A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center 

the Dialogue 

2019 | VOLUME 15 | ISSUE 3–4 

Helping People With Serious Mental Illness and 

Substance Use Disorder During Disasters 
 

 

 

 

 

 

 

 

 

IN THIS ISSUE 

3 In This Issue 

4 Contributors 

8 Caring for People With Mental Illness in Disasters 

12 Activating Legal Mechanisms in a Disaster May Help Meet the Temporary Needs of 

Individuals With Substance Use Issues 

15 The Lingering Effect of Natural Disasters on Drug and Alcohol Use 

18 U.S. Virgin Islands Recovery 

20 Missouri Planning Activities Around SMI and Disasters 

23 Strength Through Connection: Disaster Behavioral Health Training in Puerto Rico 

28 Recent Technical Assistance Requests 

Cover photo by Rob Marmion/Shutterstock.com. 

The Dialogue is a quarterly technical assistance journal on disaster behavioral health which 

is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA) 

Disaster Technical Assistance Center (DTAC). Through the pages of The Dialogue, disaster 

behavioral health professionals share information and resources while examining the 

disaster behavioral health preparedness and response issues that are important to the field. 

The Dialogue also provides a comprehensive look at the disaster training and technical 

assistance services SAMHSA DTAC provides to prepare states, territories, tribes, and local 

entities so they can deliver an effective disaster behavioral health response. 

SAMHSA DTAC provides disaster technical assistance, training, consultation, resources, 

information exchange, and knowledge brokering to help disaster behavioral health 

professionals plan for and respond effectively to mental health and substance misuse needs 

following a disaster. 

To learn more or receive The Dialogue, please call 1–800–308–3515, email dtac@samhsa. 

hhs.gov, or visit the SAMHSA DTAC website at https://www.samhsa.gov/dtac. 

The Dialogue is not responsible for the information provided by any web pages, materials, or organizations referenced in this publication. Although 

The Dialogue includes valuable articles and collections of information, SAMHSA does not necessarily endorse any specific products or services 

provided by public or private organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed by such 

sites or organizations, nor does SAMHSA warrant the validity of any information or its fitness for any particular purpose.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 3 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

In This Issue 

Over the past few years, people across the United 

States have dealt with disasters of various sizes such as 

category 5 hurricanes, mass shootings, and wildfires.

Most people touched by a disaster, whether directly 

or indirectly, are affected in some way. Many disaster

survivors are able to move on and cope with the “new 

normal” of life after a disaster, while others may find

their situation harder to handle. Preexisting conditions

such as a history of mental illness or a substance use 

disorder may play a role in the ease of their recovery.

People living with serious mental illness (SMI)

or substance use disorders (SUD) may experience

challenges in day-to-day life that can prevent them from 

preparing prior to a disaster or increase their risk of 

post-disaster adjustment reactions. Like other disaster

survivors, individuals with SMI and SUDs may also face

being cut off by the disaster from their regular sources of

treatment and medication, or their support network.

In 2017, 11.2 million adults aged 18 or older had a 

serious mental illness and 18.7 million adults aged 

18 or older had a SUD in the past year. It is 

estimated that 3.1 million adults aged 18 or older 

had a co-occurring SMI and SUD. 

Substance Abuse and Mental Health Services Administration, 2018 

This double issue of The Dialogue focuses on assisting 

disaster survivors with SMI and/or SUDs after a disaster.

Our first article, written by a psychiatrist with expertise

in disaster mental health, focuses on why people with 

mental illnesses may need additional support to recover 

after a disaster and what we can do to increase their 

disaster preparedness and aid in their recovery after 

a disaster. The next article discusses legal challenges

involved with licensing out-of-state mental and disaster 

behavioral health providers during disaster response 

and recovery. Our next article, written by an addictions

researcher, describes what disaster behavioral health 

professionals can do to assist people with SUD after a 

Photo by se media/Shutterstock.com. 

disaster more effectively. A local provider in the U.S.

Virgin Islands shares her team’s experiences after the

hurricane season of 2017 in the next article, and this is

followed by a state planner from Missouri discussing 

how her state plans and prepares to work with people 

with SMI after disasters. We wrap up this double issue

with an interview that focuses on an upcoming Substance 

Abuse and Mental Health Services Administration

(SAMHSA)-supported disaster behavioral health training

in Puerto Rico. The training focuses on the effect trauma

has on the brain and how disaster behavioral health 

professionals can use this information to assist in the 

recovery of communities affected by disaster.

Has your program had success working with disaster

survivors with SMI or SUD? Do you have suggestions

or lessons learned from your experiences? We encourage

you to contact us to share your recommendations. ■

Captain Erik Hierholzer, B.S.N. Program Management

Officer, Emergency Mental Health and Traumatic Stress

Services Branch 

erik.hierholzer@samhsa.hhs.gov 

Nikki Bellamy, Ph.D. Public Health Advisor,

Emergency Mental Health and Traumatic Stress

Services Branch 

nikki.bellamy@samhsa.hhs.gov 

Shannon Loomis, M.A. Director, SAMHSA Disaster

Technical Assistance Center

dtac@samhsa.hhs.gov 
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 4 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

 

 

Contributors 

Max Gakh, J.D., M.P.H. is an 

Assistant Professor based at

the University of Nevada, 

Las Vegas (UNLV) School

of Public Health and the

Associate Director of the UNLV

Health Law Program. His research, teaching, and

service explore how legal and policy mechanisms can

improve or hinder the health of communities. His work

includes examining the government’s legal authority to

promote public health, laws relevant to public health 

emergencies, and laws and policies outside the health 

sector that affect health. Mr. Gakh’s previous experience

includes collaborating with public health professionals 

to address real-world health issues using law and policy 

and working as a non-partisan legislative attorney.

Beckie Gierer, M.S. is the 

Director for Continuity of

Operations Planning with

the Missouri Department of 

Mental Health (DMH) Office of

Public and Legislative Affairs/

Office of Disaster Services. She has a master of science

degree from the University of Central Missouri and

has worked with the State of Missouri for 18 years.

Ms. Gierer started her career with the Department of

Public Safety and has worked for the Department of

Social Services but has spent the majority of her years 

of service with the DMH (13 years). In addition to her

role as the Director of Continuity, she serves as the

grants manager for the Hospital Preparedness Program

and Public Health Emergency Preparedness grants with

the Office of Disaster Services and supervises Crisis

Counseling Assistance and Training Program (CCP)

grants after federally declared disasters. Ms. Gierer is

also a contracted trainer with SAMHSA for the Federal

Emergency Management Agency CCP and has trained

crisis counselors in Missouri, North Carolina, and

California.

Ms. Gierer has provided trainings for DMH consumers,

staff and providers, voluntary organizations, hospitals,

community businesses, and first responders at

conferences and in agency settings. Her trainings have

covered topics such as behavioral analysis, trauma, 

self-care/team care, personal preparedness, Mental

Health First Aid, continuity of operations, Skills

for Psychological Recovery, and the importance of

accounting for the needs of individuals with mental and 

substance use disorders as part of emergency planning.

Ms. Gierer also serves on several committees in

Missouri, including the Access and Functional Needs

Committee, Governor’s Partnership, Missouri Voluntary

Organizations Active in Disaster, and the Missouri

Coalition for Community Behavioral Healthcare disaster

workgroup. She is a co-chair for the Children and Youth

in Disasters Committee and a co-lead for the Pediatric

Behavioral Health workgroup.

Linda Ligenza, LCSW is the 

Clinical Services Director

for the National Council for

Behavioral Health. She has

extensive experience providing

guidance and technical 

assistance to organizations integrating primary care 

and mental health and substance use, most recently 

through the SAMHSA-Health Resources and Services

Administration Center for Integrated Health Solutions.

Ms. Ligenza’s expertise in trauma and trauma-informed

care further assists the integration audience in improving 

practices, policies, procedures, and outcomes.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 5 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

Ms. Ligenza has a background in clinical, administrative,

and public policy work based on her 30-year career. She

worked first with the New York State Office of Mental

Health and subsequently with the U.S. Department of

Health and Human Services and SAMHSA in their

Emergency Mental Health and Traumatic Stress Services

Branch of the Center for Mental Health Services.

Lizette Llanos is the Academic

Tutoring Supervisor and Outreach 

Coordinator for Island Therapy

Solutions (ITS), a multidimensional practice that provides 

mental health services. Ms. Llanos

oversees the tutoring program, manages a team of tutors, 

and delivers direct services to clients. She also educates

the community on the wide range of services at ITS and

participates in a number of community events to broaden 

awareness and help create a more inclusive community for 

everyone, regardless of ability.

