To many, the federal government's response to Hurricane Katrina in 2005 was an object lesson in what not to do. For experts in disaster mental health, though, Katrina was the ultimate teachable moment. Never before had so many Americans sought mental health care during a crisis, and never before had so many states and agencies requested funding to advise and treat them. Since shortly after the storm, researchers have been poring over data, trying to figure out what worked and what didn't, and hoping to learn something to help mental health providers when the next natural (or manmade) disaster hits.
Miller-McCune.com spoke about the results of recent studies with Dartmouth Medical School professor Fran Norris, director and principal investigator of the National Center for Disaster Mental Health Research and now co-editor of an entire issue of Administration and Policy in Mental Health and Mental Health Services Research devoted to the way the government and nonprofits addressed the mental health needs of Katrina survivors.
Miller-McCune.com: The Crisis Counseling Assistance and Training Program, which you're studying, is the biggest source of mental health funding after disasters like Hurricane Katrina. How exactly does it work?
Fran Norris: These programs are really outreach programs, psychological and educational programs. It isn't therapy — this is getting the word out about, for example, what do we know about mental health? What are good coping strategies? How do you help your kids?
This is focused on getting resources to people, rather than trying to "fix" people who have developed disorders. And that's actually becoming one of the ongoing tensions: What do you do for people who have developed more serious problems? The program itself is not funded to deal with that.
M-M: How is it funded?
FN: Crisis Counseling is funded by the Federal Emergency Management Agency. It's linked to the presidential disaster declaration, just like housing and loan programs. FEMA has an interagency agreement with the Substance Abuse and Mental Health Services Administration, which is part of the Department of Health and Human Services. So even though FEMA funds the programs, they are administered by people in mental health. These are state-run projects — that's their greatest strength and also the biggest challenge. Some states do great jobs, others not so much. The key is keeping standards while trying not to be inflexible.
M-M: How applicable are the post-Katrina events to planning for other disasters?
FN: Certainly it's bigger by sheer scale. The number of people affected directly was just huge, and the severity of the disaster was huge. At least in contemporary times, we haven't had a disaster where so many people were killed. But if you take its major elements, other disasters are similar. Hurricane Ike in Galveston in 2008 had many similarities. It wasn't as severe in loss of life, but the nation hasn't recognized just how badly flooded Galveston and Chambers County were, or how many people were displaced.
Not to be predicting doom and gloom, but (this research is) definitely part of preparing for a large terrorist attack. Having some sense of how one might handle the need for massive population displacement matters.
M-M: The federal response to Katrina has drawn savage criticism. On mental health matters, though, you seem to think agencies did a good job. Why?
FN: This isn't about the overall response to Katrina. That is another animal, and if you talk to some of these (mental health) people they'll tell you what they were doing was trying to overcome those problems. They're the people going to individuals and trying to help them deal with a chaotic situation. It'd be a real mistake to lump these programs together with the issues that arose in those first couple weeks of the response.
These aren't clinical programs, so they can't be criticized for not proving their treatment worked. It's not what they were funded to do. They're funded to do outreach, to educate people, and help people with coping skills. We set out to evaluate them against those realistic goals. If their goal is to do outreach, how well did they reach the population? If they want to do coping capacity, how well did they do that? Louisiana's mental health response hit the ground running in spite of all the other problems we heard about.
M-M: Not everything worked as well as hoped, though. Some of the articles describe prevalent long-term psychological effects, but relatively few opportunities for long-term mental health care.
FN: In my opinion, that is a huge gap in our response plan. We have good response plans for normally resilient people who are experiencing acute, post-disaster distress. And someone who has a serious mental illness usually qualifies for other services. What's really missing is the in-between. There's this gap for individuals who have persistent reactions that need more than just crisis counseling — people who have had normal lives, but now they've really been through something terrible and they can't quite get over it. We really need more attention devoted to that.
The process of how to get individuals from one level of services to another is very challenging. One of the papers is about the specialized crisis-counseling program, which was one (promising) response to that need. It's trying to work within the framework of crisis, in a way that's consistent with its funding and intent, but also trying to offer a more intensive program of psychological services to some people.
M-M: How did such an approach make a difference?
FN: The traditional model is a one-time or two-time informal contact, where someone talks with you about your experience and helps you get perspective, gives you ideas of resources in the community. Specialized crisis counseling involves multiple contacts. This is someone who's meeting with a counselor multiple times, and more specialized counseling skills are used, perhaps with specific problem-solving techniques.
A real challenge for people who are overwhelmed by disasters is getting past their anxiety, and into making concrete plans. Often, concrete needs are so profound (that) it's hard to get past them into dealing with whatever the psychological issue you have. So you also have resource coordinators handle all the concrete tangible needs that people have, like housing assistance. That frees them to attend to mental health needs.
M-M: Based on the statistics you collected, program counselors didn't refer clients very much. Why not?
FN: Referrals to disaster relief services were made very often. The place we were noticing they were not very high — and this was striking given what we know about the epidemiology of Katrina — was referrals for psychological care. They also went down over time. That's the opposite of what you'd expect.
Even though in the community as a whole, people are getting better over time, the people who are visiting the counseling centers, the further out from the disaster, the less a counselor should be thinking: You're just going to get over this. Two weeks after, if you're anxious and sad, that is so normal I'm probably not going to make much of it. If I'm talking to you a year after a disaster and you're still anxious, I should be thinking: Here's someone who really needs professional assistance. That happens too little.
M-M: Why is that?
FN: The reasons aren't clear. Some of it is a shortage of affordable mental health care. I think there's more to it, though. There's a comfort level on the part of the counselors. We have this referral tool that was supposed to help counselors identify people who need to be offered something more than crisis counseling. Part of the feedback we got was that counselors weren't comfortable using it. If a counselor isn't comfortable asking people 10 questions about their stress, how could they possibly be comfortable identifying someone who's distressed and saying, "I think you need help"?
M-M: So how do you help counselors?
FN: One of the areas that people are working on is training. The counselors are often critical of their own training. When I'm starting up a program, I might train everyone, but there is natural attrition, and some people start before they get trained or they're trained one-on-one in the field by another worker.
M-M: Is the answer just better training, then?
FN: The issue is providing the right kind of training at the right time. It's still somewhat challenging. One difficulty: How can you begin to evaluate the quality of a training program?
M-M: The data show that having more staffers with advanced degrees improved outcomes. Is there a risk to relying on relatively inexperienced paraprofessionals?
FN: In counties where there were a higher percentage of counselors with advanced degrees, a higher percentage of people received intensive contact and more referrals. So the participants recorded greater perceived benefits. That isn't to say that all counselors need to be professionals. There's no evidence that a professional counselor does better crisis counseling than a paraprofessional. What it does mean is paraprofessional counselors need to have access to professional counselors.
If I'm a paraprofessional and I'm not comfortable, or I think a person needs more help, having you, the professional, to refer this person to is helpful because you could make a more skilled judgment about the person's needs. It's about having both. Sometimes, a program does go too far down one route or the other.
M-M: A couple analyses tried to figure out which programs had the best outcomes. What seemed to work best?
FN: Programs that emphasized having more intensive contacts with people - not just public education, but talking to individuals longer. Another characteristic is those that did more to reduce job stress among the crisis counselors, because this work is very stressful to do.
One of the other things we learned was, for the specialized crisis-counseling program, to do it sooner. Generally, you're introducing innovations so far after the fact that we miss a lot of people that could be helped. If the program from the outset was able to provide regular service and have the option for these more intensive systems, that'd be a step forward.
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