journal of the American Medical Association, 188-191, September 1959. This author assumes that the experiences of individuals in combat are analogous to those of individuals in disasters, and he makes generalizations concerning behavior in both settings. The emphasis is on individual psychological processes and individual behavior during various phases in crisis situations. The article focuses on strategies for training individuals to perform effectively under “traumatic” conditions. Grossman, Leona. Train crash: Social work and disaster services. Social Work 18:38-44, September 1973. The patterns of response on victims, their friends and relatives, and the social workers who served them are described and analyzed. Of note are the author’s observations that people in stress are oriented to mutual help, particularly if positive models are provided; that urgent needs for comfort and help require suspension of the mechanisms that usually separate professionals from clients; and that opportunities for talking things out are paramount in the proc- ess of recovery. Hall, Philip S, and Landreth, Patrick W. Assessing some long-term consequences of a natural disaster. Mass Emergencies 1(1):55-62, October 1975. In an attempt to determine long-term consequences of a flash flood, the authors analyzed routinely collected public records—police blotters, school attendance, divorce statistics, etc. They found that as a whole the community did not experience a major mental health crisis, but that there were several indicators of social stress. However, they believe the stress was felt mainly by a small segment of the population and that the Federal disaster relief program, more than the flood itself, had the greater impact on social dysfunc- tion. 191 BIBLIOGRAPHY Harshbarger, Dwight. “An Ecological Perspective on Disastrous and Facilitative Disaster Intervention Based on the Buffalo Creek Dis- aster.” Paper presented at the NIMH Continuing Education Semi- nar on Emergency Mental Health Services, Washington, D.C., June 22-24, 1973. Discusses how intervention efforts can aggravate as well as aid the recovery process. The paper outlines how attempts to speedily remove debris and find shelter for victims produced a situation that heightened stress and created a potential for emotional distur- bance. On the positive side, the author notes the development of mental health programing that was helpful and presents a concep- tual framework for looking at the nature of intervention, the problems of groups at risk, and characteristics of intervenors. An ecological model for the organization of emergency mental health services is proposed. Heffron, Edward. Project Outreach, Final Report. Nanticoke, Pa.: NIMH Contract 1-MH-4-0008, Hazelton—Nanticoke MH/MR Center, June 1975. Heffron provides a comprehensive overview of the first organized mental health effort to be made in direct response to a disaster. One outcome of this project, which pioneered in the use of specially trained indigenous paraprofessionals, was its influence on the in- clusion of Section 413 (the provision of mental health services to disaster victims) in the Disaster Relief Act of 1974. Heurta, F.C.; Horton, R.L.; and Winters, H.T. “Coping with Disaster Among the Elderly.” Paper presented at the Annual Meeting of the Western Social Science Association, Denver, Colorado, April 21-23, 1977. This report on research conducted among victims of the 1976 Teton Dam break and flood finds that, contrary to what many mental health researchers and practitioners claim, older individuals cope well with the effects of disaster. A sample of 372 elderly people in the victim population were interviewed and were found to be relatively low in alienation and feelings of deprivation and hard- ship. Rural values and a strong church orientation are seen as possible sources of strength for these elderly disaster victims. Howard, Stephen J., and Gordon, Norma S. Final Progress Report: Mental Health Intervention in a Major Disaster. Van Nuys, California: Small Research Grant, MH21649-01, San Fernando Valley Child Guidance Clinic, 7335 Van Nuys Boulevard, 