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Article 30

The Counselor and the Disaster Response Team

An Emerging Role

Julie A. Uhernik

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In the past decade, America’s response to emergency and disaster, whether it is man-made or naturally occurring, has garnered attention and galvanized the focus of our nation. This focus has included on-going planning and risk assessment for all-hazards events, and has outlined best practices in emergency planning, response, and recovery phases following a disaster. As part of this focus, a new and emerging role for counselors can be found through the integration of counselors as members of emergency response teams. Counselors can contribute their knowledge, skills and expertise in the planning, response, and recovery phases of emergency response.

The skills of the counselor were called upon heavily in disasters such as Hurricane Katrina, particularly in acute response efforts and subsequent long-term recovery. In 2005, the American Counseling Association and National Board for Certified Counselors partnered with the American Red Cross (2006) to deploy nearly 4,600 counselors and other licensed mental health professionals to assist in disaster response efforts in New Orleans and the Gulf Coast. The American Counseling Association was recognized for sending 20% of the total number of deployed mental health counselors to the Gulf Coast following Hurricane Katrina (Kennedy, 2006). In the post 9/11 environment, the knowledge and expertise of the counselor and behavioral health specialist is being sought to assist in on-going planning efforts for all-hazard emergency response, including natural disasters, biochemical and terrorist attacks. The Council for Accreditation of Counseling and Related Educational Programs (CACREP), in an effort to integrate counselors into emergency response, has included emergency preparedness competency recommendations into their 2009 Standards revision (2007). The 2009 Standards, when adopted, will include emergency response objectives in the accreditation process for college and university counseling education programs.

In the time since the terrorist attacks of 9/11, local, state and federal planning efforts have increasingly focused on multi-agency, multi-disciplinary response procedures for disaster preparedness. The National Response Framework (NRF), established by Homeland Security Presidential Directive (HSPD)-5, delineates incident management activities, including how to prevent, prepare for, respond to, and recover from terrorism, major natural disasters and other major emergencies (2004). The National Response Framework describes how the Federal government will assist local, state, and federal agencies; and tribal governments in the conduct of missions of primary Federal responsibility. It is important to understand how behavioral health response fits into larger directives, specifically within the NRF.

The NRF Annex designates 15 Emergency Support Functions (ESF) for incident management. The ESF model provides structure for coordinating interagency response. Both primary and support agencies are assigned responsibility for each function. Behavioral Health is considered an emergency response function and is grouped with Public Health and Medical Services under ESF # 8. The Department of Health and Human Services is designated the primary lead to coordinate ESF #8 agencies. In a disaster requiring activation of ESF # 8, Public Health may request the expertise of counselors for Behavioral Health planning, response or recovery.

The counselor should become familiar with components of the National Response Framework, specifically the National Incident Management System (NIMS) and the Incident Command System (ICS). The NIMS system provides a template for incident management regardless of size, scope or cause. Incident Command outlines operational management and structure as various agencies work together to address the incident. Originally developed by fire fighters in the 1970s, the standardized ICS model has been adopted by law enforcement, emergency medical services (EMS), public health agencies, and recently by school systems, hospitals, and behavioral health agencies. Familiarity with NIMS and ICS training will help counselors speak a common language with other responders, work as part of a multi-disciplinary team, and integrate quickly into a common management structure. Counselors are advised to take several basic level ICS courses to familiarize themselves with the ICS system, specifically IS 100 and IS 700 courses, available on-line through http://training.fema.gov/IS/crslist.asp . Additionally, counselors should take disaster response field trainings offered through response agencies or groups such as the American Red Cross.

Counselors that understand ICS can join with a multi- disciplinary team in disaster response. Counselors will provide the team with unique skills and a behavioral health focus. Listed below are areas that counselors have historically had an impact, as well as new areas where counselors can provide assistance in disaster response.

Planning

Counselors who work in agency settings can assist in development or review of their agency internal emergency plans. Agency specific plan input may include: call-down or emergency notification procedures, continuity of operations planning, response team deployment criteria, and resource typing.

Additionally, the behavioral expertise of the counselor can assist in crafting messages for staff, public and media. This final arena, known as risk communications, involves the counselor in the development of thoughtful and informed messages to the public that can increase compliance and direct public actions in the event of an emergency. Disciplines such as public health may seek recommendations of behavioral health professionals when considering the psychological impact of public messages. Behavioral health input can help decrease public anxiety, minimize stress and trauma, and maximize public compliance with directives. According to Flynn (2006) there are five areas where behavioral health can contribute to risk communication and enhance positive behavioral health in the public. These five areas include (a) understanding confirmatory bias, (b) promoting resilience, (c) assisting to find meaning, (d) engaging consumers in preparedness, and (e) providing opportunities for prevention. The Centers for Disease Control and Prevention (2002), also mention the importance of recognizing psychological factors in a public health emergency and providing guidance in determining effective public messages.

Counselors can collaborate with other emergency response groups as they engage in planning for different operational aspects during a disaster. For example, counselors in cooperation with coroners, law enforcement and public health can provide behavioral health planning for disasters involving mass fatalities. Counselors can advise on the set up and operation of a Family Assistance Center. They can assist law enforcement during notification of next of kin. In planning for pandemic influenza, Reissman, Watson, Klomp, Tanielian, and Prior (2006) suggested that behavioral health specialists may assist public health agencies by providing phone crisis counseling and website support, engaging faith based communities, and helping to educate the public about social distancing, isolation, or quarantine requirements.

