Anti-Stigma: Do You Know the Facts?
Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma, and the resulting discrimination, discourages individuals and their families from getting the help they need. An estimated 22 to 23 percent of the U.S. population experience a mental disorder in any given year, but almost half of these individuals do not seek treatment (U.S. Department of Health and Human Services, 2002; U.S. Surgeon General, 2001).
The educational information on this web site encourages the use of positive images to refer to people with mental illness and underscores the reality that mental illness can be successfully treated.
Do you know that an estimated 44 million Americans experience a mental disorder in any given year?
Do you know that stigma is not a matter of using the wrong word or action?
Do you know that stigma is about disrespect and using negative labels to identify a person living with mental illness?
Do you know that stigma is a barrier that discourages individuals and their families from seeking help?
Do you know that many people would rather tell employers they committed a petty crime and served time in jail, than admit to being in a psychiatric hospital?
Do you know that stigma can result in inadequate insurance coverage for mental health services?
Do you know that stigma leads to fear, mistrust, and violence against people living with mental illness and their families?
Do you know that stigma can cause families and friends to turn their backs on people with mental illness?
Do you know that stigma can prevent people from getting access to needed mental health services?
DO'S
Do use respectful language
Do emphasize abilities, not limitations.
Do tell someone if they express a stigmatizing attitude.
DONT'S
Don't portray successful persons with disabilities as super human.
Don't use generic labels such as retarded, or the mentally ill.
Don't use terms like crazy, lunatic, manic depressive, or slow functioning.
March 09, 2010
March 07, 2010
Models of Preventive Services
Models of Preventive Services
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
March 02, 2010
Helping Children Cope With Fear & Anxiety
Helping Children Cope With Fear & Anxiety
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.
The Caring for Every Child's Mental Health Campaign offers these pointers for parents and other caregivers:
Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It's okay to admit you can't answer all of their questions.
Talk on their level. Communicate with your children in a way they can understand. Don't get too technical or complicated.
Be honest. Tell them exactly what has happened. For example, don't say that someone who has died has "gone to sleep;" children may become afraid of going to bed.
Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.
Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.
Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It's an opportunity to clarify any misconceptions, answer questions and give reassurance.
Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your child feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.
To learn more about children's mental health:
Call toll-free: 1.800.789.2647
(TDD): 301.443.9006
Web site: mentalhealth.samhsa.gov/child
Comprehensive Community Mental Health Services
for Children and Their Families Program
Child, Adolescent and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.
The Caring for Every Child's Mental Health Campaign offers these pointers for parents and other caregivers:
Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It's okay to admit you can't answer all of their questions.
Talk on their level. Communicate with your children in a way they can understand. Don't get too technical or complicated.
Be honest. Tell them exactly what has happened. For example, don't say that someone who has died has "gone to sleep;" children may become afraid of going to bed.
Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.
Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.
Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It's an opportunity to clarify any misconceptions, answer questions and give reassurance.
Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your child feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.
To learn more about children's mental health:
Call toll-free: 1.800.789.2647
(TDD): 301.443.9006
Web site: mentalhealth.samhsa.gov/child
Comprehensive Community Mental Health Services
for Children and Their Families Program
Child, Adolescent and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
March 01, 2010
After an Earthquake: Mental Health
After an Earthquake: Mental Health
Following a natural disaster, when many people have suffered great losses, it is normal to feel sad, angry, or nervous.
Some who have experienced a disaster may have bad feelings right away. Others may not notice a change until much later, after the crisis is over. It can take time to feel better and for things to return to normal, especially with so much loss. Many people find support and comfort by talking to surviving family members, close friends, doctors, nurses, and religious leaders. Sometimes, help from mental health professionals may be needed.
Medical follow up will be important for the health and wellbeing of many survivors. Survivors should be encouraged to share questions and concerns about their health with their doctors.
Links to CDC resources and those of other organizations are below. Survivor experiences and needs may differ, so some sites may be more helpful to some than others.
Information available in French, Haitian-Creole, and English:
•Mental Health Information for the Public
•Mental Health Information for Professionals
•Mental Health Advisory for Health Professionals Providing Care for Survivors of the 2010 Haitian Earthquake
•General Mental Health Resources
How to find mental health services in the U.S. by state and information for developing cultural competence in disaster mental health programs.
Care Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life
Things to Remember When Trying to Understand Disaster Events
Signs that Adults Need Stress Management Assistance
Ways to Ease the Stress
Things to Remember When Trying to Understand Disaster Events
No one who sees a disaster is untouched by it.
It is normal to feel anxious about you and your family's safety.
Profound sadness, grief, and anger are normal reactions to an abnormal event.
Acknowledging our feelings helps us recover.
Focusing on our strengths and abilities will help you to heal.
Accepting help from community programs and resources is healthy.
We each have different needs and different ways of coping.
It is common to want to strike back at people who have caused great pain. However, nothing good is accomplished by hateful language or actions.
