Be Prepared to Work with Available Resources

You should be aware that resources for response and recovery vary greatly across events in terms of both immediate DMH needs and longer-term mental health treatment for those with lasting reactions. In the aftermath of the Isla Vista tragedy (Felix, Chapter 14), students had walk-in counseling available, a campus counseling center, a university that provided opportunities for memorial and ritual, and options for final exams and grading. Don't expect to see this level of generosity and understanding from most employers or communities in the US, and certainly not in resource-poor countries. The firefighters in Webster (Moskowitz, Chapter 13), like most volunteer first responder groups, did not have immediate access to trained mental health professionals after their colleagues were murdered - and the survivors of the Haitian earthquake (Jean-Charles, Chapter 18) couldn’t even assume they would have access to adequate food, let alone mental health support.

Access to mental health care tends to be more robust for survivors of human-caused events (at least in the US) as they’re often eligible for crime victims’ assistance resources. For example, the survivors of the World

Trade Center attack were eligible for resources and counseling services, and they lived in a city filled with clinicians. Survivors exposed to toxins from Ground Zero received health benefits and a 9/11 Victims Compensation fund was established to provide for economic and non-economic losses. This is not the case for most survivors of natural disasters, which tend to be larger in scope and require more resources of all kinds to respond to the needs of thousands of survivors. The Mississippi floods, the Joplin tornado, Hurricane Katrina, Super Storm Sandy, and the Oso mudslide were all devastating events, causing massive property and infrastructure damage as well as injuries and loss of life, but survivors did not get the attention and resources afforded to those of some of the high-profile, human-caused events - perhaps causing resentment over perceived disparities in access to help. Many of the communities described are still waiting for adequate assistance to rebuild properties. As climate change increases the frequency and intensity of natural disasters, we’re concerned that there will be diminishing resources for survivors and their recovery will be even harder.

This lack of resources is even more extreme in many of the less developed countries where disaster strikes. In many of the events described in our international case studies, there was such a shortage (or complete absence) of locally based trained mental health professionals that survivors’ initial psychosocial needs had to be addressed by international helpers working through non-governmental organizations like Médecins sans Frontières or the Red Cross. Some of these authors (Prewitt Diaz, Chapter 17, and Jean-Charles, Chapter 18) describe their efforts to implement innovative programs to build local capacity by training select residents in PFA and other basic forms of psychosocial support - not an easy task in a highly disrupted and impoverished environment, but one that is essential to attend to longer-term needs once the disaster response organizations pull out. Other authors in that section describe the difficulties of helping residents when the perpetrator of the disaster is their own government (Abdelaziz, Chapter 20) or, in the case of the Nauru asylum seekers (Brooker, Chapter 19), the government they were desperately seeking help from while fleeing from dire circumstances. In these cases, the betrayal and mistrust of authorities clearly complicated the practitioners’ ability to support recovery, and remind us to consider the political implications of some events.

We caution even the most dedicated humanitarian responders to get experience before volunteering to be deployed to parts of the world where they don’t understand the language or customs, or where there are hazardous physical conditions. If you respond to large natural disasters in some countries, you might be so disturbed by the high level of disease or lack of basic necessities that you’ll discover it’s more important to work to get resources to these populations rather than offer any sort of mental health services.

Make Self-Care a Priority

Many of our contributors acknowledge that witnessing chaos, grief, and tragedy up close was very disturbing for them. Authors described sidewalks littered with debris, fully armed military personnel wearing body armor and helmets, entire communities covered in mud, the smell of decaying human remains, cries and screams of anguished survivors, and fear while assisting clients who were highly contagious and dying. If you provide assistance in these circumstances you need to be prepared to see, hear, and smell the tragic and horrific. No matter how experienced and seasoned you are, you will be affected and perhaps significantly changed. Therefore, a comprehensive self-care plan is essential - and this includes attention to practical matters like what to pack as well as more emotion-focused questions like how you'll process your stress each day.