Keila M. Medina, M.A. received 

her master of arts in counseling 

psychology from the University 

of the Virgin Islands (UVI) in

May 2016. She began working

with at-risk children and 

adolescents at the age of 15 through the Lighthouse with

a Mission after-school program. As an undergraduate

student at UVI, she spent 2 years working with at-risk

young adults through a Women’s Coalition program

called Project Promise. Ms. Medina met Dr. Lindsy

Wagner in January 2013 through her practicum program.

After she successfully completed her undergraduate

studies, she was hired full time at Island Therapy

Solutions. She worked closely with Dr. Wagner as her

Psychological Assistant, Master’s Intern, and currently a

Pre-licensure Intern. After the two category 5 hurricanes

that hit the U.S. Virgin Islands, she was one of the team

leads for the Crisis Counseling Assistance and Training

Program. She is currently preparing for the Examination

for Professional Practice in Psychology (EPPP); and

upon successful completion, she will become an 

Associate Psychologist.

Imelda K. Moise, Ph.D., M.P.H. 

is an Assistant Professor of

Geography at the University of

Miami, Florida, where she also

holds secondary appointments 

in the Departments of Public

Health Sciences and International Studies. The

goal of her research is to understand the effect of

social determinants of health on health inequalities,

particularly related to geographical targeting, the health 

of mothers and children, other vulnerable populations, 

and issues related to natural disasters. She is an expert

on supporting neighborhood-scale interventions and 

linking research to practice or policy. Prior to joining

the University of Miami, Dr. Moise was a Geographic

Information System (GIS)/Global Health Monitoring

and Evaluation Advisor in Washington, DC, where she

supported U.S. Agency for International Developmentfunded health programs in low- and middle-income 

countries on various scopes of work. She has also

worked with different international development

agencies and nongovernmental organizations, and 

she spent 5 years as a research specialist in Illinois.

She spent time coordinating federally funded research 

projects and program evaluation for state agency 

initiatives and ongoing programs aimed at improving 

health and well-being of low-income pregnant 

women, children, and their families; prevention of

underage drinking; and at-risk alcohol use during

pregnancy. She is currently finalizing a Robert Wood

Johnson Foundation-funded research project titled

“Examining age, race/ethnic, and gender differences

in alcohol-related hospitalizations of young people 

and the impact of liquor-related ordinances.” She also

recently completed a fellowship with the American

Evaluation Association focused on culturally responsive

evaluation theory, and she recently coedited a book 

titled Public Health, Disease and Development in Africa 

(Geographies of Health Series, Routledge, 2018).
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 6 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Joshua C. Morganstein, 

M.D. is Associate Professor

and Assistant Chair in the

Department of Psychiatry

and Assistant Director of

the Center for the Study of

Traumatic Stress at the Uniformed Services University 

of the Health Sciences in Bethesda, Maryland. Dr.

Morganstein is Chair of the American Psychiatric

Association’s Committee on the Psychiatric Dimensions

of Disaster and a Captain in the Commissioned Corps

of the U.S. Public Health Service. He leads disaster

mental health education and consultation services 

at the Center for the Study of Traumatic Stress and

provides disaster mental health subject matter expertise

to federal and national organizations. Dr. Morganstein

advised on the United Nations’ 2015 Sendai Framework

for Disaster Risk Reduction and coauthored the first

curriculum recommendations for disaster behavioral 

health professionals. He served as a coauthor for

the “Mental Health and Well-Being” chapter in a

landmark interagency report, The Impacts of Climate 

Change on Human Health in the United States, and the 

American Psychiatric Association’s position statement

and resource document on climate change and mental 

health. Dr. Morganstein has authored a range of

articles, chapters, and technical reports on the mental 

health impact of various disaster events including 

natural disasters, mass violence, terrorism, pandemics, 

and nuclear exposure. He is Assistant Editor for the

second edition of the Cambridge Textbook of Disaster 

Psychiatry. In collaboration with the National Institute

of Justice and University of California, Los Angeles, Dr.

Morganstein is the site Principal Investigator for a study

of community mass violence, focusing on the 2013

Washington Navy Yard workplace shooting.

Cheryl Sharp, M.S.W., ALWF 

holds the unique perspective

of a person who has recovered 

from significant mental health

challenges, and is a trauma 

survivor, a family member 

of a loved one who died as a result of mental health 

challenges, and a provider of substance use and mental 

health services. Ms. Sharp received her undergraduate

degrees in psychology and women’s studies followed

by her master’s degree in social work specializing in

health and aging. Ms. Sharp has worked with adult

trauma survivors for over 33 years training and speaking

internationally on trauma-informed approaches and 

suicide prevention. She led the development of the

National Council for Behavioral Health’s curriculum

to create trauma-informed approaches within over 

700 organizations across the country. She received

a SAMHSA Voice Award in 2015 for her work

and personal stories educating the public about 

trauma, mental health and substance use, and suicide 

prevention, and the Lou Ann Townsend Courage

Award for her contributions to people with psychiatric

disabilities. Most recently, she received the On Our

Own of Maryland 2018 Achievement Award for her

contributions to the State of Maryland’s Wellness

Recovery Action Plan (WRAP) Outreach Project. Ms.

Sharp believes in the limitless possibilities found within 

each of us to live our lives from a place of personal 

power. She has been a longtime supporter of the

Copeland Center for Wellness and Recovery and serves

on the Board of Directors. She enjoys living her life to

the fullest as a mother and grandmother in eastern North 

Carolina. Ms. Sharp is an avid gardener, reader, sailor,

traveler, and companion to her cat, Music.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 7 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Lindsy Wagner, Psy.D., a 

licensed clinical psychologist, 

is the owner and Chief

Executive Officer of Island

Therapy Solutions. She is

also the Founder and Board

President of Coral Reef Academy, a school for

children with autism and developmental disabilities.

Her clinical specialties include conducting diagnostic

evaluations, neuropsychological evaluations, and 

forensic neuropsychological evaluations, and providing 

consultation and training for children and families with 

a variety of presenting concerns including learning 

disabilities, neurological disorders, and emotional and 

behavioral concerns. Dr. Wagner also specializes in

diagnosis and treatment of autism spectrum disorder.

She conducts social skills groups with children with 

autism spectrum disorders as well as individual and 

family therapy. Dr. Wagner has taught at the University

of the Virgin Islands. Prior to moving to St. Croix, Dr.

Wagner was the Director of Training at the Watson

Institute in Pennsylvania. Dr. Wagner completed her

doctorate at the American School of Professional

Psychology in Washington, DC. She completed 2 years

of training at Children’s National Medical Center in

Washington, DC, in the Pediatric Neuropsychology Unit.

Hurricane Harvey disaster survivors Mellisa Velez (right) and David Walker 

(center right) meet with Jose Vidal (left), Disaster Survivor Crew Lead, at a 

Mobile Communications Operations Vehicle (MCOV) in Rockport, Texas, on 

the Gulf of Mexico near Corpus Christi. The Federal Emergency Management 

Agency (FEMA) deploys MCOVs to support the response work of Disaster 

Survivor Assistance teams in the field. Photo by Christopher Mardorf/FEMA.

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2019 | VOLUME 15 | ISSUE 3–4 | PAGE 8 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

Caring for People With Mental Illness in Disasters 

By Joshua Morganstein, M.D. 

Introduction

There are about 11 million people 

in the United States living with 

a serious mental illness (SMI).

Broadly, SMI is defined as the

presence of a diagnosable mental 

illness and significant disability

such that the person has difficulty

with one or more life activities.

Most people with SMI experience

episodes of psychosis or severe 

depression.

In order to function well, persons

with SMI often rely on healthcare

and community support resources.

They have increased risk for adverse 

outcomes following disasters (Norris

et al., 2002). In the acute stages of

a natural disaster, those living with 

SMI may function relatively well.

Like the rest of the population,

they often rise to the occasion to 

assist themselves and others in a 

time of great need. However, those

with SMI are often less prepared

for disasters and may have more 

extreme reactions when exposed to

the stress or trauma of a large-scale 

community disaster. In addition,

damaged infrastructure and diversion 

of community resources to lifesaving 

and sustaining activities often disrupt 

critical sources of support upon 

which people rely (such as jobs,

supported housing, etc.), ultimately

threatening the well-being of persons 

with SMI. Relevant public and

private entities can mitigate adverse 

outcomes by engaging in disaster 

planning and response to address the 

needs of persons with SMI.