Signs that Adults Need Stress Management Assistance
Difficulty communicating thoughts
Difficulty sleeping
Difficulty maintaining balance
Easily frustrated
Increased use of drugs/alcohol
Limited attention span
Poor work performance
Headaches/stomach problems
Tunnel vision/muffled hearing
Colds or flu-like symptoms.
Disorientation or confusion
Difficulty concentrating
Reluctance to leave home
Depression, sadness
Feelings of hopelessness
Mood-swings
Crying easily
Overwhelming guilt and self-doubt
Fear of crowds, strangers, or being alone
Ways to Ease the Stress
Talk with someone about your feelings– anger, sorrow, and other emotions-- even though it may be difficult.
Don't hold yourself responsible for the disastrous event or be frustrated because you feel that you cannot help directly in the rescue work.
Take steps to promote your own physical and emotional healing by staying active in your daily life patterns or by adjusting them. This healthy outlook will help yourself and your family. (i.e. healthy eating, rest, exercise, relaxation, meditation.)
Maintain a normal household and daily routine, limiting demanding responsibilities of yourself and your family.
Spend time with family and friends.
Participate in memorials, rituals, and use of symbols as a way to express feelings.
Use existing supports groups of family, friends, and church.
Establish a family emergency plan. Feeling that there is something that you can do can be very comforting.
* When to Seek Help: If self help strategies are not helping or you find that you are using drugs/alcohol in order to cope, you may wish to seek outside or professional assistance with your stress symptoms.
Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake
Updated February 24, 2010
In the aftermath of disasters, many survivors will show acute reactions to stress. Reactions to stress may appear immediately after traumatic events or days and even weeks later. Although many reactions to stress may also be symptoms of psychiatric disorders if they persist, reactions to stress are expected responses to traumatic events in the context of disasters. Reactions to stress may be confusing and frightening, and some may view their reactions as signs of weakness or mental illness. Providing reassurance that it is very natural to have physical and emotional responses after a disaster can help to reduce distress and promote better functioning. Common reactions include:
•Physical Reactions: rapid heart rate, trembling hands, unexplained somatic symptoms (e.g., headaches, backaches, chest or abdominal pain), dizziness, blurry vision, sweating/trembling/shaking for no reason, sleep problems, loss of appetite, feeling choked or smothered
•Cognitive Reactions: problems concentrating or remembering things, confusion, disorientation
•Emotional Reactions: feeling tense and nervous, excessive fatigue, crying often or easily, feeling numb, being angry or irritable, feeling nervous or anxious around reminders of the earthquake, and nightmares/intrusive memories/mental images related to the earthquake
•Interpersonal Reactions: problems in relationships with family or friends, conflict, withdrawal, isolation
In evaluating patients, clinicians should keep in mind that some patients may present with signs and symptoms that appear to be reactions to stress but may also be manifestations of medical illness. Adverse reactions to medications or having recently stopped taking medications are other potential causes of physical or mental status changes that should be considered as part of a clinical evaluation.
Grief – Grief is normal and to be expected given the extensive loss of life that occurred after the earthquake; however sometimes grief can become so severe or persistent as to interfere with daily function to a degree that warrants clinical attention.
Long-Term Psychological Responses: The majority of people who experience reactions to stress after disasters and emergencies show resilience and do not go on to develop long-term psychopathology. However, in some survivors, the symptoms do not resolve. Posttraumatic Stress Disorder (PTSD), anxiety disorders, major depression, or other psychiatric disorders may develop. Such illnesses may be serious, even fatal, and warrant prompt follow up.
Depending on the severity of symptoms, level of function, potential risks, clinical questions, and/or other factors, referral to a mental health professional (and/or another health professional) may be warranted even in the absence of a psychiatric disorder.
Suicidal or homicidal ideation may occur in a variety of psychiatric disorders, and warrant immediate attention.
Alcohol and substance use may also increase suicide risk, as well as the risk of motor vehicle crashes and violence. Alcohol and substance use may increase following natural disasters.
Some examples of symptoms that may be indicative of PTSD include: dissociation (e.g., feeling unreal or outside oneself, having "blank" periods of time that one cannot remember); intrusive re-experiencing (e.g., disturbing memories, nightmares, or flashbacks); avoidance of reminders of the disaster (e.g., avoiding activities that remind one of the earthquake, withdrawing from other people); emotional numbing (e.g., unable to feel emotion, as if empty); hyper-arousal (e.g., startle responses, rage, extreme irritability, intense agitation). Diagnostic criteria for PTSD and other psychiatric disorders are included in the most recent edition of the DSM IV (American Psychiatric Association, 2000).