1972. Following an earthquake, a clinic offered crisis services to children and families. They found that disaster services were utilized by a 192 BIBLIOGRAPHY higher socioeconomic group than those ordinarily using the clinic, and that children using clinic services showed an overall higher level of symptomatology than a control group, with fears and sleep disturbances still present a year later. Kirn, Steven P. “Community Mental Health Centers and Disaster: Considerations Regarding Response During the Post-Impact Period.” Paper presented at the meeting of the Southeastern Psy— chological Association, Atlanta, Georgia, March 28, 1975. This paper recounts the author’s first-hand experience as a mental health professional in the Brandenburg, Kentucky tornado of 1974. Two approaches—special training of crisis intervention workers and a “participation response” by local professionals—are con- trasted. Activities engaged in by mental health workers in Branden- burg as part of their response to the tornado are discussed, and a community-oriented program, without explicit mental health over- tones, is advocated. Kliman, Ann S. The Corning flood project: Psychological first aid following a natural disaster. In: Emergency and Disaster Manage- ment: A Mental Health Sourcebook, Parad, Howard J.; Resnik, H.L.P.; and Parad, Libbie G., eds. Bowie, Maryland: Charles Press Publishers, 1975, pp. 325-335. This article describes a program utilizing local professionals and paraprofessionals, which was developed to provide crisis interven- tion and related mental health services to victims of the 1972 Corn- ing, New York flood. Beginning with the assumption that all resi- dents of a disaster-stricken community are either direct or indirect victims in a psychological sense, the program consisted of several elements, including victim discussion groups, an emergency mental health phone-in service, and public education programs. Kliman is among the first to highlight the mental health needs of the “hidden victims,” the caregivers in the disaster setting. Lifton, Robert Jay, and Olson, Eric. The human meaning of total dis- aster. Psychiatry, 39:1-18, February 1976. The authors discuss how, in Buffalo Creek, the simultaneous occur— rence of five characteristics of disaster: suddenness, human callous— ness in causation, continuing relationship of survivors to the dis- aster, isolation of the community, and totality of destruction, pro- duced a situation unique in its potential for producing emotional pathology. They state that everyone exposed to the disaster ex- perienced some or all manifestations of death imprinting, death guilt, psychic numbing, unfocused rage, and the struggle to explain 193 BIBLIOGRAPHY and integrate the disaster to themselves so as to allow resolution of inner conflicts. Lindemann, Erich. Symptomatology and management of acute grief. American Journal of Psychiatry 101:141-148, September 1944. Acute grief is recognized to be a consequence of loss of significant others and even of important possessions. Based on observations of bereaved disaster victims, Lindemann concludes that acute grief is a definite syndrome that may appear at any time after a crisis, may be normal or distorted, may even appear to be absent. He describes the symptomatology of both normal and morbid grief reactions, the course of the reaction, and discusses how proper management tech- niques can help people resolve the crisis. Marnocha, Mark, and Zarle, Thomas H. “Disaster Intervention: An Investigation of the Correlates of Helping in a Naturalistic Set- ting.” West Lafayette, Indiana, Department of Psychological Sciences, Purdue University, 1974. This study attempted to determine how three groups of in— dividuals—helpers, nonhelping visitors, and nonhelping-nonvisit- ing controls—in a postdisaster recovery period differed on selected personality, attitudinal, and experience variables. The results are discussed in terms of their implications for altruism research and of the possibility of visitor defensiveness. McGee, Richard K. The Role of Crisis Intervention Services in Dis- aster Recovery Center for