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Mental Health All-Hazards Disaster Planning Guidance

PART TWO - THE PLANNING PROCESS

According to Albert Ashwood, Director of the Oklahoma Department of Civil Emergency Management, all-hazards planning can be summed up in two points, "The process is where the real plan comes through," and, "Until mental health, health, and emergency management make [coordinated planning] a priority, little will happen."

There seems to be a consensus that the process of planning is nearly as important as the content of the plans. Individual and organizational relationships among interested parties are formed and solidified, planning responsibilities of the SMHA and others are established, and multiple plans are integrated during the process.

States benefit from an honest assessment of the resources available to them to establish and maintain a plan at the beginning of the planning process. Sound planning and the effort needed to keep plans current require resources and ongoing commitment. Few organizations will have the resources to accomplish everything they desire, but most will be able to delineate at least the basic elements of a plan.

In addition, the scope of a State's disaster mental health response will have an impact on financial and human resources as well as on existing programs. These considerations should be incorporated into the planning process. For example, intensive outreach and case finding will result in the identification of more individuals in need of assistance, necessitating additional funding and personnel. Some victims, while typically in the minority, will develop significant mental health problems. Planning should include an assessment of the ability of the State mental health infrastructure to absorb additional individuals in need of services.

Effective plans are exercised, modified, and updated regularly. If a plan is developed and not kept alive and vital, it will have limited value. For that reason, it is important to develop a plan that is meaningful but also fairly basic, so that it can be maintained and updated regularly.

• Having plans in place and having a good working relationship with the SEMA make it easy to modify the plans because there is an established structure and mutual trust.
• A strong commitment from the Commissioner resulted in positive planning and plan outcomes.
• The planning process enhanced relationships with the Red Cross and resulted in the development of crisis response teams, which assist emergency personnel in times of emotional instability.
• The planning process enhanced collaborations with other State and county agencies.
• The process allowed and facilitated completion of a statewide needs assessment, increased information available online, and garnered support of the SEMA.
• The process resulted in the establishment of full-time positions in the SMHA devoted to disaster preparedness, response, and recovery.

• Lack of human and financial resources to do the work;
• The "back burner" status of disaster mental health planning when the public mental health system struggles with inadequate staff and funding for basic mental health services;
• Little political will to focus on disaster mental health over many years once a disaster passes;
• Mental health being overlooked in favor of safety and security concerns;
• Less than optimal mental health planning because of the barriers to ensuring that mental health concerns are reflected in the policies, practices, and planning of public safety, disease control, and law enforcement officials. These barriers may include lack of State mental health agency resources, organizational separation, and lack of knowledge about and appreciation for the importance of behavioral health issues and impacts;
• Emerging local and regional mental health groups (e.g., new advocacy groups, local and State critical incident management groups, etc.), as well as local and regional safety and security groups (e.g., groups organizing for community security, groups marketing security equipment, plans for individuals and businesses, etc.), with little knowledge of State disaster and disaster mental health infrastructure;
• The lack of collaboration and consistency among federal departments and agencies and corresponding State departments and agencies receiving disaster and terrorism funding-SAMHSA/CMHS, the Department of Justice, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration were specifically mentioned; and
• The lack of well-defined, studied, and easily implemented programs in disaster mental health that can be adopted widely.

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It will be helpful to keep in mind the following contextual and fundamental guidelines before formal planning begins. Remember that each State differs from others in its planning and disaster history, its structure, and its resources for preparedness activities. States will need to adapt the following guidelines to their unique situations and may find it useful to prioritize these elements. The unifying essential characteristics of these guidelines are good preparation and a diplomatic process sensitive to strengths, challenges, and other priorities.

• Secure support for planning at the highest possible level of State government (e.g., the Governor's Office or at the Cabinet level).
• Plan developers should know the culture of the State government and the major players before starting. (Table 3 contains a listing of some suggested major players). For example, will making changes and establishing new collaborations be easy and/or valued? Are the major agencies/organizations involved seeking change, or are they likely to try to maintain the status quo? Is this planning taking place in the context of fiscal expansion or contraction? The SMHA is typically part of a larger State response and recovery effort and it often functions under SEMA's authority. It is important to know who is responsible and/or in charge of the larger operation.
• Exactly how planning occurs-considering the variables delineated above-is not well documented at the national level. It is anticipated that as plans emerge and as the process becomes documented more completely by the State Disaster Mental Health Coordinators, more State-specific guidance will be developed and disseminated.