Risk Factors: People who have experienced any of the following are more likely to experience long-term difficulties and may be at higher risk for developing psychopathology:
•Direct and indirect exposure to the earthquake and its impact, e.g., being injured in the earthquake, seeing injured or dead people, hearing people screaming
•Loss of loved ones or friends
•Exposure to prior traumas (e.g., disasters, sexual abuse, motor vehicle crashes, combat)
•Pre-existing mental health issues such as depression or anxiety disorders
•Social isolation
•Multiple relocations and displacements
•Loss of home, valued possessions, neighborhood, or community
•Recent or subsequent major life stressors or emotional strain (e.g., intense emotional demands, searching for survivors, interacting with bereaved family members)
•Extreme fatigue, weather exposure, hunger, or sleep deprivation
Cross-Cultural Issues: Clinicians should be aware that in Haitian culture, there is stigma associated with experiencing or disclosing behaviors associated with mental illness, and there are different culturally appropriate ways of expressing grief, pain, and loss. Haitian patients may be reluctant to discuss or admit to mental health problems, or may refer to stress and psychiatric symptoms in culturally-specific ways, e.g., referring to saisissement (rapid heartbeat and cool blood, due to trauma), and supernatural causes of symptoms, e.g., voudou and hexes. Any discussions of mental health or reactions to stress should be explained in culturally sensitive, supportive, and non-stigmatizing ways.
Children: Children’s immature abilities to understand and process the immediate and long-term effects of emergencies make them among the most vulnerable members of affected communities. Because of stigma in Haitian culture around mental illness, many children may be reluctant to discuss or admit to mental health problems. Likewise, prior caregivers in Haiti may not have fully explored such issues, even prior to the earthquake. Clinicians should consider potential mental health and developmental issues. Reactions to stress differ depending on developmental level and are generally marked by changes in typical behavior for the specific child or adolescent. Some children will warrant referral to a mental health professional.
Acknowledging Psychological Distress: Clinicians should be aware that many patients may be reluctant to acknowledge psychiatric symptoms or distress. Earthquake survivors may fear being stigmatized within their community or denied entrance to the United States, and aid workers and military personnel may fear being penalized professionally if they have psychiatric diagnoses noted on their medical records. Whenever mental health referrals are warranted, added care should be taken to explain and arrange such referrals to the patient and his/her caregivers in a culturally sensitive, supportive, and non-stigmatizing way.
Potential for Misattribution of Symptoms of Non-Psychiatric Medical Conditions to Psychological Distress – In the aftermath of the earthquake, some patients may experience symptoms of head injury, cardiovascular disease, infection, or other undiagnosed medical conditions which may present themselves through mental status changes. Health care providers examining patients who have survived the earthquake need to be alert to that possibility.
Following a natural disaster, when many people have suffered great losses, it is normal to feel sad, angry, or nervous.
Some who have experienced a disaster may have bad feelings right away. Others may not notice a change until much later, after the crisis is over. It can take time to feel better and for things to return to normal, especially with so much loss. Many people find support and comfort by talking to surviving family members, close friends, doctors, nurses, and religious leaders. Sometimes, help from mental health professionals may be needed.
Medical follow up will be important for the health and wellbeing of many survivors. Survivors should be encouraged to share questions and concerns about their health with their doctors.
Links to CDC resources and those of other organizations are below. Survivor experiences and needs may differ, so some sites may be more helpful to some than others.
Information available in French, Haitian-Creole, and English:
•Mental Health Information for the Public
•Mental Health Information for Professionals
•Mental Health Advisory for Health Professionals Providing Care for Survivors of the 2010 Haitian Earthquake
•General Mental Health Resources
How to find mental health services in the U.S. by state and information for developing cultural competence in disaster mental health programs.
Care Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life
Things to Remember When Trying to Understand Disaster Events
Signs that Adults Need Stress Management Assistance
Ways to Ease the Stress
Things to Remember When Trying to Understand Disaster Events
No one who sees a disaster is untouched by it.
It is normal to feel anxious about you and your family's safety.
Profound sadness, grief, and anger are normal reactions to an abnormal event.
Acknowledging our feelings helps us recover.
Focusing on our strengths and abilities will help you to heal.
Accepting help from community programs and resources is healthy.
We each have different needs and different ways of coping.
It is common to want to strike back at people who have caused great pain. However, nothing good is accomplished by hateful language or actions.
Signs that Adults Need Stress Management Assistance
Difficulty communicating thoughts
Difficulty sleeping
Difficulty maintaining balance
Easily frustrated
Increased use of drugs/alcohol
Limited attention span
Poor work performance
Headaches/stomach problems
Tunnel vision/muffled hearing
Colds or flu-like symptoms.
Disorientation or confusion
Difficulty concentrating
Reluctance to leave home
Depression, sadness
Feelings of hopelessness
Mood-swings
Crying easily
Overwhelming guilt and self-doubt
Fear of crowds, strangers, or being alone
Ways to Ease the Stress
Talk with someone about your feelings– anger, sorrow, and other emotions-- even though it may be difficult.
Don't hold yourself responsible for the disastrous event or be frustrated because you feel that you cannot help directly in the rescue work.