Crisis Intervention Research. Gainesville, Florida, University of Florida, 1973. Beginning with the rationale for applying crisis intervention methodology to disaster recovery, McGee proceeds to discuss the training provided for paraprofesSionals in two project areas. Cap- sule summaries are used to illustrate the eight types of problems that, at the minimum, crisis workers must be prepared to handle. Issues related to how this type of human service delivery system can most efficiently be developed are considered briefly. Moore, Harry Estill. Some emotional concomitants of disaster. Men- tal Hygiene, 42:45-50, January 1958. This article is based on survey and interview data collected follow- ing a tornado and a severe storm and tornado threat which struck San Angelo, Texas in 2 consecutive years, 1953 and 1954. Some ob- jective measures and a variety of self-reported data on individuals’ psychological states are cited in support of the author’s contention that the disasters had a lasting effect on victims’ psychological ad- justments. 194 BIBLIOGRAPHY Omaha Tornado Project. Final Report. Omaha, Nebraska, 1976. Report of the activities of a mental health task force set up to deliver services to victims of the May 6, 1975 tornado which struck Omaha. Topics discussed include: individual and community reac- tions to disaster; nature and types of problems displayed by in- dividuals who were recipients of direct services; and various programs designed to reach target groups in the community. Leng- thy appendixes detail the approaches used with victims, and recom- mendations are made for improved future service delivery. Parad, Howard; Resnik, H.L.P.; and Parad, Libbie, eds. Emergency and Disaster Management: A Mental Health Sourcebook. Bowie, Maryland: The Charles Press Publishers, 1976. Defining a mental health emergency as one resulting from an un- foreseen incident which, if not responded to, will result in psy- chologically damaging consequences, this is the first major book to focus on the management of such emergencies. Its format is a series of case histories (many of which are cited separately in this bibliography) which have been contributed from several disciplines. Typically, intervention follows a conceptual model grounded in crisis theory, which sets goals and localizes treatment within the community. Penick, Elizabeth C.; Larcen, Steven W.; and Powell, Barbara J. Final Report of the Lieutenant Governor’s Task Force for Mental Health Delivery Systems in Time of Disaster. St. Louis, Missouri, Depart- ment of Psychological Services, Malcolm Bliss Mental Health _ Center, 1974. This report is based on a study of the need for, and delivery of, men- tal health and other human services following the 1973 Mississippi River floods in Missouri. The report contains (1) a discussion of a needs-assessment survey (interview type) performed by the Task Force; (2) a set of recommendations for the development of a more adequate disaster response on the part of the mental health sector; and (3) a series of appendixes containing program outlines, media treatments of disaster mental health problems, task force meeting minutes, and other materials, including a copy of the survey instru- ment. Poulshock, S. Walter, and Cohen, Elias S. The elderly in the after- math of a disaster. The Gerontologist, 152357-361, August 1975. Survey data obtained from a sample of elderly flood victims 1 year after impact indicate their perceived need for “hard” services such as housing, increased income, and transportation. Implications for normal circumstances center on the stigma that seems to hold for services proffered by public assistance and mental health agencies. 