Emergency Mental Health and
Traumatic Stress

Substance Abuse Services within Crisis Counseling Programs

Note: This is the fifth in a series of program guidance documents developed to ensure consistency in addressing key program issues in the Crisis Counseling Training and Assistance Program (CCP). The Crisis Counseling Training and Assistance Program is funded by the Federal Emergency Management Agency (FEMA) under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act. On behalf of FEMA, the Center for Mental Health Services (CMHS), Emergency Services and Disaster Relief Branch (ESDRB) provides technical assistance, program guidance and oversight.

Purpose
This program guidance is designed to clarify the role of the Crisis Counseling Program (CCP) in providing assistance for those who may abuse or are addicted to substances. In a number of disasters, there have been questions about the role of the crisis counseling program in providing "mental health treatment" to special needs groups, including providing "treatment" to people abusing substances. Confusion has occurred as a result of similar terminology in that services provided through the CCP are similar to what is often called "treatment" in the substance abuse field.

The Role of the Crisis Counseling Program
The amount and kind of stress and trauma that individuals experience in a disaster will vary from person to person. However, experience has shown that many survivors may be vulnerable to adopting or resuming unhealthy coping strategies following a disaster. People may begin abusing substances, resume abusing substances, or engage in addictive behavior because they are overwhelmed by their disaster experience.

The purpose of the Crisis Counseling Program is to assist individuals in understanding that emotional reactions to a disaster are normal and to help them develop appropriate coping skills so that they can resume their pre-disaster level of functioning. The program also assists in the identification and referral of individuals who may need services outside the scope of the Crisis Counseling Program. The CCP has a responsibility to provide counseling and education for disaster related problems. Program staff cannot ignore survivors who are abusing substances (or are at risk of doing so) as they attempt to cope with the disaster. Yet, the program is not responsible for providing substance abuse treatment and should not operate 12-Step groups under its auspices. Crisis Counseling Program staff should refer individuals with difficulties requiring specialized expertise to treatment programs with trained and credentialed staff. Referrals may be made to detoxification and/or community-based recovery programs for individuals identified as substance abusers. In rare instances, the CCP might help to facilitate re-activation of recovery groups that may have been temporarily disrupted due to the disaster or whose members may have been dispersed because of the disaster. However, Crisis Counseling Programs are not designed to sponsor these efforts.

The State Mental Health Authority (responsible for overseeing the Crisis Counseling Program) should be in early and continuous contact with the State Substance Abuse Authority to assess needs and resources and to assure that planning and program operations following a disaster are coordinated. Early in the implementation of the CCP, linkages should be made with local public and private substance abuse treatment programs to coordinate possible referrals. Community resources for detoxification, inpatient and outpatient treatment should be researched and the information made available to the crisis counselors. Assessment is one of the most important functions in addressing the problem of use, abuse or addiction with disaster survivors and is an appropriate function in the Crisis Counseling Program. Local substance abuse agencies and organizations, as well as the State Substance Abuse Agency, should be able to provide information on methods for assessment of substance abuse problems.

Staffing
Crisis Counseling Programs are encouraged to consider including crisis counselors who are active in the 12-Step recovery community (e.g. Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Al-Anon and Ala-Teen, companion groups for friends and family) in their complement of staff. Members of the recovery community can be very helpful in the assessment and intervention process. They can educate crisis counselors about enabling behavior, ways to approach the individual who is in denial and provide sound guidance about the level of motivation in the substance abuser. Prospective crisis counselors who have a history of addiction should be drug free or "clean and sober" for two years before being considered for a counseling position. They should be sensitive to the cultural aspects of substance abuse as these will vary from one ethnic group to another and recovery groups will vary in the degree to which they welcome and accommodate diversity. The limits of the CCP with regard to substance abuse treatment should also be made clear to staff. Active members of the companion programs Al-Anon, AlaTeen and Nar-Anon can be helpful in working with families of substance abusers as post disaster substance abuse will often increase stress and tension in families. Crisis counselors with companion program experience can help families find healthy ways of coping with the substance abuse as they pursue their own emotional recovery from the disaster.

Intervention
In the past, States have made requests to fund staffing for detoxification programs, substance abuse hot lines and support to relief workers in substance abuse treatment programs. The exclusion of these activities is based upon the determination that the services represent specialized treatment as opposed to disaster crisis counseling services; it is not based on an assumption that substance abuse issues predate the disaster. It is not appropriate for staff to engage in specialized treatment activities.

Substance abuse is one of the most difficult disorders to assess and treat. Denial, ethnic and cultural views, legal factors, and stigma all contribute to this difficulty. If assessment of an individual determines that a substance abuse problem may be present, then intervention, within the context of the CCP, begins with an exploration of what the disaster victim has done about the history and seriousness of the problem. If the person has experienced inpatient or outpatient treatment or has been in a 12-Step recovery program, re-establishing contact with these should be explored. Re-establishing contact is especially important if the person has a sponsor or a therapist. If the problem is new, the survivor should be strongly encouraged, in addition to continuing involvement with the Crisis Counseling Program, to seek assistance from substance abuse resources in the local community. The crisis counselor may refer the individual to the appropriate program or agency. Most 12-Step recovery programs have a local, 24-hour hotline and referral number through which meeting times and places can be obtained. Members of AA and other 12-step recovery programs will often go out of their way to help a prospective member get to a meeting. Al-Anon and AlaTeen programs are also widely available for family members.

Information and Referral Resources

Adult Children of Alcoholics (AcoA)
P.O. Box 3216
Torrance, CA 90510
(310) 534-1815
www.AdultChildren.org

Al-Anon Family Group Headquarters
1600 Corporate Landing Pkwy
Virginia Beach, VA 23454
Information Line 800-344-2666
National Referral Line 888-4AL-ANON (M-F, 8AM to 6PM EST)
www.al-anon.org

Alcoholics Anonymous
P.O. Box 459
Grand Central Station
New York, NY 10163
Phone (212) 870-3400
http://www.alcoholics-anonymous.org

AlaTeen
P.O. Box 459
Grand Central Station
New York, NY 10163
Phone (212) 870-3400
www.al-anon.org/alateen.html
National Referral Line 888-4AL-ANON (M-F, 8AM to 6PM EST)

Center for Substance Abuse Prevention
1 Choke Cherry Road
Room 4-1057
Rockville, MD 20850
Phone: 240-276-2420
http://www.samhsa.gov/centers/csap/csap.html

Publications: http://ncadistore.samhsa.gov/catalog/web.aspx?topic=166&h=publications

Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20850
Phone: 301-443-8956

Children of Alcoholics Foundation
33 West 60th Street, 5th Floor
New York, NY 10023
Phone (800) 359-2623
www.coaf.org

Cocaine Anonymous
3740 Overland Avenue, Ste C
Los Angeles, CA 90034
Phone (310) 559-5833
www.ca.org
National Referral Line 800-347-8998

Nar-Anon Family Group Headquarters
P.O. Box 2562
Palos Verdes Peninsula, CA 90274
Phone (310) 547-5800

Narcotics Anonymous
PO Box 9999
Van Nuys, CA 91409
Phone (818) 773-9999
www.na.org

For More Information
This program guidance was developed to ensure that the context, boundaries and strategies of the Crisis Counseling Program are consistently implemented throughout the United States. If program managers have questions regarding this guidance, they should contact their State disaster mental health program director for clarification. If the State program director needs additional guidance, he or she should contact their CMHS Project Officer.

Center for Mental Health Services
Emergency Mental Health and Traumatic Stress Services Branch
1 Choke Cherry Road, 6th Floor
Rockville, MD 20850
Fax: 240-276-1890

11/2000