Take steps to promote your own physical and emotional healing by staying active in your daily life patterns or by adjusting them. This healthy outlook will help yourself and your family. (i.e. healthy eating, rest, exercise, relaxation, meditation.)
Maintain a normal household and daily routine, limiting demanding responsibilities of yourself and your family.
Spend time with family and friends.
Participate in memorials, rituals, and use of symbols as a way to express feelings.
Use existing supports groups of family, friends, and church.
Establish a family emergency plan. Feeling that there is something that you can do can be very comforting.
* When to Seek Help: If self help strategies are not helping or you find that you are using drugs/alcohol in order to cope, you may wish to seek outside or professional assistance with your stress symptoms.
Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake
Updated February 24, 2010
In the aftermath of disasters, many survivors will show acute reactions to stress. Reactions to stress may appear immediately after traumatic events or days and even weeks later. Although many reactions to stress may also be symptoms of psychiatric disorders if they persist, reactions to stress are expected responses to traumatic events in the context of disasters. Reactions to stress may be confusing and frightening, and some may view their reactions as signs of weakness or mental illness. Providing reassurance that it is very natural to have physical and emotional responses after a disaster can help to reduce distress and promote better functioning. Common reactions include:
•Physical Reactions: rapid heart rate, trembling hands, unexplained somatic symptoms (e.g., headaches, backaches, chest or abdominal pain), dizziness, blurry vision, sweating/trembling/shaking for no reason, sleep problems, loss of appetite, feeling choked or smothered
•Cognitive Reactions: problems concentrating or remembering things, confusion, disorientation
•Emotional Reactions: feeling tense and nervous, excessive fatigue, crying often or easily, feeling numb, being angry or irritable, feeling nervous or anxious around reminders of the earthquake, and nightmares/intrusive memories/mental images related to the earthquake
•Interpersonal Reactions: problems in relationships with family or friends, conflict, withdrawal, isolation
In evaluating patients, clinicians should keep in mind that some patients may present with signs and symptoms that appear to be reactions to stress but may also be manifestations of medical illness. Adverse reactions to medications or having recently stopped taking medications are other potential causes of physical or mental status changes that should be considered as part of a clinical evaluation.
Grief – Grief is normal and to be expected given the extensive loss of life that occurred after the earthquake; however sometimes grief can become so severe or persistent as to interfere with daily function to a degree that warrants clinical attention.
Long-Term Psychological Responses: The majority of people who experience reactions to stress after disasters and emergencies show resilience and do not go on to develop long-term psychopathology. However, in some survivors, the symptoms do not resolve. Posttraumatic Stress Disorder (PTSD), anxiety disorders, major depression, or other psychiatric disorders may develop. Such illnesses may be serious, even fatal, and warrant prompt follow up.
Depending on the severity of symptoms, level of function, potential risks, clinical questions, and/or other factors, referral to a mental health professional (and/or another health professional) may be warranted even in the absence of a psychiatric disorder.
Suicidal or homicidal ideation may occur in a variety of psychiatric disorders, and warrant immediate attention.
Alcohol and substance use may also increase suicide risk, as well as the risk of motor vehicle crashes and violence. Alcohol and substance use may increase following natural disasters.
Some examples of symptoms that may be indicative of PTSD include: dissociation (e.g., feeling unreal or outside oneself, having "blank" periods of time that one cannot remember); intrusive re-experiencing (e.g., disturbing memories, nightmares, or flashbacks); avoidance of reminders of the disaster (e.g., avoiding activities that remind one of the earthquake, withdrawing from other people); emotional numbing (e.g., unable to feel emotion, as if empty); hyper-arousal (e.g., startle responses, rage, extreme irritability, intense agitation). Diagnostic criteria for PTSD and other psychiatric disorders are included in the most recent edition of the DSM IV (American Psychiatric Association, 2000).
Risk Factors: People who have experienced any of the following are more likely to experience long-term difficulties and may be at higher risk for developing psychopathology:
•Direct and indirect exposure to the earthquake and its impact, e.g., being injured in the earthquake, seeing injured or dead people, hearing people screaming
•Loss of loved ones or friends
•Exposure to prior traumas (e.g., disasters, sexual abuse, motor vehicle crashes, combat)
•Pre-existing mental health issues such as depression or anxiety disorders
•Social isolation
•Multiple relocations and displacements
•Loss of home, valued possessions, neighborhood, or community
•Recent or subsequent major life stressors or emotional strain (e.g., intense emotional demands, searching for survivors, interacting with bereaved family members)
•Extreme fatigue, weather exposure, hunger, or sleep deprivation
Cross-Cultural Issues: Clinicians should be aware that in Haitian culture, there is stigma associated with experiencing or disclosing behaviors associated with mental illness, and there are different culturally appropriate ways of expressing grief, pain, and loss. Haitian patients may be reluctant to discuss or admit to mental health problems, or may refer to stress and psychiatric symptoms in culturally-specific ways, e.g., referring to saisissement (rapid heartbeat and cool blood, due to trauma), and supernatural causes of symptoms, e.g., voudou and hexes. Any discussions of mental health or reactions to stress should be explained in culturally sensitive, supportive, and non-stigmatizing ways.