• Try to anticipate problems from the start.
• Err on the side of over-inclusion rather than leaving some portion of the system out. If key players are left out, the value of their contribution could be lost and valuable time and human resources may be expended to mend fences and/or cope with resistance to the process or product.
• Have a leader, but share the work. Without someone to guide and oversee this process it frequently becomes the victim of other emerging priorities. At the same time, workload and differential expertise and authorities demand that the work be shared.
• Keep reminding participants of the benefits of the effort.
• Appreciate and acknowledge the concerns/constraints/expertise of others.
• Involve representatives who can make decisions for their agencies/departments/organizations. Enormous amounts of time and energy can be wasted when decisions must wait for clearance, which can be lengthy, or if decisions or components are later changed because the planning participant lacked authority.
• Encourage agencies/departments/organizations to do what they do best.
• Keep expectations and timelines realistic.
• Understand that in many ways the process is as valuable as the product. The teamwork developed in the planning process will be the teamwork you depend on in the disaster response efforts.

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When the focus group for this project convened, members identified several parts of the planning process they felt were important to successful outcomes. They offered the following suggestions and observations about the process of developing plans.

• Much information already exists and is readily available. While comprehensive, all-hazards plans are scarce, most States have existing and emerging plans that can be very helpful. Officials should review the plans of other States with an eye toward identifying those elements that might be applicable in their State. Some examples of elements derived from States' plans are included throughout this document.
• Literature, available through a wide variety of sources commonly known to State emergency coordinators, should be utilized to support and assist the planning process. For example, numerous preparedness publications are available from FEMA (See Part IV for contact information). Meeting with the SEMA at the beginning of the planning process can be useful in a variety of ways, including gaining access to preparedness aids/documents that the SEMA has found helpful in the past. The SMHA will likely find some of these resources more helpful than others.
• In addition, different providers of services have different definitions of services, as well as who is eligible for these services-specifically in regard to mental health interventions. For example, three major national providers/supporters of disaster mental health services include CMHS (operating this program for FEMA), the American Red Cross, and the Office for Victims of Crime (See Part IV for contact information). The information in Table 1 may be useful in understanding service provider similarities and differences.

The information in Table 1 is an example of how definitions of eligibility vary as a function of the type of event and funding source in the mental health arena. Each State will want to consider carefully the types of events that may occur, what definitions apply, and who will provide the relevant services to the various victims. In addition to the groups listed in the table above, other potential providers/supporters of post-disaster mental health services may include health insurance programs, employee assistance programs, and faith-based services.