Vulnerability

Individuals with SMI are often less

prepared for a disaster; they may be

less likely to have needed supplies 

on hand or an established emergency 

plan (Eisenman et al., 2009). They

may be more dependent on others to 

take necessary precautions prior to 

a disaster or assist them in the event 

of an evacuation. Persons with SMI

may also lack stable housing, access 

to health care, and adequate social

In 2017, an estimated 

11.2 million adults 

in the United States had a SMI. 

This number represented 

4.5% of all U.S. adults. 4.5% of all U.S. adults.

National Institute of Mental Health. (2019). Mental illness. Retrieved from

https://www.nimh.nih.gov/health/statistics/mental-illness.shtml 

Photo by Semmick Photo/Shutterstock.com. 
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 9 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

support, and they may therefore be 

missing critical elements of support 

in the immediate aftermath of a 

disaster.

Following a disaster, those with

mental illness are more likely to 

develop stress-related symptoms or a 

relapse of prior symptoms (Norris et

al., 2002). They may have difficulty

tolerating psychological distress or 

a disruption in their social networks.

Those with a prior diagnosis of 

posttraumatic stress disorder (PTSD)

may be particularly vulnerable to an 

exacerbation of symptoms due to an

association of elements of the current 

disaster and response, such as sirens 

or other loud noises, with their prior 

trauma (Neria et al., 2008).

Disrupted Support

and Services

Many people living with SMI

often rely on the care and support 

of family members, friends, or 

other caretakers. In the wake of a

disaster, access to these caretakers 

may be disrupted. Family members

may need to divert their time and 

energy to basic tasks of recovery, 

such as securing food, water, and 

safe housing, leaving less time and 

resources to care for their family 

member with mental illness.

Individuals with SMI may also rely

on supported environments and 

mental health care, and these systems 

are often disrupted or overwhelmed 

following a disaster (Wang et al.,

2007). Inpatient psychiatric units,

hospitals, and outpatient clinics may 

close after a disaster. Individuals

living in skilled facilities, group 

homes, or shelters may have been 

evacuated to an unfamiliar setting.

Facilities may be understaffed and

patients or residents required to

relocate or evacuate. Pharmacies

may be closed, or their supply 

chains interrupted, resulting in the 

inability to receive medications.

Problems with transportation

infrastructure may make it difficult

to get to appointments. Increased

demand for mental health services 

The prevalence of SMI 

was higher among women 

(5.7%) than men (3.3%). 

women 

5.7% 

men 

3.3% 

National Institute of Mental Health. (2019).

Mental illness. Retrieved from https://www.

nimh.nih.gov/health/statistics/mentalillness.shtml 

commonly observed following 

mass trauma may divert resources 

from those with SMI. Further,

persons with SMI experiencing

significant adverse effects frequently

do not obtain mental health care, 

receive inadequate interventions,

and prematurely drop out of care 

(Rodriguez & Kohn, 2008).

Services and Interventions

The provision of disaster resources 

varies based on size and scope of the 

event. Large-scale, complex events

typically result in significant influx

of resources, whereas smaller events 

may result in no new resources.

Though people with SMI may

have exacerbations or relapse of

symptoms, they also experience

the expected range of responses

to trauma exposure. Thorough

evaluation for people with SMI

helps to differentiate expected

responses to disaster exposure

from exacerbation or recurrence

of symptoms of the underlying 

mental illness. When common

disaster responses occur, providing 

reassurance and appropriate 

early interventions can prevent 

unnecessary stigmatization and 

demoralization. At the same time,

mental health personnel should 

monitor people with SMI for

exacerbation or relapse, as well as

diminished functioning. This often

delicate balance, when effectively

managed, enhances self-efficacy,

reduces stigma, and optimizes 

the effective and efficient use of

resources.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 10 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Adults 

aged 50

and older 

(2.7%) Adults 

18–25 

years

Adults (7.5%)

26–49 

years

(5.6%) 

18–25 years 18–25 years 

Young adults aged 

had the 

highest prevalence of 

SMI (7.5%) compared to 

adults aged 

(5.6%) and aged 

26–49 years 26–49 years 

50 and older 50 and older (2.7%). 

National Institute of Mental Health. (2019).

Mental illness. Retrieved from https://www.

nimh.nih.gov/health/statistics/mentalillness.shtml 

Disaster mental health services 

designed for the general population, 

such as those based on concepts 

of Psychological First Aid, are

equally beneficial for disaster

survivors with SMI (Hobfoll et

al., 2007). Procedures addressing

safety, calming, social connection, 

personal and community efficacy,

and a sense of hope and optimism 

are helpful during or immediately 

after a disaster. Care should be taken

to avoid isolating or stigmatizing 

those with SMI. Encouraging those

with SMI to be active partners in

solving problems for themselves and 

their community fosters the critical 

elements of efficacy, hope, and

social connectedness.

Photo by Semmick Photo/Shutterstock.com. 

Given the frequent deterioration

or exacerbation of mental health

symptoms associated with insomnia, 

optimizing sleep is essential for 

persons with SMI and can serve to

enhance the essential element of 

calming (McKibben et al., 2010).

Behavioral interventions should 

be used to the extent possible

and augmented with rational 

pharmacotherapy when needed.

Pharmacies in the disaster region

should include a broad range of 

psychiatric medications in order 

to allow those with SMI to stay on

their prior regimens, anticipating 

refills as well as the need to replace

medications lost or forgotten during 

evacuation.

The stress of the disaster and 

disruption in prior treatment 

may result in the deterioration 

of mental health status for some.

Psychiatric hospitalization and

normal supports may be necessary 

for stabilization. Although rates of

hospitalizations do not typically 

increase significantly following

disasters, disruption to existing

facilities and staffing shortages often

make it more difficult to obtain

inpatient psychiatric services when 

needed. Ensuring personnel and

resources are also available to assist 

with housing, employment, and 

reestablishment of prior psychiatric 

care can enhance recovery following 

a disaster.

Preparedness and Planning

When persons with SMI and those

who care for them are prepared 

for disasters, distress is frequently

reduced. In addition, limited
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 11 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

Photo by Ekaterina_Minaeva/Shutterstock.com. 

cognitive resources can be focused 

on executing existing plans, rather

than engaging in frantic efforts

to figure out what actions to take

during an acutely stressful period.

An important initial step in planning

involves identifying people with 

SMI within the community,

including those living in residential 

facilities as well as people 

experiencing homelessness, whose

rates of SMI are significantly greater

than the general population (Folsom

et al., 2005).

Caretakers and providers should

work closely with those who have 

SMI to collaborate on development

of disaster plans. A simple disaster

plan can include emergency contact 

information, a list of medications 

and other items needed in the event 

of an emergency, and an adequate

supply of critical medical and 

basic household items. In addition,

helpful disaster planning practices 

include refilling medications

before they are empty to avoid 

abrupt discontinuation following 

8.1% 

5.2% 

2.4% 

2 or more white Asian 

races adults adults 

adults 

The prevalence of SMI 

was highest among the 

adults reporting two 

or more races (8.1%), 

followed by white adults 

(5.2%). The prevalence 

of SMI was lowest among 

Asian adults (2.4%). 

National Institute of Mental Health. (2019).

Mental illness. Retrieved from https://www.

nimh.nih.gov/health/statistics/mentalillness.shtml 

an unexpected event. Identify

emergency shelter and temporary 

housing options outside the local 

area able to accommodate persons 

with SMI in order to facilitate

evacuation, rescue, or emergency 

evaluations at the time of a disaster.

Emergency personnel are

increasingly called upon to assist 

individuals with acute exacerbation

of mental illness in the community 

(Ford-Jones & Chaufan, 2017).

First responders should be trained

to identify and assist people with 

signs of active mental illness 

following a disaster. Symptoms of

particular concern include psychosis 

(hallucinations, delusions, paranoia,

and disorganized thought processes);

severe depression; suicidal or

homicidal ideation or behavior;

and substance misuse. Responders

need training to assist persons with 

SMI in ways that assure successful

communication and safety. Training

should include an understanding of 

the common adverse psychological 

and behavioral responses to 

trauma, effective communication

and interaction to avoid escalating 

adverse reactions, legal and ethical 

factors, and how to assist with 

medical and psychiatric referral 

when needed. For instance, simply

asking if an individual has his or her 

usual medications and what they are 

for can begin a helping relationship.