195 BIBLIOGRAPHY Schulberg, Herbert. Disaster, crisis theory, and intervention strategies. Omega, 5(1):77-87, 1974. Schulberg discusses the proliferation of definitions and usages of the concept of crisis, depending on whether it is viewed as a clinical syndrome, a prototype of the interaction between the individual and his environment, a normative experience, or a change tactic. Pointing out as well those features of crisis which are central to most viewpoints, he suggests a probability formulation of whether or not individuals or groups will experience crisis and discusses both anticipatory and participatory strategies of disaster interven- tion. Sundel, Martin. “Problems Facing a Community Mental Health Center in Delivery of Mental Health Services to a Disaster Area.” Paper based on a presentation made at the Annual Meeting of the National Council of CMHCs, Washington, DC, February 25, 1975. Sundel presents a detailed account of a regional CMHC program’s response to a tornado. At the time of impact, services were mainly ad hoc consultation and education. In following months various direct and indirect services were provided to both victims and caregivers; concurrently, planning was done for a formal disaster plan incorporating CMHC services with those of other agencies. Several attachments are included, covering training, crisis inter- vention techniques, and a proposal for CMHC roles in predisaster, during, and postdisaster intervention. Taylor, Verta A., et 31. Delivery of Mental Health Services in Dis- asters: The Xenia Tornado and Some Implications. Columbus, Ohio: The Ohio State University, The Disaster Research Center Book and Monograph Series No. 11, 1976. The first attempt to survey the overall delivery of mental health services in a community after disaster, this work is aimed at ascer- taining the characteristics of the organized response. The questions asked center around the who, what, for whom, how, why, and where of service delivery. Secondary attention is paid to the conditions for and the consequences resulting from the overall response. Titchener, James L., and Kapp, Frederic T. Family and character change at Buffalo Creek. American Journal of Psychiatry, 133(3):295-299, March 1976. Two years after the 1972 flood which wiped out an entire valley, psychoanalytically oriented evaluation teams studied psychological after effects. They found traumatic neurotic reactions in 80 percent of the survivors, characterized by a definite symptom complex of unresolved grief, survivor shame, and feeling of impotent rage and 196 BIBLIOGRAPHY hopelessness. The authors posit that the very means used by sur- vivors to cope with their feelings actually preserved symptoms and suggest that professional services aimed at helping victims work through personal crisis would be of value. Tuckman, Alan J. Disaster and mental health intervention. Com- munity Mental Health Journal, 9(2):151-157, 1973. Tuckman sees disaster relief as a proper arena for community men— tal health practice, but one that requires reaching out to victims and departing from traditional professional roles. The paper ex— plores the psychological reactions to a major school bus accident and the intervention techniques that were utilized. Tyhurst, J.S. Psychological and social aspects of civilian disaster. Canadian Medical Association Journal, 76:385-393, March 1957. Tyhurst was one of the first to note consistent patterns in individual response to disaster. He outlines the characteristics, the duration, and the psychological phenomena associated with three phases: the period of impact, of recoil, and the posttraumatic period. Some of his observations, relating to the extent of emotional disturbance and the degree of helplessness in populations, have not withstood the test of time. However, his central premise, that disaster is essen- tially a social phenomenon, is compatible with current thinking on disaster mental health. I Wolfenstein, Martha. Disaster: A Psychological Essay, Glencoe, California: Free Press, 1957. This book is based on data collected for the Committee on Disaster Studies of the National Academy of Sciences—National Research Council. It focuses primarily on peacetime disasters in the United States. The analysis is at the individual level, and various psy- chological processes thought to operate during the threat, impact, and postimpact periods are discussed. Psychoanalytical concepts are used in the explanation of phenomena such as the denial of threat, “the disaster syndrome,” and postdisaster altruism and uto- pian