Finally, counselor expertise can be integral to emergency planning related to populations with special needs. Counseling has long considered cultural diversity and multi-cultural awareness as a central value and a guiding factor to the services counselors provide. This awareness and sensitivity is of value in emergency planning which recognizes the needs of special populations and develops appropriate educational messages to assist in outreach efforts to these populations. (U.S. Department of Health and Humans Services, 2003)

Response

In response efforts, the counselor can apply knowledge of psychological, sociological and developmental principles in emergency response. Counselors should become familiar with evidence based best practices as well as research gaps regarding efficacy of behavioral health response models. There is currently an emphasis on recognizing individual and community resilience, and fostering resiliency during the immediate post disaster period. Reissman, Klomp, Kent, and Pfefferbaum (2004) point to the need for further study on resilience, both individual and societal, that may help to protect against future disasters such as terrorism. According to Norris, Byrne, Diaz, and Kaniasty (2007), interventions in the immediate period of response, whether directed at the community, the family or individual, should focus on empowerment, and build on strengths, capabilities and self- sufficiency. An operating assumption is that the majority of survivors will have a normal (i.e., common) response to the abnormal disaster situation. Current thought holds that an immediate behavioral health response should help leverage individual and community resilience to provide support and cushion against later development of persistent psychopathology.

There are a number of models for immediate disaster behavioral health response. Several deserving mention include Critical Incident Stress Management (CISM), Psychological First Aid (PFA) and Cognitive Behavioral Therapies. CISM was first developed for use with military combat veterans, and later expanded to include civilian first responders in the 1980s. Previously, Critical Incident Stress Management, with emphasis on Psychological Debriefing (PD), was frequently used as an intervention model in the immediate post disaster period. CISM, with debriefing models that promote cathartic verbal review of stressful experiences and accompanying emotions, now sometimes called Critical Incident Stress Debriefing (CISD), has fallen out of favor as a response model. Raphael, Meldrum, and McFarlane (1995) point to research that indicate debriefing may not be effective for many people, does not consistently reduce the risk for later development of mental health problems and may actually increase the risk for subsequent problems in some individuals.

Ruzek (2006) discussed empirically supported cognitive- behavioral approaches in the treatment of trauma populations. Ruzek outlines cognitive-behavioral models of structured intervention that include skills training, self-monitoring, and recording of key behaviors and task assignments as a possible early intervention model. Counselors working in acute emergency response can add cognitive- behavioral techniques to their emergency response interventions.

Recent attention has looked to Psychological First Aid (PFA) as an evidence- informed model for acute disaster mental health response. PFA supports disaster survivors by encouraging self-efficacy, mastery, perceived control, and social support. PFA response promotes the following basic actions: (a) Contact and engagement; (b) provide safety and comfort; (c) provide stabilization; (d) gather information; (e) provide practical assistance; (f) establish connection with social supports both primary and within community; and (g) provide information on stress reactions, coping skills, and promote resiliency and empowerment (National Center for Child Traumatic Stress, 2006). There is a need for on-going, empirical research on the effectiveness of Psychological First Aid as a disaster behavioral health response model. Research efforts must account for the ethical considerations in withholding a potentially beneficial treatment or intervention. Future development of ethical and definitive research designs will clarify best practice and effective disaster response models. Counselors in emergency response should be aware of emerging research to incorporate best practice in emergency response. Integrating the common elements of PFA and well researched models such as cognitive- behavioral interventions may be best practice guidelines for providing disaster behavioral health response.

The counselor, being a member of a multi-disciplinary team, will often be required to assess levels of stress and vicarious trauma among disaster survivors and all members of the response team, particularly first responders, staff and fellow behavioral health responders. This dual response role necessitates special skills and a focus on teamwork, peer assistance, and work shift time limits for behavioral health responders. Finally, and perhaps most important, counselors in emergency response will do well to foster and build personal resilience in their own lives as they are called to become members of emergency response teams.

Recovery

Counselors have a prominent response team role in the recovery phase of a disaster. Long after the acute response teams have completed their duties, counselors skilled in treatment of trauma continue to provide mental health service delivery to impacted and recovering communities in which they reside. Counselors provide assessment and treatment of individuals with PTSD, substance abuse and other post disaster mental health issues, and they continue to provide crisis counseling and trauma intervention. The recovery effort following Hurricane Katrina is an excellent example. Counselors working in programs such as Access to Care have provided behavioral health and education services to nearly 12,000 hurricane survivors and are continuing in the recovery effort (American Red Cross, 2007).

Summary

In all phases of emergency planning, response, and recovery, the counselor is recognized as a valuable and essential member of an emergency response team. Counselors and behavioral health responders can provide evaluation on community resilience and rebuilding, provide assistance in future planning, and make recommendations on best practices. The counseling profession has taken a committed, proactive stance to providing new counselors with knowledge and training through CACREP emergency preparedness initiatives. Counselors interested in the field can learn more about the role of the emergency responder through NIMS and ICS training. Finally, counselors can promote their own personal resilience and the resilience of the communities that they serve.