Children: Children’s immature abilities to understand and process the immediate and long-term effects of emergencies make them among the most vulnerable members of affected communities. Because of stigma in Haitian culture around mental illness, many children may be reluctant to discuss or admit to mental health problems. Likewise, prior caregivers in Haiti may not have fully explored such issues, even prior to the earthquake. Clinicians should consider potential mental health and developmental issues. Reactions to stress differ depending on developmental level and are generally marked by changes in typical behavior for the specific child or adolescent. Some children will warrant referral to a mental health professional.
Acknowledging Psychological Distress: Clinicians should be aware that many patients may be reluctant to acknowledge psychiatric symptoms or distress. Earthquake survivors may fear being stigmatized within their community or denied entrance to the United States, and aid workers and military personnel may fear being penalized professionally if they have psychiatric diagnoses noted on their medical records. Whenever mental health referrals are warranted, added care should be taken to explain and arrange such referrals to the patient and his/her caregivers in a culturally sensitive, supportive, and non-stigmatizing way.
Potential for Misattribution of Symptoms of Non-Psychiatric Medical Conditions to Psychological Distress – In the aftermath of the earthquake, some patients may experience symptoms of head injury, cardiovascular disease, infection, or other undiagnosed medical conditions which may present themselves through mental status changes. Health care providers examining patients who have survived the earthquake need to be alert to that possibility.
February 28, 2010
Disaster Crisis Counseling Program
Crisis Counseling Programs for the Rural Community
Disaster Crisis Counseling Program
The Nature of Disasters
Definition of a Federal Disaster Declaration
The Federal Emergency Management Agency (FEMA) provides supplemental funding to States for short-term crisis counseling projects to assist survivors/victims of Presidentially declared major disasters. FEMA supplements, but does not supplant, mental health services traditionally provided by State and local mental health agencies. The Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) was first authorized by the U.S. Congress under the Disaster Relief Act of 1974 (Public Law 93-288) and later modified by the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (Public Law 100-707). FEMA is responsible for administering the disaster assistance programs of the Stafford Act, including Federal assistance for crisis counseling services.
A major disaster, as defined by the Stafford Act, is any natural catastrophe, or regardless of cause, any fire, flood, or explosion, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance to supplement efforts and available resources of States, local government, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused by the disaster.
Disaster Types
Different types of disasters covered by the Stafford Act that may impact rural areas include: hurricane, tornado, storm, high water, wind driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, drought, fire, flood, or explosion. Disasters also differ by a number of characteristics including the following:
Origin of disaster (natural versus human-caused)
Length of warning time
Intensity of the event
Extent of property damage
Number of persons impacted
Number of injuries and deaths
Dynamics of the recovery period
Each type of disaster has its own unique pattern of destruction and characteristics that affect the emotional response of disaster victims (NIMH, 1983):
Flood disasters can result in long incident periods and the evacuation of whole communities.
Earthquakes strike without warning and after shocks intensify fright and despair.
Tornadoes randomly choose their victims, skipping one house and striking the next.
Hurricanes can be unpredictable and suddenly change course causing the evacuation of large areas.
Disasters may be classified as either natural or human-caused. The following chart describes the different characteristics of natural and human-caused disasters. Blame is a characteristic that differs significantly for natural and human-caused disasters. Disaster survivors of human-caused disasters may blame and feel anger toward individuals, groups, or organizations they believe caused or contributed to the disaster. In contrast, survivors of natural disasters may blame and feel anger toward themselves, believe it is "God's Will" or a punishment. Survivors of natural disasters may project their anger onto caretakers, disaster workers, or others (CMHS, 1996).
Natural vs. Human-Caused Disasters
Natural Human-Caused
Causes Forces of nature Human error, malfunctioning
Examples Earthquakes, hurricanes, floods Airplane crashes, major chemical leaks, nuclear reactor accidents
Blame No one Person, government, business
Scope Various locations Locations may be inaccessible to rescuers, unfamiliar to survivors, little advance warning
Post-disaster
Distress High Higher, often felt by family members not involved in actual disaster
Source: CMHS. Psychosocial Issues for Children and Families in Disasters. A Guide for the Primary Care Physician. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.
Definition of Crisis Counseling Services
The Crisis Counseling Program, as it has been supported in the past twenty-five years by the Federal government, provides for short-term interventions with individuals and groups experiencing psychological sequelae from Presidentially-declared disasters. This type of intervention involves classic counseling goals of helping people to understand their current situation and reactions, assisting in the review of their options, providing emotional support, and encouraging linkage with other resources and agencies who may assist the individual. The assistance is focused upon helping the person deal with the current situation in which they may find themselves.