feelings. Zarle, Thomas H.; Hartsough, Don M.; and Ottinger, Donald R.. Tor- nado recovery: The development of a professional-parapr0fessional response to a disaster. Journal of Community Psychology, 2(4):311-320, October 1974. When formal mental health agencies did not involve themselves in the recovery operations, mental health resources from a nearby university, coupled with indigenous paraprofessionals, formulated a response. The authors report on the eight phases of the project, describe the training manual and schedule used, and spell out the 197 REFERENCES specific goals of what came to be known as the Neighbor to Neighbor Team. With both immediate and long-term objectives in mind, the project shifted over time from a referral-based crisis in— tervention response to a coordinated outreach program grounded in both crisis intervention and social systems theory. REFERENCES Barton, Allen H. Communities in Disaster: A Sociological analysis of Collective Stress Situations. Garden City, New York: Anchor, Doubleday Books, 1970. Blanshan, S. “Disaster Myths of Mayhem and Their Implications: A Replication.” Unpublished paper. Bloch, Donald; Silber, Earle; and Perry, Stewart, Some Factors in the Emotional Reaction of Children to Disaster. Laboratory of Child Research under contract to NIMH, 1953. Bowman, S. “Disaster Intervention: From the Inside.” Paper pre— sented at APA (American Psychological Association), Chicago, 1975. Caplan, G. Principles of Preventive Psychiatry. New York: Basic Books, 1964. Cohen, Julius. The effect of distance on use of outpatient services in a rural mental health center. Hospital and Community Psychiatry, 23(1):27-28, 1972. Collins, Alice H., and Pancoast, Diane L. Natural Helping Networks: A Strategy for Prevention. Washington, DC: NASW Publication, 1976. Dewey, R. The rural-urban continuum: Real but relatively unimpor- tant. American Journal of Sociology, 66:60-66, 1960. Dillman, Don A., and Tremblay, Kenneth R., Jr. The quality of life in rural America. The Annals, 429:115-129, 1977. Dohrenwend, Bruce R, and Dohrenwend, Barbara Snell. Psychiatric disorders in urban settings, Chapter 29. American Handbook of Psychiatry, 11:424-447. New York: Basic Books, 1974. Drabek, Thomas E., and Boggs, Keith S. “Families in disaster: Reac- tions and relatives. Journal of Marriage and the Family, 30, August 1968. 198 REFERENCES Dynes, Russell R. Organized Behavior in Disaster. Monograph Series #3. Columbus, Ohio: The Disaster Research Center, The Ohio State University, 1974, 235 pp. Dynes, Russell R.; Quarantelli, EL; and Kreps, Gary. A Perspective on Disaster Planning. Report Series # 1 1. Columbus, Ohio: The Dis- aster Research Center, The Ohio State University, 1972. Edgerton, J. Wilbert, and Bentz, W. Kenneth. Attitudes and opinions of rural people about mental illness and program services. American Journal of Public Health, 59(3):470-477, 1969. Edgerton, J. Wilbert; Bentz, Willard K.; and Hollister, William G. Demographic factors and responses to stress among “rural” people. American Journal of Public Health, 60(6):1065—1071, June 1970. Eisdorfer, Carl; Altrocchi, John; and Young, Robert. Principles of community mental health in a rural setting: The Halifax County program. Community Mental Health Journal, 4(3):211-220, 1968. Erikson, Kai T. Everything in Its Path. New York: Simon and Schuster, 1976. Foley, Henry A. Community Mental Health Legislation. Lexington, Massachusetts: D.C. Heath and Company, 1975. Form, William, and Nosow, Sigmund. Final report on the Flint- Beecher tornado, Chapter 9. Community in Disaster. New York: Harper, 1958. Frederick, Calvin J. Current thinking about crises or psychological in- tervention in United States disasters. Mass Emergencies, 2:43-50, 1977a. Frederick, Calvin J. Psychological first aid: Emergency mental health and disaster assistance. The Psychotherapy Bulletin, 10(1):15-30, 1977. Fritz, Charles E. Disaster. In: Robert Merton and Robert Nisbet, eds, Social Problems. New York: Harcourt, Brace and World, 1961. Glenn, Norval, and Hill, Lester, Jr. Rural-urban differences in at- titudes and behavior in the US. The Annals, 429:36-50, 1977. Guillozet, Noel. Community mental health—New approaches for rural areas using psychiatric social workers. Medical Care, 13(1):59-67, 1975. Guillozet, Noel. Group practice approach to rural community mental health. Western Journal of Medicine, 121(3):249-253, 1974. 