Conclusion

Persons with SMI have special

needs and vulnerabilities following 

natural disasters. In large part this is

due to the disruption of relationships 

and resources upon which they often 

rely. At the same time, care must

be taken to ensure that common 

reactions to disaster exposure are

not treated as pathological. Disaster

planning that addresses the unique

needs of those with SMI allows

for services and interventions 

that mitigate adverse effects by

improving the preparedness of 

individuals with SMI and their

support systems, ensuring those 

who provide routine and emergency 

care are adequately trained, and

optimizing continuity of essential 

healthcare infrastructure and social 

services. ■
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 12 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Activating Legal Mechanisms in a Disaster May

Help Meet the Temporary Needs of Individuals 

With Substance Use Issues 

By Maxim Gakh, J.D., M.P.H. 

Disasters pose many challenges 

and necessitate readiness both by 

governments and communities (U.S.

Department of Homeland Security,

Federal Emergency Management

Agency [FEMA] 2011). Too

often, disasters disproportionately 

affect the health and well-being

of vulnerable populations (Bethel,

Foreman, & Burke, 2011). This

includes individuals with preexisting

substance use issues, many of 

whom are particularly susceptible 

to the impacts of disasters (North &

Pfefferbaum, 2013).

A disaster’s immediate aftermath

may exacerbate or resurface

existing substance use issues at

the same time that the existing

systems and services needed to 

address such issues are strained 

(Palinkas, 2015; Hodge, Rutkow,

& Corcoran, 2010). Disaster plans

should thoroughly account for 

mental health and substance use 

needs (North & Pfefferbaum, 2013;

Hodge, Rutkow, & Corcoran,

2010; Pfefferbaum et al., 2012).

However, previous experience

illustrates that responding to the 

needs of individuals with substance 

use issues in a disaster’s aftermath

remains a challenge (Rutkow, Vernick,

Mojtabai, Rodman, & Kaufmann,

2012). Immediately after Hurricane

Sandy, for instance, individuals in 

medication-assisted treatment for 

opioid use disorder in New York City

had difficulty obtaining medications

(Pouget, Sandoval, Nikolopoulos,

& Friedman, 2015). Similarly, some

individuals staying in shelters after 

Hurricane Katrina required care for

preexisting substance use conditions

(North et al., 2015).

Photo by Igor Stevanovic/Shutterstock.com. 
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One-tenth to one-third of people who survive trauma linked 

to an accident, illness, or disaster report problematic alcohol use, 

especially if they are troubled by persistent health problems or pain. 

New York State, Office of Alcoholism and Substance Abuse Services. (2012). Substance use 

disorders and disasters. Retrieved from https://www.oasas.ny.gov/AdMed/FYI/subused.cfm 

Photo by Viktoriia Hnatiuk/Shutterstock.com. 

Meeting the disaster-related needs of 

individuals with substance use issues 

requires legal preparedness (Hodge

et al., 2010; Rutkow et al., 2012).

Legal preparedness is paramount for

disaster planning across a range of 

issues and is important for disaster 

readiness (Hodge & Anderson,

2008; Moulton, Gottfried, Goodman,

Murphy, & Rawson, 2003). It

involves the capacity, capability, 

and ability to use laws to reach 

preparedness goals (Moulton et al.,

2003).

One important function of legal 

preparedness can be to boost the 

availability of licensed out-of-state 

providers in a disaster to meet the 

needs of individuals with substance 

use conditions and with other 

mental health and substance use 

needs (Hodge et al., 2010; Rutkow

et al., 2012). This may be critical

to disaster response because outof-state providers can increase 

the capacity of a community to 

address disaster-related surges in 

mental health and substance use 

needs (Yun, Lurie, & Hyde, 2010).

Legal preparedness operates in

the context of provider licensure

laws, which vary by state. State

laws typically define educational

and training requirements, scope of

practice confines, reciprocity and

endorsement, and other requirements

for different types of providers

(Page et al., 2017). However, a state

government faced with a disaster 

may declare an emergency and 

provisionally alter certain existing

legal requirements and structures

(Hodge & Anderson, 2008).

Some states have adopted laws that 

aim to enable out-of-state providers 

to respond to disaster-related needs 

(Hodge et al., 2010; Hodge &

Anderson, 2008; Rutkow, Vernick,

Wissow, Kaufmann, & Hodge, 2011;

Kels & Kels, 2013). For example,

during a government-declared 

emergency, volunteer providers 

who hold a valid professional 

license in another state and who 

are preregistered may be permitted 

to practice temporarily (National

Conference of Commissioners on

Uniform State Laws [ULC], 2007)

in 18 states and Washington, DC, all

of which incorporated the Uniform 

Emergency Volunteer Health

Practitioners Act (UEVHPA) into

their laws (ULC, 2018). Similarly,

during a declared emergency, 

the Emergency Management

Assistance Compact (EMAC)—a

multi-jurisdictional effort adopted

by all U.S. states and many

territories (EMAC, n.d.)—enables

government-employed healthcare 

providers licensed in another state 

to practice temporarily in the 

state responding to the disaster 

(EMAC, 1996). And 17 states

and Washington, DC, have also
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adopted a version of the Model 

State Emergency Health Powers Act

(MSEHPA) provision that allows

the state government responding to 

a declared disaster to waive in-state 

licensing requirements to enable

response (Network for Public Health

Law, 2012). Efforts like UEVHPA,

EMAC, and MSEHPA facilitate

disaster-related licensure portability 

and can help meet disaster-related 

needs, such as the needs of 

individuals with substance use issues 

(Kels & Kels, 2013; Rutkow et al.,

2011).

In addition to multi-state efforts,

some states permit disaster-related 

licensure portability through other 

statutes or through executive action

(Kels & Kels, 2013; Hodge, Gable,

& Cálves, 2005). For example, Idaho

permits out-of-state psychiatrists 

to practice temporarily in the state 

during a disaster (Idaho Code Ann.

§ 54-1804). Recent gubernatorial

action in North Carolina empowered

licensed out-of-state providers,

including psychologists, counselors,

clinical social workers, and

substance use counselors, to practice

in North Carolina as part of the

Hurricane Florence response (N.C.

Exec. Order No. 64, 2018).

Permitting out-of-state professionals

to practice temporarily in a disaster 

is necessary for a response strategy 

that relies on these professionals 

to help address the surge in need 

experienced by individuals with

substance use issues. However,

a response strategy that relies on 

out-of-state providers also requires

planning around other 

legal questions, such as

the availability of liability 

protections and workers’

compensation for out-ofstate professionals aiding 

in a response (Hodge,

Pepe, & Henning, 2007;

Lopez, Kershner, &

Penn, 2013).

Disaster recovery also involves 

challenges for addressing the needs 

of individuals with substance use 

issues. Disasters are linked to

substance use and misuse, which 

may increase in a community 

recovering from a natural or humancaused disaster (Alexander & Ward,

2018; Kleinman & Biddinger,

2018; Gould, Teich, Pemberton,

Pierannunzi, & Larson, 2015; Fan,

Prescott, Zhao, Gotway, & Galea,

2015; Stoddard et al., 2011; Vlahov

et al., 2002). A disaster may involve

treating substance use issues that 

predate the disaster, intensify 

preexisting substance use problems,

or present new venues or ways to 

connect individuals with treatment 

(North, Kawasaki, Spitznagel, &

Hong, 2004; North & Pfefferbaum,

2013; North, 2007).

Despite these needs, disaster 

recovery can be slow and can lack 

the resources and infrastructure 

available during response (Chandra

& Acosta, 2010). In addition, many

legal tools and protections available 

for disaster response are limited 

to the disaster’s direct aftermath

(Hodge et al., 2010). The assets

available to address the needs of 

Photo by Iakov Filimonov/Shutterstock.com. 

individuals with substance use issues 

may therefore be especially strained 

during disaster recovery (Chandra &

Acosta, 2010).

At the same time, communities

recovering from a disaster may be 

returning to pre-disaster shortages of 

service professionals for individuals 

with substance use disorders. Such

professionals include psychiatrists, 

psychologists, social workers, 

counselors, nurse practitioners, and 

physician assistants who focus on 

substance use (Health Resources and

Services Administration [HRSA],

2015). Every day this workforce

is stretched in parts of the country, 

where supply fails to meet demand 

(HRSA, 2015; HRSA, 2018). Major

investment is necessary to help 

close the current “national treatment 

gap”—that is, the discrepancy

between those who need and those 

who actually receive substance use 

treatment—a problem that exists

outside the preparedness landscape 

(Shepard et al., 2005). Such an

investment is critical to prepare for 

and respond to a disaster, as well 

as to mitigate its consequences

for individuals with substance use 

issues. ■
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Produced by the SAMHSA Disaster Technical Assistance Center

 

The Lingering Effect of Natural Disasters on

Drug and Alcohol Use 

By Imelda K. Moise, Ph.D., M.P.H. 