It draws upon the assumption, until there are contradictory indications, that the individual can resume a productive and fulfilling life following the disaster experience if given support, assistance, and information at a time and in a manner appropriate to his or her experience, education, developmental stage, and ethnicity (CMHS, 1994.
The Emergency Services and Disaster Relief Branch (ESDRB) of the Center for Mental Health Services (CMHS) will provide technical assistance to states in developing a grant request.
The ESDRB can be reached by phone at (301) 443-4735.
The Crisis Counseling Program is unique in comparison to the mix of Federal programs made available through a Presidential disaster declaration. It is the one program for which virtually anyone qualifies and where the person affected by disaster does not have to recall numbers, estimate damages, or otherwise justify need. The program provides primary assistance in dealing with the emotional sequelae to disaster.
Robert T. Stafford Act
The Stafford Act authorizes the President to provide training and services to alleviate mental health problems caused or aggravated by declared disasters. The Crisis Counseling Program is designed to provide supplemental funding to States for short-term crisis counseling services and is implemented when creating such services are beyond the resources of the State or local providers, given a Presidential disaster declaration.
FEMA may fund two separate portions of the Crisis Counseling Program: Immediate Services (IS) and Regular Services (RS). The IS grant enables the State and its local agency to respond to the immediate mental health needs with crisis counseling services. IS can be funded for up to sixty days after the Presidential declaration. If an RS application has been submitted, the program period for the immediate services may be extended thirty days and additional funding may be awarded. FEMA may approve a longer extension, if the review process of the regular program application exceeds thirty days. Costs incurred from the date of the incident to the date of declaration may be reimbursable under the immediate services program. The RS provides up to nine months of crisis counseling services, community outreach, and consultation and education services to people affected by the disaster. Funding for RS is separate from IS. The State may apply for either or both portions of the Crisis Counseling Program.
Application for IS funding must be completed within fourteen days of the disaster declaration. The application must contain a disaster description, needs assessment, program plan, budget, and budget narrative. The needs assessment is based on the needs of the affected communities and the ability of the current mental health system to respond to those needs. A State must demonstrate that State and local resources are insufficient to provide adequate services.
Differences Between Disaster Mental Health and Traditional Mental Health Programs
Disaster Crisis Counseling Programs are a departure from traditional mental health practice in many ways. The program is designed to address incident specific stress reactions, rather than ongoing or developmental mental health needs (CMHS, 1994). Programs must be structured and implemented according to Federally established guidelines and for a specific period. Emphasis is on serving individuals, families, and groups of people - all of whom share a devastating event that most likely changed the face of their entire community.
CRISIS COUNSELING PROGRAM
Immediate Services
Application due in fourteen days
Sixty-day program
Extension if RS is applied for
Regular Services
Apply within sixty days of declaration
Nine month program
Applications must include
Disaster description
Needs Assessment
Program Plan
Budget
Budget narrative
for more information click below
crisis counseling ceus
Outreach and crisis counseling activities are the core of the Crisis Counseling Program and create a unique set of challenges. Disaster crisis counseling requires breaking out of traditional ways of identifying people in need of services, providing access to those services, maintaining documentation, and determining effectiveness. Mental health professionals will work hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors/victims of the disaster in ways that may be foreign to their clinical training. This publication will focus on the implementation of appropriate crisis counseling services for rural communities across the United States.
Disaster Crisis Counseling Program
The Nature of Disasters
Definition of a Federal Disaster Declaration
The Federal Emergency Management Agency (FEMA) provides supplemental funding to States for short-term crisis counseling projects to assist survivors/victims of Presidentially declared major disasters. FEMA supplements, but does not supplant, mental health services traditionally provided by State and local mental health agencies. The Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) was first authorized by the U.S. Congress under the Disaster Relief Act of 1974 (Public Law 93-288) and later modified by the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (Public Law 100-707). FEMA is responsible for administering the disaster assistance programs of the Stafford Act, including Federal assistance for crisis counseling services.
A major disaster, as defined by the Stafford Act, is any natural catastrophe, or regardless of cause, any fire, flood, or explosion, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance to supplement efforts and available resources of States, local government, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused by the disaster.
Disaster Types
Different types of disasters covered by the Stafford Act that may impact rural areas include: hurricane, tornado, storm, high water, wind driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, drought, fire, flood, or explosion. Disasters also differ by a number of characteristics including the following:
Origin of disaster (natural versus human-caused)
Length of warning time
Intensity of the event
Extent of property damage
Number of persons impacted
Number of injuries and deaths
Dynamics of the recovery period
Each type of disaster has its own unique pattern of destruction and characteristics that affect the emotional response of disaster victims (NIMH, 1983):
Flood disasters can result in long incident periods and the evacuation of whole communities.
Earthquakes strike without warning and after shocks intensify fright and despair.
Tornadoes randomly choose their victims, skipping one house and striking the next.