199 REFERENCES Hall, Philip S., and Landreth, Patrick W. Assessing some long-term consequences of a natural disaster. Mass Emergencies, 1:55-61, 1975. Heffron, Edward. Project Outreach Final Report. Nanticobe, Penn- sylvania: Hagleton-Nanticobe Mental Health/Mental Retardation Center, 1975. Hinkle, Lawrence E. The effect of exposure to cultural change, social change, and interpersonal relationships. Stressful Life Events: Their Nature and Source. New York: Wiley and Sons, 1974. Hofstatter, L.; Ulett, G.A.; Thompson, W.A.; Ameiss, A.; and Gannon, P.J. A modern psychiatric delivery system for urban and rural areas. Southern Medical Journal, 65(7):875-881, 1972. Hollingshead, A.B., and Redlich, F.C. Social Class and Mental Ill- ness. New York: Wiley and Sons, 1958. Hollister, William; Edgerton, J.W.; Bentz, W.K.; Miller, F.T.; and Aponte, J .F. Experiences in Rural Mental Health. Under contract to NIMH. Chapel Hill, North Carolina: University of North Carolina. 1973. Holmes, TH, and Rahe, R.H. The social readjustment rating scale. Journal of Psychosomatic Medicine, 11:213-218, 1967. Howard, Stephen J ., and Gordon, Norma. “Mental Health Interven- tion in a Major Disaster.” Final report to National Institute of Mental Health. Van Nuys, California: San Fernando Child Gui- dance Clinic, 1972. Huerta, F.C.; Horton, R.L.; and Winters, H.T. “Coping with Disaster Among the Elderly.” Paper presented at Western Social Science Association, Denver, Colorado, April 21-23, 1977. Huessy, Hans R. Tactics and targets in the rural setting, Chapter 30. Handbook of Community Mental Health. New York: Appleton- Century-Crofts, 1972. Janis, Irving L. Air War and Emotional Stress. New York: McGraw- Hill, 1951. Jones, James D.; Wagenfeld, Morton 0.; and Robin, Stanley S. A profile of the rural community mental health center. Community Mental Health Journal, 12(2):176-181, 1976. Kinston, Warren, and Rosser, Rachel. Disaster: Effects on mental and physical state. Journal of Psychosomatic Research, 18:437-456, 1974. Kim, Steven P. “Community Mental Health Centers and Disaster: Considerations Regarding Response During the Post-Impact 200 REFERENCES Period.” Paper presented at the Southeast Psychological Associa- tion, Atlanta, Georgia, March 28, 1975. Knoke, David, and Henry, Constance. Political structure of rural America. The Annals, 429:51-62, 1977. Lee, Soong H.; Gianturco, Daniel T.; and Eisdorfer, Carl. Community mental health center accessibility. Archives of General Psychiatry, 31:335-339, 1974. Leighton, A.I-I.; Lambo, T.A.; Hughes, C.C.; Leighton, D.C.; Murphy, J.M.; and Macklin, P.B. Psychiatric Disorder Among the Yaruba. Ithaca, N.Y.: Cornell University Press, 1963. Leighton, D.C.; Leighton, A.H.; and Armstrong, R.A. Community psy- chiatry in a rural area: A social psychiatric approach. Chapter 7. Handbook of Community Psychiatry and Community Mental Health. New York: Grune and Stratton, 1967. Lifton, Robert J., and Olson, Eric. The human meaning of total dis- aster. Psychiatry 3921-18, 1976. Marks, Eli S., et al. Human Reactions in Disaster Situations. Three volumes, 861 pp. Chicago, Illinois: National Opinion Research Center, University of Chicago, 1954. McGee, Richard K. “The Role of Crisis Intervention Services in Dis- aster Recovery.” Paper presented at NIMH meeting, 1973. Mentally, the Urban Life Beats the Rural. New York Times, May 8, 1977. Miller, Donald H. Community Mental Health: A Study of Services and Clients. Lexington, Mass: D.C. Heath and Company, 1974. National Institute of Mental Health. The Mental Health of Rural America: The Rural Programs ofNIMH, Segal, J., ed. DHEW Pub. No. (HSM):73-9035. Washington, DC: Superintendent of Docu- ments, US. Government Printing Office, 1973. Nelsen, Hart M., and Potvin, Raymond H. The rural church and rural religion: Analysis of data from children and youth. The Annals, 429:103-114,1977. Omaha Tornado Project. “Final Report to Federal Disaster Assis— tance Administration.” Omaha, Nebraska: Eastern Nebraska Human Services Agency, 1976. Peipert, James R. Mental Health Studied During Irish Violence. Col- umbus Dispatch, B-12, June 5, 1975. 