• It is important to acknowledge that other State departments and agencies may be further along in planning and preparedness than the SMHA. Other State agencies may be very helpful while the mental health disaster plan is being developed.
• Along with understanding organizational differences in terms of eligibility and services, as mentioned above, SMHAs will enhance collaborations if they make an effort to understand new administrative and operational terminology, especially from the SEMA and FEMA, as they begin the planning process. The establishment of common definitions is also important, and each State will be able to determine which of those common definitions are important to establish. Examples may include shared incident definitions, common command and control definitions, and administrative terms.
• It is important to consider the intended audience(s) for the plan as the process begins. This may vary from State to State and it may be necessary for States to prioritize their audiences, as it is difficult for a plan to meet fully the needs of everyone. Factors affecting priority setting may include financing, politics, structure, extent, and nature of operational responsibilities, etc. Audiences may include the SMHA, SEMA, other State agencies and departments, the Governor, State legislature, components of the larger mental health system, State and local Red Cross chapters, and the Federal government. Planners will want to consider how much of the plan they want to make available (on the SMHA's Web site, for instance) to the general public. A wide distribution of parts of the plan may be useful, while other parts (i.e., portions identifying potential targets for terrorism) may warrant a narrower distribution.
• SMHAs vary widely in their flexibility and adaptability to emergency and disaster situations. A candid appraisal of these characteristics can help ensure that expectations of the system in the wake of such an event are realistic. The extent to which a State engages in assertive outreach, for example, will have a significant impact upon the number of people they find with both disaster-related stress as well as preexisting mental disorders. It is important to acknowledge this issue in the preparedness stage in the context of such factors as the State's ability to obtain and/or re-deploy resources (and for how long), absorb additional caseload, and sustain expanded expectations.
• It is far better to develop relationships prior to an event than attempting to forge them during an event.
• It is important to identify specifically who will have responsibility for putting the plan together and to update this information on a periodic basis. This person must have a sound understanding of the SMHA, the legal responsibility for response and recovery operations, and knowledge of where this responsibility falls within the State emergency plan.
• Key partners in disaster planning may already have experience dealing with the SMHA. That experience may have been positive or negative, it may have been general or specific to a single issue, and it could have occurred recently or in the distant past. It is helpful to learn what those experiences are and the type of impression the person may have left. One may identify attitudes and perspectives through this process that may be important during the collaboration process. Ask around to determine if division and/or departmental initiatives may have preceded the current effort and existing plans and relationships must be taken into consideration.
• Others will participate in the planning process more readily if they see some benefit to their organization or operation following an event. Mental health planners should identify how others will benefit from collaboration with the SMHA. As an example, a local mental health agency or school that does not have staff trained in large-scale crisis response may benefit by having staff trained as part of the preparation effort. In addition, the planning process will enable these organizations to better know and understand each other, thereby opening doors to collaborations outside the disaster context.
• It is important to identify the mission of the planning process, the purpose(s) of the plan, and the legal obligations of the SMHA, early on.
• Viewing mental health concerns in a public health context that is broader than direct service interventions (e.g., counseling, debriefing, etc.) is one of many benefits derived from approaching the planning process and the plan from a public health perspective. Terrorist events have made public health a national security issue and few in the public health sector have managed to see the benefits of including mental/behavioral health as part of this system. Like mental health, public health shares the same interest in primary, secondary, and tertiary prevention. So there is much to be gained from a close collaboration between the SMHA and the public health agency in the areas of preparedness and response. The requirements of State health agencies regarding smallpox vaccination, as an example, provide an opportunity for collaboration. Federal guidelines require health departments to establish plans for dealing with the mental health consequences of an outbreak. Some SMHAs have used this requirement to engage the public health authorities on a variety of issues including consultation on risk communication.
• Defining the victims is not an easy process, as many people who are exposed to most large-scale events are impacted. Even though people may be negatively affected, not all will need, accept, or necessarily benefit from various interventions. Definitions also may differ depending on the type of event - especially the difference between natural disasters and terrorist events (i.e. victims of terrorist events are crime victims and may therefore be eligible for services and resources not available in natural disasters). Some States have identified groups that represent primary populations who must be served (e.g., adults with severe mental illness; children and adolescents with severe emotional difficulties) and then identified other populations who can be served if possible or if additional resources are available.
• In the priority-setting process, both research and practical experience points to exposure as a prime predictor of the development of psychological sequelae. Figure 1 is an illustration of exposure categories. It generally is agreed that all who experience a disaster are somehow affected by it. However, a number of groups warrant specialized approaches and services, even if they're not at great risk, including, but not limited to, children, those with pre-existing mental disorders, disaster and emergency workers, the frail elderly, and racial and cultural minorities. An excellent summary of the empirical research, including a discussion of risk and status factors, can be found at http://www.ncptsd.org/facts/disasters/fs_range.html.

• Membership on a planning group should be given careful consideration. A State may opt to establish a consistent team that will develop the plan. Others may opt for a "core team" that includes all who are legally mandated to be involved, and a larger "adjunct team" that includes the core team as well as any other agency that has an interest. The following information has been excerpted from the Texas Model (TEXAS DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION, 2002)

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The role of the State Crisis Consortium is to coordinate, manage, and ensure the credibility of services provided and eliminate the duplication of services to victims following a catastrophic event. The State Crisis Consortium is a unique and innovative element in disaster response and recovery and is comprised of the following core programs:

The Texas Department of Mental Health and Mental Retardation's Disaster Assistance and Crisis Response Services program is the lead agency in the coordination of the State Crisis Consortium and provides assessment and evaluation of the immediate long-term mental health needs of victims and responders, immediate crisis counseling and mental health services to victims and responders, and coordinates federal Crisis Counseling and Training programs following federally declared disasters.