The intensity, occurrence, and 

seriousness of recent storms, along 

with projections that these trends 

will continue or get worse, have 

made the study and management 

of natural disasters a new normal 

for public health. Storms have

demonstrated their capacity not only 

to destroy property and take lives, 

but also to leave lasting psychiatric 

consequences on those in their path

(Kessler, Galea, Jones, Parker, &

Hurricane Katrina Community

Advisory Group, 2006; Kessler,

Galea, Gruber, Sampson, Ursano,

& Wessely, 2008; Rhodes, Chan,

Paxson, Rouse, Waters, & Fussell,

2010). Experts have long tried

to quantify the damage caused

by storms. Unlike destruction to

infrastructure and property, some 

of the effects a storm has on the

population in the affected areas are

neither immediate nor obvious.

Exposure to a natural disaster is

undeniably a stressful experience.

Survivors of natural disasters have 

endured ordeals unfathomable to 

many, including loss of family, 

friends, homes, and community. It

is understandable why there may 

be an increase in drug and alcohol 

use and misuse during and after 

disasters. Many of those affected by

a disaster have experienced physical

threats, and they may exhibit postdisaster behavior and readjustment 

Following Hurricane Katrina, hospitalization rates for 

substance use disorders rose from 

population in 2004 to in 2008. 

7.13 per 1,000 

9.65 per 1,000 

HOSPITALIZATION RATES 

FOR SUBSTANCE USE DISORDERS 

10 9.65 

9 

8 7.13 

7 

6 

5 

4 

3 

2 

1 

0 

2004 2008 

BEFORE AFTER 

HURRICANE HURRICANE 

KATRINA KATRINA 

Moise, I. K., & Ruiz, O. M. (2016). Hospitalizations for substance abuse

disorders before and after Hurricane Katrina: Spatial clustering and

area-level predictors, New Orleans, 2004 and 2008. Preventing Chronic

Disease, 13(E145). https://doi.org/10.5888/pcd13.160107 
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 16 

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problems as they process and 

address the trauma. In addition to

addressing post-disaster behavior 

and readjustment problems, previous 

mental health issues may resurface 

during stressful or traumatic periods 

such as after a natural disaster.

For example, a study conducted

with survivors of the Oklahoma City

bombing (1995) found a prevalence

of bombing-related PTSD of 41

percent, with over a quarter (26

percent) of study participants

still experiencing active PSTD 7

years after the bombing (North,

Pfefferbaum, Kawasaki, Lee, &

Spitznagel, 2011). Participants with

pre-disaster mental illness were 

more likely than those without to 

develop bombing-related PTSD

(North et al., 1999). Similarly, a

study of survivors of Hurricane

Sandy (2012) found them more

likely to suffer from disaster-related

PTSD and depression, with even

MANAGING ALCOHOL, MEDICATION, 

AND DRUG USE AFTER A DISASTER

Pay attention to any change in your use of 

alcohol and/or drugs. 

Consult with a healthcare professional about 

safe ways to reduce anxiety, depression, muscle 

tension, and sleep deprivation. 

Use prescription and over-the-counter medication 

as indicated. 

If you find that you have greater difficulty 

controlling alcohol or substance use since the 

disaster, seek support in doing so. 

Eat well, exercise, and get enough sleep, and 

reach out to your family and others for support. 

If you believe you have a problem with substance 

use, talk to your doctor or counselor about it. 

New York State, Office of Mental Health. (n.d.). Alcohol, medication, and drug use 

after a disaster. Retrieved from https://www.omh.ny.gov/omhweb/disaster_

resources/pandemic_influenza/children/alcohol_medication_drug_use_after_

disaster.html 

higher rates of depression among 

those who experienced greater

numbers of hurricane-related 

stressors (e.g., being injured or

having a family member injured or 

killed during the disaster) (Gruebner,

Lowe, Sampson, & Galea, 2015).

Regarding substance use and

misuse in the wake of natural 

disasters, it is difficult to decipher

the synergistic relationships and 

mediating factors that cause people 

to increase their use of drugs and/

or alcohol. Previous research has

shown that people tend to use drugs 

and alcohol to self-soothe in times 

of crisis or extreme stress (Cepeda,

Valdez, Kaplan, & Hill, 2010;

Flory, Hankin, Kloos, Cheely, &

Turecki, 2009; Rohrbach, Grana,

Vernberg, Sussman, & Sun, 2009).

In our recent study, we reviewed

hospital admissions records from 

New Orleans from 2004 and 2008 

to see if there was a change in the 

rate of hospitalizations for substance 

misuse from before Hurricane

Katrina (2005) to after the storm

(Moise & Ruiz, 2016). We found

that although the hurricane itself 

was a trauma for those who lived in 

the affected areas, the mental strain

did not stop after the floodwaters

receded. In some people, this strain

manifested in hospitalization due to 

substance use disorders. Of note, the

rate of hospitalizations had increased 

by almost one-third 3 years after

the hurricane. People who had less

money (people living in poverty),

those who lived in close proximity

to areas with levee breaches, and 
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Public health professionals 

and treatment programs 

continue to learn new things 

and are always looking 

to improve treatment and 

disaster behavioral health 

Photo by Patryk Kosmider/Shutterstock.com. preparedness and response. 

those who lived in areas where 

cleanup efforts were delayed

were found to be at higher risk of 

hospitalization than their relatively 

less-affected counterparts.

So, the question becomes, what can

you do to help? The link between

substance use and misuse, mental 

illness, and disasters places public 

health professionals in a unique

position to prepare, respond, and 

provide disaster behavioral health 

services to people with prior 

diagnoses and to those identified

as high-risk (e.g., people living in

poverty) during immediate relief

and in future reconstruction efforts.

Key components of immediate

relief efforts may include a needs

assessment; Psychological First Aid;

monitoring and referral, including 

educating responders regarding 

disaster-related trauma; and

psychiatric presentations on topics 

such as substance use and misuse.

Strategies for promoting resilience 

and recovery during reconstruction 

efforts must be flexible and allow

communities to develop strengths, 

acquire skills to cope, manage stress,

and recover from the disaster and its 

mental health- and substance userelated effects.

Public health professionals and

treatment programs continue to learn 

new things and are always looking 

to improve treatment and disaster 

behavioral health preparedness and 

response. Therefore, in addition

to providing survivors of natural 

disasters with disaster supplies, 

it may be necessary to increase 

access to counseling, treatment, and 

psychotherapy. We must understand

that the need for humanitarian 

assistance during and after disasters 

goes beyond the provision of food, 

water, sanitation supplies, and 

medicine and must include mental 

health or social support services.

As public health professionals,

we must also be cognizant of the 

words we use when identifying 

and interacting with individuals 

affected by a substance use disorder

and understand the role of stigma 

in these disorders. For the best

terminology and language to use, 

and how to portray individuals 

with substance use disorders 

accurately, see SAMHSA’s series of

webcasts The Power of Language 

and Portrayals: What We Hear, What 

We See at https://www.samhsa.gov/ 

power-language-portrayals. 

There is also great opportunity for 

collaboration and interdisciplinary 

work in prevention of substance use 

and misuse issues and conditions. In

particular, geographers can contribute 

when trying to tease out connections 

between neighborhood contributions 

(place effects) on substance use and

misuse and health disparities. For

example, in the aftermath of natural

disasters, geographers and local 

city governments can use geospatial 

techniques and analyses to pinpoint

areas of greatest need. Then, working

with disaster response personnel and 

volunteers, we can facilitate decision 

making around planning, design, 

and delivery of targeted mental 

health and substance use services 

and resource allocation in a timely 

manner, optimizing both outcomes 

and cost. While these techniques can

be applied anywhere, for any public 

health outcome, they are especially 

relevant in post-disaster settings. ■

Additional Resource

A Process Guide to Monitoring and 

Evaluation for Informed Decision 

Making provides an overview of 

geospatial analysis techniques and

ways to apply geospatial analysis 

within the context of monitoring

and evaluation, along with 

additional resources. (https://www. 

measureevaluation.org/resources/ 

publications/ms-14-98).
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 18 

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U.S. Virgin Islands Recovery 

By Lizette Llanos, Keila Medina, M.A., and Lindsy Wagner, Psy.D. 