Hurricanes can be unpredictable and suddenly change course causing the evacuation of large areas.
Disasters may be classified as either natural or human-caused. The following chart describes the different characteristics of natural and human-caused disasters. Blame is a characteristic that differs significantly for natural and human-caused disasters. Disaster survivors of human-caused disasters may blame and feel anger toward individuals, groups, or organizations they believe caused or contributed to the disaster. In contrast, survivors of natural disasters may blame and feel anger toward themselves, believe it is "God's Will" or a punishment. Survivors of natural disasters may project their anger onto caretakers, disaster workers, or others (CMHS, 1996).
Natural vs. Human-Caused Disasters
Natural Human-Caused
Causes Forces of nature Human error, malfunctioning
Examples Earthquakes, hurricanes, floods Airplane crashes, major chemical leaks, nuclear reactor accidents
Blame No one Person, government, business
Scope Various locations Locations may be inaccessible to rescuers, unfamiliar to survivors, little advance warning
Post-disaster
Distress High Higher, often felt by family members not involved in actual disaster
Source: CMHS. Psychosocial Issues for Children and Families in Disasters. A Guide for the Primary Care Physician. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.
Definition of Crisis Counseling Services
The Crisis Counseling Program, as it has been supported in the past twenty-five years by the Federal government, provides for short-term interventions with individuals and groups experiencing psychological sequelae from Presidentially-declared disasters. This type of intervention involves classic counseling goals of helping people to understand their current situation and reactions, assisting in the review of their options, providing emotional support, and encouraging linkage with other resources and agencies who may assist the individual. The assistance is focused upon helping the person deal with the current situation in which they may find themselves.
It draws upon the assumption, until there are contradictory indications, that the individual can resume a productive and fulfilling life following the disaster experience if given support, assistance, and information at a time and in a manner appropriate to his or her experience, education, developmental stage, and ethnicity (CMHS, 1994.
The Emergency Services and Disaster Relief Branch (ESDRB) of the Center for Mental Health Services (CMHS) will provide technical assistance to states in developing a grant request.
The ESDRB can be reached by phone at (301) 443-4735.
The Crisis Counseling Program is unique in comparison to the mix of Federal programs made available through a Presidential disaster declaration. It is the one program for which virtually anyone qualifies and where the person affected by disaster does not have to recall numbers, estimate damages, or otherwise justify need. The program provides primary assistance in dealing with the emotional sequelae to disaster.
Robert T. Stafford Act
The Stafford Act authorizes the President to provide training and services to alleviate mental health problems caused or aggravated by declared disasters. The Crisis Counseling Program is designed to provide supplemental funding to States for short-term crisis counseling services and is implemented when creating such services are beyond the resources of the State or local providers, given a Presidential disaster declaration.
FEMA may fund two separate portions of the Crisis Counseling Program: Immediate Services (IS) and Regular Services (RS). The IS grant enables the State and its local agency to respond to the immediate mental health needs with crisis counseling services. IS can be funded for up to sixty days after the Presidential declaration. If an RS application has been submitted, the program period for the immediate services may be extended thirty days and additional funding may be awarded. FEMA may approve a longer extension, if the review process of the regular program application exceeds thirty days. Costs incurred from the date of the incident to the date of declaration may be reimbursable under the immediate services program. The RS provides up to nine months of crisis counseling services, community outreach, and consultation and education services to people affected by the disaster. Funding for RS is separate from IS. The State may apply for either or both portions of the Crisis Counseling Program.
Application for IS funding must be completed within fourteen days of the disaster declaration. The application must contain a disaster description, needs assessment, program plan, budget, and budget narrative. The needs assessment is based on the needs of the affected communities and the ability of the current mental health system to respond to those needs. A State must demonstrate that State and local resources are insufficient to provide adequate services.
Differences Between Disaster Mental Health and Traditional Mental Health Programs
Disaster Crisis Counseling Programs are a departure from traditional mental health practice in many ways. The program is designed to address incident specific stress reactions, rather than ongoing or developmental mental health needs (CMHS, 1994). Programs must be structured and implemented according to Federally established guidelines and for a specific period. Emphasis is on serving individuals, families, and groups of people - all of whom share a devastating event that most likely changed the face of their entire community.
CRISIS COUNSELING PROGRAM
Immediate Services
Application due in fourteen days
Sixty-day program
Extension if RS is applied for
Regular Services
Apply within sixty days of declaration
Nine month program
Applications must include
Disaster description
Needs Assessment
Program Plan
Budget
Budget narrative
for more information click below
crisis counseling ceus
Outreach and crisis counseling activities are the core of the Crisis Counseling Program and create a unique set of challenges. Disaster crisis counseling requires breaking out of traditional ways of identifying people in need of services, providing access to those services, maintaining documentation, and determining effectiveness. Mental health professionals will work hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors/victims of the disaster in ways that may be foreign to their clinical training. This publication will focus on the implementation of appropriate crisis counseling services for rural communities across the United States.