The Texas Department of Public Safety Psychological Services Division provides peer support and victim services to responders and their families including short-term counseling and referral.

The Texas Department of Health Critical Incident Stress Management Network provides for the pre- and post-incident stress management and educational support to emergency service workers and their primary support systems, and provides support after any situation faced by personnel that causes them to experience unusually strong emotional reactions.

The Office of the Attorney General Crime Victim Services Division provides for crime victim compensation services if the event is criminal in nature. The Consumer Protection Division provides support, protection and recovery from consumer fraud and deceptive practices following disaster or critical events.

• Ideal plans identify a clear decision making structure and articulate the authority of each plan participant.
• Both State and local mental health agencies can best exert influence and respond to changing events if they are represented in State and local Emergency Operations Centers.
• The SMHA can play a valuable "gate-keeping" role if the plans incorporate it. These can include distribution of mental health provider resources and management of research interests.
• In States with both regional and central SMHA offices, identifying the respective roles and responsibilities of each is a very important part of the planning process.
• Plans should include clear documentation on how to access Federal resources through State structure. In the past, some SMHAs have had a better understanding of the Federal administrative process to obtain funding than of the State process required to obtain and distribute these funds. In some cases, this has resulted in unnecessary delays in funding. To reduce delays and other setbacks, the following questions should be considered: Under what circumstances can a State apply for the Federal Crisis Counseling program? Through which internal State processes and paths do these decisions and processes flow? How do Federal funds flow from the Governor's Office to the SEMA, to the SMHA, and on to vendors? SMHAs may find it useful to review their individual State laws with an eye toward needs (such as speedy hiring, rapid contracting, and the ability to reprogram funds) that are common in disaster situations. In some cases, States may consider policy changes, either themselves, or in concert with other State disaster response entities, that will allow for these urgent activities. Table 2 contains examples of relevant legislation from Louisiana and Minnesota.
• The important relationship between the SMHA and the health agency can benefit from the creation of a formal Memorandum of Understanding (a legal document which details the two agency's potential collaboration) established during the planning process.

Recommended Planning Participants

Involvement of, and collaboration with, a wide variety of both public and private agencies and organizations is strongly encouraged. Partnering with some or all of the organizations listed in Table 3 is recommended.

Planners may find it useful to sort groups into categories such as those having legal responsibility for planning, those whose responsibilities are primarily response, and those who might serve best as advisors. In addition, as noted earlier, most States will want to prioritize these groups based on factors such as centrality to the SMHA disaster mission and a State's political, structural, and financial context.

As noted earlier in this document, the scope and depth of a given SMHA's investment in this planning process will vary depending on a number of factors, especially human and fiscal resources. The scope of the above list may seem beyond the resources of some. Each SMHA is encouraged to be realistic about its resources and assess priority linkages in their State. Some of the entities on the above list may not be involved in initial planning, but may be incorporated at a later date if time and resources are not available to accommodate all. However, the following list of entities includes core organizations that must be involved in any planning effort.