201 REFERENCES Penick, Elizabeth C.; Larcen, Stephen W.; and Powell, Barbara J. Final Report: Lt. Governor’s Task Force for Mental Health Deliv- ery Systems in Times of Disaster. St. Louis, Missouri: Printing Department, St. Louis State Hospital, 1974. Poulshock, S. Walter, and Cohen, Elias S. The elderly in the after- math of a disaster. The Gerontologist, 15:357—361, 1975. Quarantelli, EL, and Dynes, Russell R. Operational Problems of Organizations in Disasters. Emergency Operations Symposium. Santa Monica, California: System Development Corporation, 1967, pp. 151-175. Quarantelli, EL, and Dynes, Russell R. When disaster strikes (It isn’t much like what you’ve heard and read about). Psychology Today, 5266-70, 1972. Rabkin, Judith. Public attitudes toward mental illness: A review of the literature. Schizophrenia Bulletin, 10:9-33, 1974. Raft, David D.; Coley, Silas B.; and Miller, Francis T. Using a service guide to provide comprehensive care in a rural mental health clinic. Hospital and Community Psychiatry, 27(8):553, 1976. Reissman, Frank. A neighborhood-based mental health approach. Emergent Approaches to Mental Health Problems, Cowan, Gardner, Zax, eds. New York: Appleton-Century-Crofts, 1967. Schulberg, Herbert C. Disaster, crisis theory, and intervention strategies. Omega, 5:77-87, 1974. Schwab, J.J., and Warheit, G.J. Evaluating Southern mental health needs and services. Journal of Florida Medical Association, Janu- ary 1972. Smith, T. Lynn, and Zopf, Paul E., Jr. Principles of Inductive Rural Sociology. Philadelphia: F.A. Davis, 1970. Taeuber, Irene B. The Changing Distribution of the Population in the US. in the Twentieth Century. Population, Distribution and Policy, US. Government Printing Office, 1972. Taylor, Verta; Ross, G. Alexander; and Quarantelli, E.L. Delivery of Mental Health Services in Disasters: The Xenia Tornado and Some Implications. Monograph #11. Columbus, Ohio: The Disaster Research Center, The Ohio State University, 197 6. Titchener, James L., Kapp, Frederic T. Family and character change at Buffalo Creek. American Journal of Psychiatry, 133:3, 1976, pp. 295-299. Tuckman, Alan. Disaster and mental health intervention. Community Mental Health Journal, 9:151-157, 1973. 202 & .sf’ {5* . nm-‘n fi" 243""; REFERENCES Tyhurst, J.S. Individual reactions to a community disaster: The natural history of a psychiatric projective phenomena. American Journal of Psychiatry 107:764-769, 1951. Warheit, George J.; Holzer, Charles, 111; Bell, Roger; and Arey, Sandra. Mental Health in the Southeast: An Epidemiological Report. Under contract to NIMH, 1975. -Warheit, George J.; Schwab, John J.; Holzer, Charles, III; and Nadeau, Stephen E. “New Data from the South on Race, Sex, Age and Mental Illness.” Paper presented at annual ASA meeting, August 28-30, 1973. Weiss, Peter; Macaulay, Jacqueline R.; and Pincus, Allen. Geographic location and State hospital utilization. American Journal of Psy- chiatry, 124:637-641, 1967. Wenger, Dennis E.; Dykes, James D.; Sphak, Thomas B.; and Neff Joan L. It’s a matter of myths: An empirical examination of in- dividual insight into disaster response. Mass Emergencies, 1:33-46, 1975. Willie, Charles V. Health care needs of the disadvantaged in a rural-urban area. HSMHA Health Reports, 87:1:81-86, 1972. Wright, Joseph E. Organizational prestige and task saliency in dis- ‘ aster. In: Disasters: Theory and Research. London: Sage Publica- tions, 1978. Youmans, E. Grant. The rural aged. The Annals, 429, 1977. Zarle, Thomas H.; Hartsough, Don M.; and Ottinger, Donald R. Tor— nado recovery: The development of a professional-paraprofessional response to a disaster. Journal of Community Psychology, 2:331-320, 1974. 'fi' U.S. GOVERNMENT PRINTING OFFICE : 1979 0—295-679 203 a U. S. GOVERNMENT PRINTING OFFICE : 1979 295—679/226 QBERKELEV LIBRARIES CUE‘IIBBLEH