After The Disaster: A Children’s Mental Health Checklist
After The Disaster: A Children’s Mental Health Checklist
Disasters can be particularly traumatic to children. Sometimes, it can be difficult to determine the extent of the psychological trauma, and whether or not professional mental health services are indicated. This checklist is one way to assess a child’s mental health status.
Add up the pluses and minuses to obtain a final score. If the child scores more than 35, it is suggested you seek a mental health consultation.
Has the child had more than one major stress within a year BEFORE this disaster, such as a death in the family, a molestation, a major physical illness or divorce? If yes: +5
Does the child have a network of supportive, caring persons who continue to relate to him daily? If yes: -10
Has the child had to move out of his house because of the disaster? If yes: +5
Was there reliable housing within one week of the earthquake with resumption of the usual household members living together? If yes: -10
Is the child showing severe disobedience or delinquency? If yes: +5
Is the child showing any of the following as NEW behaviors for more than three weeks after the disaster?
Nightly states of terror? +5
Waking from dreams confused or in a sweat? +5
Difficulty concentrating? +5
Extreme irritability? +5
Loss of previous achievements in toilet or speech? +5
Onset of stuttering or lisping? +5
Persistent severe anxiety or phobias? +5
Obstinacy? +5
New or exaggerated fears? +5
Rituals or compulsions? +5
Severe clinging to adults? +5
Inability to fall asleep or stay asleep? +5
Startling at any reminder of the disaster? +5
Loss of ambition for the future? +5
Loss of pleasure in usual activities? +5
Loss of curiosity? +5
Persistent sadness or crying? +5
Persistent headaches or stomach aches? +5
Hypochondria? +5
Has anyone in the child’s immediate family been killed or severely injured in the disaster (including severe injury to the child)? +15
Note: Preoccupation with death, unusual accident proneness or suicidal threats are reasons for immediate consultations. It is also recommended that any child who has been seriously injured or who has lost a parent, sibling or caregiver by death, have a psychological evaluation and/or brief therapy.
Note: This checklist was developed under the auspices of Project COPE, a federal funded (FEMA) crisis counseling program activated in Santa Cruz, California, in response to the October 17, 1989 Loma Prieta Earthquake. The project provided individual, family and group counseling, agency debriefing services and a school intervention program. Over the course of 16 months, the project provided services to more than 25,000 individuals. Peter J. Spofford, M.S. served as Project COPE Director.
Disasters can be particularly traumatic to children. Sometimes, it can be difficult to determine the extent of the psychological trauma, and whether or not professional mental health services are indicated. This checklist is one way to assess a child’s mental health status.
Add up the pluses and minuses to obtain a final score. If the child scores more than 35, it is suggested you seek a mental health consultation.
Has the child had more than one major stress within a year BEFORE this disaster, such as a death in the family, a molestation, a major physical illness or divorce? If yes: +5
Does the child have a network of supportive, caring persons who continue to relate to him daily? If yes: -10
Has the child had to move out of his house because of the disaster? If yes: +5
Was there reliable housing within one week of the earthquake with resumption of the usual household members living together? If yes: -10
Is the child showing severe disobedience or delinquency? If yes: +5
Is the child showing any of the following as NEW behaviors for more than three weeks after the disaster?
Nightly states of terror? +5
Waking from dreams confused or in a sweat? +5
Difficulty concentrating? +5
Extreme irritability? +5
Loss of previous achievements in toilet or speech? +5
Onset of stuttering or lisping? +5
Persistent severe anxiety or phobias? +5
Obstinacy? +5
New or exaggerated fears? +5
Rituals or compulsions? +5
Severe clinging to adults? +5
Inability to fall asleep or stay asleep? +5
Startling at any reminder of the disaster? +5
Loss of ambition for the future? +5
Loss of pleasure in usual activities? +5
Loss of curiosity? +5
Persistent sadness or crying? +5
Persistent headaches or stomach aches? +5
Hypochondria? +5
Has anyone in the child’s immediate family been killed or severely injured in the disaster (including severe injury to the child)? +15
Note: Preoccupation with death, unusual accident proneness or suicidal threats are reasons for immediate consultations. It is also recommended that any child who has been seriously injured or who has lost a parent, sibling or caregiver by death, have a psychological evaluation and/or brief therapy.
Note: This checklist was developed under the auspices of Project COPE, a federal funded (FEMA) crisis counseling program activated in Santa Cruz, California, in response to the October 17, 1989 Loma Prieta Earthquake. The project provided individual, family and group counseling, agency debriefing services and a school intervention program. Over the course of 16 months, the project provided services to more than 25,000 individuals. Peter J. Spofford, M.S. served as Project COPE Director.
February 27, 2010
Questions to Help Children Talk About a Disaster
Emergency Mental Health and Traumatic Stress
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
Subscribe to:
Posts (Atom)