There are serious practical and physical considerations for self-care that you can learn from our contributors’ experiences. Be very mindful when packing to keep your comfort in mind. One contributor notes how important it was to have comfortable sneakers. If you think you'll be doing outreach in a community we advocate investing in comfortable, waterproof shoes, and breaking them in before you deploy. Blisters or soggy socks can be a nightmare and while you can never be sure if you’ll be spending time outdoors, you can be sure you'll be on your feet for long hours. Several of our authors mentioned sleeping in a staff shelter or shared hotel room with people snoring and disrupting their sleep. Bring earplugs or headphones to mitigate the noise. Bring chargers and sunscreen and mosquito repellent, as well as any medications you might need. One author pointed out that if you’re assigned to assist at a multi-casualty disaster you should pack clothing appropriate for a memorial service or bereavement visit.

Be aware of physical hazards that might cause short- or long-term health problems. Exposure to mold is common after hurricanes and floods, and air quality can cause respiratory issues after wildfires. More troubling is the risk of long-term problems like the cancers many 9/11 responders have developed after breathing the toxic air at Ground Zero. As Tramontin says in Chapter 11. “it’s paramount to make your physical safety a priority. You may not always know this in advance. When in doubt, allow yourself the option of not responding.”

On the more emotional level, many authors write about feeling very connected to the communities and populations they worked with. This connection is obviously necessary but also takes a toll. Many described their pain and distress at witnessing these tragedies and several mentioned that they should have been deployed for a shorter time. Others described the upset they experienced in leaving the disaster and the people they were helping. The case studies make clear that DMH workers need to be very careful about honoring their limits and not staying too long on-scene. Know in advance the signs that indicate you need a break, a day off, or to return home - and heed those signs rather than ignoring them. As McGee-Smith notes in Chapter 5, “rest when you can rest, eat when you can eat, and sit when you can sit.” Ryan (Chapter 8) and others report that extended deployment can take a toll on personal lives and relationships; while it may be necessary to put your own needs aside temporarily to support your community, you do need to deal with your emotions eventually. Authors used different self-care strategies when leaving the disaster and arriving home that were best for them, from scuba diving to talking with disaster buddies (a very popular strategy), so find a self-care strategy that works for you and be sure to actually practice it.

Although all of the responders discussed the hazards of doing DMH work, it was very clear that they also experienced enormous rewards. Most returned home exhausted, but wrote that their primary experience was not one of sacrifice. They reported much personal satisfaction, personal growth, a sense of bonding with survivors, colleagues and communities, and a sense of accomplishment from being part of a meaningful humanitarian effort. We hope that will be your experience when you work in the field.

Prevent What You Can, and Share What You Learn

We did not ask our authors to write about how to prevent or lessen the impact of disaster, but it would seem irresponsible for us to not address this issue. Of course, we can't eliminate natural or human-caused disasters, or eliminate the poverty that so exacerbates the disasters in less developed areas, but we can raise our voices and engage in the political process to reduce the likelihood or impact of these events.

Gun violence is a serious public health crisis in the US. Although the US has half the population of 22 other developed nations, Americans are 10 times more likely to be killed by guns than all those nations combined (Grinshteyn & Hemenway, 2016). In the first two years following the 2016 Pulse nightclub shooting described in the book, there were at least 700 mass shootings (defined as events involving four or more victims) across the United States (New York Times, 2018), and according to the Centers for Disease Control, on an average day, 96 Americans die by firearms. As mental health students and professionals with an understanding of trauma and grief we re in a position to advocate for effective gun safety laws. We can also lead efforts to limit climate change in order to slow the growth of some natural disasters including more frequent and more devastating floods and droughts, and we can become active in efforts to challenge the political oppression that fuels many humanitarian disasters and causes the forced migration that leads refugees into danger. We encourage readers to consider the role you might play in these harm prevention efforts.

We also hope that you’ll not only participate in Disaster Mental Health work, but will try to share your experiences and the insights you gain with other practitioners, just as our 17 authors do here. We believe there is far more clinical wisdom and insight that’s been earned through experience in the field than ever gets disseminated through traditional academic publishing. Missing in the literature in particular (including in this book, we acknowledge), is what the survivors actually found helpful. Felix, Dowdy, and Green’s study (2018, and summarized in Chapter 14) of student reactions to post-massacre memorials is an example of the kind of research we think is badly needed in the field, so we encourage you to assess how helpful your DMH practices are to those you're working with, and to be creative in spreading the word about best practices to others.