The U.S. Virgin Islands have

experienced natural disasters in

the past, but none compare to 

the hurricane season of 2017. On

September 6, 2017, Hurricane Irma,

a category 5 storm with top winds at 

185 miles per hour, pummeled the 

U.S. territories, leaving significant

damage to St. John and St. Thomas,

and to a lesser degree, St. Croix. Two

weeks later, on September 19, 2017,

Hurricane Maria, also a category 5

storm with top speeds recorded at 

165 miles per hour, passed south of 

St. Croix. The devastation of both

went far beyond the loss of material 

possessions as residents continue to 

grapple with life after the storms.

Many damaged homes across 

the territory remain abandoned 

or covered with temporary blue 

tarps. The fragility of roadway,

hospital, and government agency 

infrastructure compounds an already 

stressful situation. In the months

post-hurricanes, many residents have 

not adopted the coping skills needed 

to maneuver stressors, including 

family dynamics, relocation logistics, 

the slow rebuilding process, and the 

lack of vital medical services.

Our office, Island Therapy Solutions

(ITS), has seen a significant increase

in clients in need of counseling 

services. Colleagues agree that the

weight of the hurricanes, a slow 

rebuilding process, lack of adequate

St. Thomas, U. S. Virgin Islands – November 7, 2017: Top-heavy power pole leans precariously over 

road to St. John’s ferry in Red Hook months after Hurricanes Irma and Maria hit. Photo by Dedicated 

Living/Shutterstock.com. 

resources, and the annual hurricane 

season have caused undeniable 

trauma to people who are already 

under an incredible amount of 

pressure. Those who were on

island during Hurricane Hugo, a

category 4 storm that hit the territory 

in September of 1989, were retraumatized. When we speak to

these individuals, they indicate that 

there are major differences in posthurricane recovery efforts.

One of the differences indicated is

that in 1989, the federal agencies

provided financial resources to

families almost immediately after 

the storms. The FEMA process is

now more lengthy and difficult;

people have experienced delays

in receiving needed funds, which 

has created high levels of stress.

One issue that many families have 

run into is that the sole owner of 

their home was either off the island

A literature review estimated that 

developed 

posttraumatic stress 

disorder after the disaster. 

Goldmann, E., & Galea, S. (2014). Mental

health consequences of disasters. Annual 

Review of Public Health, 35, 169–183. 

https://doi.org/10.1146/annurevpublhealth-032013-182435 

30–40% of direct disaster 

victims 

or deceased when the hurricane 

occurred. Families were required

to obtain death certificates or

notarized letters from the owner 

to receive funding. With limited
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communication and government 

services, obtaining these 

documents was difficult.

Another difference was the

overall recovery with two backto-back category 5 hurricanes.

After Hurricane Irma, the people

of St. Croix donated thousands

of items to the sister islands. The

residents of St. Croix took supplies

to St. John and St. Thomas for the

entire 10 days following Hurricane

Irma. This left the island of St.

Croix unprepared for Hurricane

Maria, as they were without many 

vital supplies including canned 

goods, gas, water, plywood, tarps, 

and generators. The people of St.

Croix were short on supplies when

Hurricane Maria became a threat,

causing panic and chaos.

Many areas on the east end of 

the island had little damage and 

recovered quickly; however,

many areas on the west end were 

devastated. Racial tension developed

as it appeared the more affluent,

Caucasian residents of the east end

were served more quickly than

local Black residents of the west 

end. A silent division that endured

for decades resurfaced, so much so 

that Governor Mapp discussed it

during one of his press conferences.

He reminded the communities that

all of the islands were affected by

the hurricanes and that soon the 

entire territory would be in recovery 

mode. The governor provided hope

to the people during his weekly 

conferences, and after the Crisis

Counseling Assistance and Training

Hurricane Irma hit the U.S. Virgin Islands on 

September 6, 2017. Ten days later, on September 

19th, Hurricane Maria made landfall at the U.S. 

Virgin Islands. Both hurricanes were category 5. 

Irma Maria

Photos by National Aeronautics and Space Administration, 

https://worldview.earthdata.nasa.gov. 

Program (CCP) was granted in

November 2017, the crisis counselors 

provided essential emotional support 

on all islands.

Through hope and emotional 

support, many communities and 

neighborhoods offered provisions

for each other, including generators, 

food, or babysitting. Regardless of

the emotional supports, many were 

financially stressed. Businesses

closed or reopened slowly, resulting 

in involuntary layoffs. Several publicschool buildings on the islands were 

condemned. The financial burdens,

including lack of resources to repair 

homes or send school-aged children 

to private schools, became a major 

stressor. Due to these burdens, many

families made life-changing decisions 

such as migrating and sending 

their children to live with family 

on the mainland, as well as sharing 

living quarters with other families

comprising five generations.

These moves ultimately affected

the mental health of individuals on 

the islands, some of whom have 

gotten counseling through the 

CCP. The crisis counselors of St.

Croix facilitated individual crisis

counseling to over 3,700 residents;

provided public education and 

group counseling to over 

2,700 residents; and had brief

educational and supportive 

contact with over 8,000 

residents, many of whom were 

referred by other programs 

assisting with recovery such 

as the Women’s Coalition, the

Village, and ITS.

To date, ITS has provided free

counseling services to 242 people 

through additional supplemental 

funding. The individuals had

approximately 1,595 total visits from

October 2018 through July 2019.

Their diagnoses include PTSD,

adjustment disorders, and anxiety

disorders; we have seen an increase

in cannabis use disorder and alcohol 

use disorder. The need for counseling

is varied; individuals have had one to

eight visits, depending on the severity 

of their situation or diagnosis.

Our providers have facilitated 

therapy using a range of techniques

and theories including cognitive 

behavioral therapy, dialectical 

behavior therapy, trauma-informed 

therapy, group therapy, and family 

therapy.

Today, almost 2 years after the 

storms, the changes the hurricanes 

wrought are still noticeable. Some

are slowly recovering with hope, 

positivity, and preparedness, while 

others have moved on and made 

a new life elsewhere. ITS on St.

Croix and Beautiful Dreamers on St.

Thomas and St. John are working

to help the people of the U.S. Virgin

Islands be psychologically ready for

another hurricane season. ■
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 20 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Missouri Planning Activities Around SMI 

and Disasters 

By Beckie Gierer, M.S. 

Missouri experiences natural

disasters regularly. We received

Presidential disaster declarations

for back-to-back floods in 2016

and 2017 and for the EF5 tornado

in Joplin in 2011. Since 2000,

Missouri has received 31 major

disaster declarations. Our breadth of

experience ranges from the floods of

1993 to the death of Michael Brown

in Ferguson to the duck boat tragedy

in Branson. Following each event,

we conduct after-action reviews to 

improve our response efforts and

document lessons learned within our 

plans.

Missouri’s Department of Mental Joplin, Missouri, 10 days after the 2011 EF5 tornado. Photo by Bob Webster/Creative Commons. 

Health (DMH) is the state mental

health authority and annually 

serves more than 170,000 

Missourians with mental illness, 

developmental disabilities, and 

substance use disorders. Within

the DMH Director’s Office is

the Office of Disaster Services

(ODS), which is part of the Office

of Public and Legislative Affairs

and funded through the Hospital

Preparedness Program and Public

Health Emergency Preparedness

grants. The Missouri DMH ODS

collaborates with partners (state

and nongovernmental agencies,

faith-based organizations, federal 

agencies, and communities) on

activities to support a coordinated 

mental health response for all 

Missourians in disaster situations.

When disasters strike, ODS works

with community mental health 

centers (CMHCs) to deploy

staff to assist the individuals and

communities affected by the event. 

Serious mental illness costs America 

$193.2 billion in lost earnings per year. 

In a national survey, more than 18% of U.S. adults 

reported that they had experienced a past-year anxiety disorder, such 

as posttraumatic stress disorder, obsessive-compulsive 

disorder, or specific phobias.

National Alliance on Mental Illness. (n.d.). Mental health by the numbers. Retrieved from 

https://www.nami.org/learn-more/mental-health-by-the-numbers 
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The CMHCs serve Missourians

with SMI daily in 36 catchment

areas covering 114 counties and 

the City of St. Louis. Studies cited

at websites of organizations such 

as SAMHSA and the Center for

the Study of Traumatic Stress 

show that individuals living with 

SMI may be more vulnerable to

disasters than individuals without 

SMI. People living with SMI may

be less prepared than other people 

for disasters; can develop new or

have a reoccurrence of symptoms 

after a disaster; and, like others,

may experience a lapse in services

following a disaster for various 

reasons. They often require an

increase in services after a disaster.