• Involve local mental health agencies in planning from the beginning.
• Seek the collaboration between the SMHA and the SEMA-perhaps the most important collaboration within State government. Planners should note that SEMA plans are already in place and that SMHA planning should be integrated into those existing plans.
• Establish a relationship with the largest employers in the State. These employers may have special needs following a disaster, resources that could be helpful following a disaster, and plans that should be coordinated with the State plan. In some cases, these large employers may be potential targets for terrorism.
• Identify potential mental health resources. Sources might include:
• Veterans Administration hospitals and clinics often have significant numbers of mental health professionals well trained in trauma work;
• Academic institutions — faculty and student health services may have resources;
• Professional associations — State chapters may be able/willing to identify/train their members to serve; and
• State-operated services — State mental health provider institutions/agencies in unaffected areas may be able to deploy staff to areas of need; and
• Most disaster responses utilize mental health professionals as well as trained para-professionals. The mix of responders may vary depending on the type of incident, source of funding, availability of professionals, and duration of the recovery. It is important to identify potential resources and to consider the initial and ongoing training needs of everyone. A list of resources is included in Part IV of this publication.
• The Red Cross is active in nearly all emergencies and disasters, providing general post-disaster services and specialized mental health services. Through a partnership with the National Highway Traffic Safety Administration, the Red Cross has taken the lead in serving families of victims in transportation emergencies and disasters. The development of coordinated planning with the Red Cross is essential. Without such agreements, the potential for misunderstandings, inefficient use of mental health resources, and organizational conflict is increased. SAMHSA's recently established Disaster Technical Assistance Center (DTAC) is collecting helpful examples of these agreements for State planners to utilize (See Part IV for contact information). The Red Cross has chapters in counties and cities throughout the United States. In addition, each State has a lead chapter responsible for developing mental health planning. A copy of each State's plan is on file at the Red Cross national office. The Red Cross trains mental health professionals with appropriate licenses and credentials in basic Red Cross procedure, and these individuals are promoted commensurate with their experience. By the time a major disaster happens, they should have a clear idea of how to work with State and local representatives.
• As noted earlier, one of the most significant relationships is the one between the SMHA and the State health agency. This link is especially critical in the areas of terrorism involving chemical, nuclear, or biological weapons.
• A relationship based on expertise and trust should exist between SMHA public information staff and their counterparts in emergency management.
• Most SEMAs have established links with other State departments as well as interstate collaboration for events that cross borders or might activate mutual aid agreements. SMHAs might explore opportunities to build upon those existing emergency management relationships as they plan. Specific suggestions include: learning about the existence of SEMA interstate collaborations; assessing the relevance of existing collaborative arrangements for disaster mental health response; identifying opportunities for the SMHA to collaborate; contacting SMHA counterparts in other jurisdictions; and sharing relevant portions of the SMHA plan or planning process to promote coordination/collaboration following an event. Participation in multi-jurisdictional exercises also can be very beneficial. Contact the SEMA Individual Assistance Officer to discuss existing partnerships and to create a Memorandum of Understanding (MOU) or other mutual aid agreement that could serve as a starting point for similar agreements benefiting the SMHA plan.
• Most SMHAs work closely with consumers and family members in their routine activities. These groups can contribute an important perspective to disaster planning and response as well. Representatives from other vulnerable populations such as children, the aged/geriatric population, and those who are hard of hearing or deaf can also contribute. It is known from years of disaster mental health experience that these groups have special needs following disasters (although they may not be at higher risk for development of mental disorders). In addition, they may be receiving services through multiple organizations that may be part of the planning process for the SMHA plan (e.g., schools, health care facilities, etc.). Including representatives from these groups in the planning process can help ensure that planning proceeds in a manner that incorporates their particular needs.

• Establish a system for notification and call-up of key response staff as events occur.
• Ensure access to areas where staff is needed by issuing proper identification and establishing a method to easily identify mental health workers (e.g., baseball caps, labeled T-shirts). In some States, the SEMA has issued SEMA badges to SMHA employees.
• Establish a plan, prior to an event, for deployment of mental health personnel. Mutual aid agreements for deploying mental health personnel from one jurisdiction to another should be considered. A Statewide deployment plan should detail the specific agencies involved as well as the method of deployment for these agencies. Careful consideration should be given to the availability of resources and the backfilling of temporary vacancies, as well as transportation, communication, and safety issues. In particular, communication systems (cell phones, "ham" radios, etc.) should provide redundancy to ensure capability if infrastructure has been destroyed. Do not oversimplify this critical procedural element of the plan.
• Be sure that SMHA leadership understands the incident command system and establishes plans for immediate mental health activities as part of unified incident command.
• Clarify how communications will take place and the reporting expectations. The use of preexisting forms is recommended.

• It would be helpful to have a common and nationally consistent definition of what constitutes the responsibility of the SMHA for mental health response and recovery after a disaster. It is a challenge for key State leaders outside the SMHA to understand the nature of disaster mental health services and how these services differ from traditional mental health services, because most SMHAs focus primarily (sometimes exclusively) on those with the most serious mental health disorders.
• Public education following an event is critical. Many victims will require nothing more than information that reassures and provides anticipatory guidance and meaningful advice about what can be done to reduce and/or manage disaster-related stress. Consistency in these messages is critical.
• A response is only as good as the responders. A plan must be in place to ensure physical and psychological support for mental health workers as well as staffing depth to ensure ongoing operational capacity.
• There often is significant lag time between the decision to implement services and the actual implementation. States should develop a mechanism to expedite the implantation of services so the process is unencumbered by procedural delays.

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