ODS hears regularly from 

community partners regarding 

general mental health concerns and 

disaster mental health planning 

requests for their staff, the

Among adolescent survivors of 

2011 tornadoes in Joplin, Missouri, 

2.8% experienced substance 

use disorders in combination with

posttraumatic stress disorder (PTSD)

or depression. The prevalence of 

substance use disorders as a sole 

outcome was less than 1x%. 

Schiff, M., & Fang, L. (2016). Adolescents’ exposure to disasters and substance use. 

Current Psychiatry Reports, 18(6), 1–6. https://doi.org/10.1007/s11920-016-0693-2 

Missouri Institute of Mental Health, & Missouri 

Department of Mental Health (2018). Mental 

Health First Aid Missouri. Retrieved from http:// 

mhfamissouri.org 

individuals they serve, and their 

communities. Missouri is addressing

these concerns through these 

planning activities: 

 Behavioral Health Strike Team

(BHST)—ODS in collaboration

with the CMHCs is creating a

statewide cadre whose members

will train, participate in training

exercises, and respond as

requested. Our plan is to sustain

and maintain the disaster

behavioral health expertise that so

many of our agencies have from 

Crisis Counseling Assistance and

Training Programs (CCPs) and

community events, and grow that 

expertise in other agencies. BHSTs

will deploy (1) for a mass-casualty

or other crisis that affects the

community but does not qualify

for federal crisis counseling 

funding or (2) as backup to other

regions of the state that may be 

overwhelmed responding to such 

an event. Status: In development.

 Addressing SMI—ODS

sponsored two Mental Health First

Aid (MHFA) Train the Trainers

courses funded through existing

grants. MHFA educates and

empowers community members

and agencies to support individuals

with SMI. Hospitals, healthcare

coalitions, social services, and

mental health and substance use

agency staff participated with

the understanding they would

train and be a local resource for

individuals within their agencies

and communities. Status: Ongoing.

 Committees/Workgroups—ODS

participates in 21 committees and

workgroups that place a focus on

SMI and planning, preparedness,

response, and recovery. For

example, the Children and Youth

in Disasters Committee promotes

comprehensive interagency

planning for the needs of children

and youth in emergencies

and disasters. There are six

workgroups within this committee,

and ODS co-chairs the Pediatric
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 22 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

 

Behavioral Health Workgroup. It

focuses on substance use, SMI,

human trafficking, and suicide

prevention as it relates in the 

aftermath of a disaster or other 

traumatic event. Status: Ongoing.

 Joint Emergency Preparedness 

Committee—Ozark Center led the

CCP after the Joplin tornado and

chairs this committee. Members

include Missouri DMH, the

Missouri Coalition for Community

Behavioral Healthcare, and several

of Missouri’s CMHCs. The

committee’s focus is to prepare

CMHCs for any event so they can

continue to provide treatment and 

support services to approximately

250,000 Missourians. This

committee is engaged in building 

the BHST in Missouri. Status:

Ongoing.

 Education/Training—In the last

calendar year, ODS delivered 

education and training to our 

facilities, agencies, and offices

and trained approximately

1,500 people in the state on 

continuity of operations, MHFA,

Psychological First Aid, active

threat, sheltering, the importance 

of including disaster behavioral 

health in emergency operations 

plans, self-care/team-care,

responder care after a disaster, 

situational awareness, and hospital 

evacuation. In addition, ODS

conducted 11 tabletop exercises

with staff from DMH facilities

and chief executive officers from

CMHCs on earthquakes, blizzards,

and ice storms. Tabletop exercises

Among adolescents who survived 

Hurricane Rita, which hit the Gulf Coast in 2005, 

of those who did not use or misuse 

drugs or alcohol 13 months before the hurricane, 

15% had started smoking after the hurricane, 

25% had begun drinking, 

and 8–9% had started smoking marijuana. r

Schiff, M., & Fang, L. (2016). Adolescents’ exposure to disasters and substance use. 

Current Psychiatry Reports, 18(6), 1–6. https://doi.org/10.1007/s11920-016-0693-2 

allow staff to review how their

facility or agency would handle 

a disruption of services, a loss 

of a facility, staffing concerns,

medication concerns, and 

communication challenges. Status:

Ongoing.

 Communication—DMH has

7,000 employees system-wide,

and many DMH facilities

operate community-based homes 

or campus cottages located 

away from the main building.

As a result, communication

is a challenge. In 2018,

ODS implemented a mass 

communication system for all 

DMH facilities and staff to

communicate emergently via text,

phone call (landline and cell), and

email. Last fall, a facility went on

a full lockdown due to an active 

threat. Fortunately, no one was

hurt, the lockdown was activated 

and lifted via the communication 

tool, and the system’s value was

established. Status: Ongoing.

Missouri DMH ODS facilitates

disaster preparedness tools and 

training for all Missourians, with 

a focus on DMH staff; community

partners; and individuals living with

SMI, developmental disabilities, and

substance use. The bottom line is

that our mission to serve our clients, 

at all times, is at the forefront of 

everything we do! ■

You can find more information

on the Missouri DMH website at

https://dmh.mo.gov/disaster. 

Links to follow us on Facebook

and Twitter are available at 

https://dmh.mo.gov/about/ 

socialmediadirectory.html.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 23 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

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INTERVIEW 

Strength Through Connection: Disaster 

Behavioral Health Training in Puerto Rico 

An interview with Linda Ligenza, LCSW and Cheryl Sharp, M.S.W., ALWF 

Hurricane Maria hit Puerto Rico

in September 2017, with winds 

reaching 155 miles per hour 

(Pasch, Penny, & Berg, 2019;

U.S. Department of Commerce,

National Oceanic and Atmospheric

Administration, Storm Prediction

Center, n.d.). Maria caused flooding

on the island up to 9 feet above

ground level, requiring rooftop

rescue of hundreds of families. After

the hurricane, no one on the island 

had electricity, 95 percent of cellular

sites were nonfunctional, and only 2 

percent of roads were usable (U.S.

Department of Homeland Security,

FEMA, 2017). Hurricane Maria was

the third most expensive hurricane in

U.S. history (Pasch, Penny, & Berg,

2019).

To help Puerto Rico and the U.S.

Virgin Islands in the aftermath of

the 2017 hurricanes, SAMHSA

is supporting mental health and 

substance misuse consultation and 

training. The Dialogue recently 

spoke with trainers for Puerto Rico

about how disasters and trauma 

affect survivors, the importance

of connections, and how disaster 

survivors’ strengths can help in

disaster recovery.

What will your training cover? 

Linda Ligenza: On the first day,

we’ll define trauma, its impact and

prevalence, and how it affects the

brain. We will cover various types of

trauma, and how staff can recognize

it. On the second day, we will focus

on how responders can use a variety 

of approaches to promote healing 

and recovery. That’s where we’ll talk

about building individual capacity 

to cope with adversity, using group 

methodologies and community 

resources.

Cheryl Sharp: We will be providing

people with foundational knowledge

of trauma and its impact and the

information they need to tease out

where people fall and what they

need.

Whom will you be training?

Linda Ligenza: We will be training

crisis counselors, including some

mental health professionals and first

responders. They’ve been in the field

for more than a year.

Hurricane Maria hit Puerto Rico in September 2017. Photo by JEAN-FRANCOIS Manuel/Shutterstock.com. 
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 24 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

“For someone who has experienced a trauma, when 

a fresh trauma occurs, it goes back to the part of the 

brain where the original trauma occurred, activating 

the same neural pathways.” 

Cloud cover presages Hurricane Florence. Photo by kckate16/Shutterstock.com. 

How do disasters and 

trauma affect the brain and

neurological systems? 

Linda Ligenza: Trauma affects

people in different ways. In people

with preexisting trauma, the

disaster may trigger old traumatic 

experiences and wounds and may

cause more intense reactions. This

population should be considered at 

higher risk for adverse reactions.

Are effects different for

individuals with SMI? 

Linda Ligenza: Individuals with

SMI tend to react in two ways. For

some, the disaster and its aftermath 

will exacerbate their symptoms,

or, if their symptoms were under 

control, they may come back. On the

other hand, some people with SMI

are so used to dealing with stressors 

that they actually respond well to 

the disaster and function pretty well 

after it. They often have supports

through their mental health services 

and are more used to dealing with 

adversity.

Cheryl Sharp: I am a Hurricane

Florence survivor. I am also a

trauma survivor. I had a tremendous

struggle throughout my young 

adulthood and eventually came to a 

place where I feel I have recovered

and healed, but having gone 

through Florence and watching the

devastation in my community, it 

does retrigger me. It’s that sense of

powerlessness. For someone who

has experienced a trauma, when a

fresh trauma occurs, it goes back 

to the part of the brain where the 

original trauma occurred, activating 

the same neural pathways. On the

other hand, like others with trauma 

who have gone through recovery, I

had a way to respond to what was 

going on during and after Florence.

How can staff recognize

those impacts? Are there 

symptoms or signs that staff

should look for?

Linda Ligenza: When staff talk

with disaster survivors, they want to 

try to engage them in a conversation.

Some survivors will want to share 

their experience while others may

not. Staff should watch for signs

indicating whether or not the person 

is able to perform their usual daily 

functions. For some people, if they

had health problems before, those 

health problems may be exacerbated.

Staff may see more anger and

hostility, as well as difficulty

managing emotions, especially in 

children. They may also be seeing

symptoms such as feeling depressed.

You have to distinguish between

situational and clinical depression.

If a person is not getting up in

the morning, can’t get the kids to

school—that is more serious than

someone feeling down but still being 

able to function. Interference with

functional abilities is a huge sign.

Cheryl Sharp: It’s that whole

idea of having a conversation 

before jumping to judgment and 

labeling people. If you’re looking

for PTSD, it’s important to be able

to ask how the person is sleeping, 

functionality questions, how their

mood is, and their level of fear. You

can point out that your community 

has been through something that 

was really hard and ask people 

how they are coping. They may be

coping in maladaptive ways, but the 

point is that we can only find out
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 25 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

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about a person’s strengths through

conversation.

All over our community, people

have really risen up to be there for 

each other. This is common after

disasters. People throw away their

assumptions about people who are 

different, and they get back to the

idea that we are all human beings.

It’s also important to realize that you

can’t be in relationships with folks

without having hard conversations.

You need to be able to ask questions

about many issues, including 

suicidality. Being able to ask hard

questions is important, and making

sure the person does not feel judged.

What can communities do to 

support their members and 

build capacity to recover from

future disasters?

Linda Ligenza: After a disaster,

there may be community stressors 

and triggers that prolong disaster 

reactions for some. As the

community recovers physically, 

the people tend to recover and 

heal. Most communities will come

together after a disaster and outside 

assistance is common. These

supports contribute greatly to the 

community healing. There are

memorial services and anniversary 

events. Faith-based and cultural

organizations play a big role in 

helping the community heal and 

recover.

Cheryl Sharp: In my own

community, I’m part of a disaster

relief committee with several 

subcommittees. I sit on the

Emotional and Spiritual Impact

Subcommittee. We work to figure out

how we can provide resources that 

people can access, regardless of their 

financial situation. The group has

brought together therapists willing 

to give a certain amount of time 

and number of sessions. Some of

us will also do spiritual counseling.

It’s not clinical, but we’re giving

people access to someone to talk to 

and helping them use their spiritual 

beliefs as one of their strengths.

What are some considerations 

in working after disasters

with individuals with 

preexisting SMI? 

Linda Ligenza: In the states

generally people with SMI are

already connected to mental health 

services; the important task is

getting them reconnected to services 

following a disaster. For many with

SMI, they are most at risk of being

unable to access their medications 

Photo by Mangostar/Shutterstock.com. 

because of destruction to service 

centers. People in medicationassisted treatment for substance use 

disorders may be unable to access 

their medication as well. Also,

people can get disconnected from 

their services because they couldn’t

get to service sites during and after 

the disaster, and so they may need 

support in getting reconnected.

What are ways to help disaster 

survivors toward better mental 

health, and to help them be 

better prepared for future

challenges? Are there specific

techniques staff can use?

Linda Ligenza: One of the most 

important strategies staff can use

is to connect with individuals.

Healing happens in relationships.

After a disaster, people may become

isolated. Staff can help disaster

survivors connect with family 

members and friends and build those 

connections.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 26 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Cheryl Sharp: If people are restimulated or triggered by an event, 

they aren’t in the present. They

are either back in the trauma, or 

they believe the current disaster 

has overtaken their life and they 

will never recover. You can teach

mindfulness, both to children and 

adults. You can also teach people to

go to a place of immediate gratitude 

versus being overwhelmed by what 

has happened. It is about allowing

someone to be in extreme distress,

while also allowing him or her 

options to come back to the present.

Physical activity is also beneficial,

and a way for community members 

to come together. It can be helpful to

teach people breathing techniques to

bring them back to center.

Linda Ligenza: Yoga is an

important way of helping to reduce 

stress and build capacity to cope.

Volunteering can be helpful. It’s

also important to do enjoyable 

things, even when there have been 

losses. People may feel that they

don’t have the right to do something

enjoyable when so many people 

have died. Encouraging people

to engage in recreational and fun 

activities, especially as a family, can 

be healing. Getting back to normal,

routine activities is important as 

well.

Cheryl Sharp: Helping people

focus on self-care is crucial. For us,

for my family and what we went 

through, in those first days, there

was not even a single thought of 

self-care. We were just thinking

about the next thing that we needed

to do. Disaster survivors may also

be dealing with guilt. I lost very

little in Florence but was really

overcome with watching what other 

people had lost. I had to step back

and think about who I wanted to be

in the situation, and how I would

take responsibility for my own 

well-being. A lot of people don’t

know how to do that, so it’s a good

opportunity for people to learn those 

skills. ■

Photo by fizkes/Shutterstock.com.

“Yoga is an important way of helping to reduce stress 

and build capacity to cope. Volunteering can be helpful. 

It’s also important to do enjoyable things, even when 

there have been losses.” 

Photo by Andy Dean Photography/Shutterstock.com. 
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 27 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

RECOMMENDED RESOURCES 

National Center for PTSD: The Effects of Disaster on

People with Severe Mental Illness 

This article from the National Center for PTSD reviews

research on how individuals with SMI may react to a

disaster. It covers the likelihood that people with SMI

will develop PTSD, as well as how disasters and war

may affect people with SMI. The article also describes

ways mental health professionals can meet the needs of 

individuals with SMI.

Find the article at https://bit.ly/2UAlPeV. 

Psychological First Aid: Alcohol and Drug Use 

after Disasters 

This handout from the National Child Traumatic Stress

Network discusses the potential for substance use and 

misuse after a disaster in an effort to relieve negative

feelings and symptoms. It also explains the importance

of choosing to stay in recovery for individuals that have 

had substance use issues in the past. Tips on how to

maintain recovery include increasing attendance at 

support groups and talking to loved ones about providing 

extra support.

Download the handout at https://bit.ly/2X2kb2f. 

Access the handout in Spanish at https://bit.ly/2G5Vn2E. 

Access the handout in Chinese at https://bit.ly/2USj3kj. 

Access the handout in Japanese at https://bit.ly/2UsP8zP. 

Creating Safe Scenes Training Course 

This course provides information to help first responders

ensure safety for all involved in calls in which an 

individual is in crisis related to a mental illness or 

substance use disorder. The course covers signs and

symptoms of specific mental and substance use

disorders, risk assessment, and de-escalation techniques.

Find the training at https://bit.ly/2v3c1L7.

NAMI: Navigating a Mental Health Crisis 

This guide from the National Alliance on Mental Illness

(NAMI) describes mental illness and mental health crises

and offers steps to take if a crisis occurs. An individual

may experience a mental health crisis because of a

variety of stressors, including trauma and exposure to

violence. This guide provides techniques to help deescalate a crisis, what a medical or law enforcement 

response may look like, and more.

Download the manual at http://bit.ly/2J06ay8. 

Mental Health Response to Mass Violence and 

Terrorism: A Field Guide 

This manual from the SAMHSA Store aids disaster

response workers in assisting survivors after an act of 

terrorism or mass violence. It has a section on individuals

with SMI and their potential need for additional support

after a traumatic experience.

Read or download the manual at https://bit.ly/2Z5jerW.
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 28 

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center

 

Recent Technical Assistance Requests 

In this section, read about responses SAMHSA Disaster Technical Assistance Center (DTAC) staff have provided to

recent technical assistance requests. Send your questions and comments to dtac@samhsa.hhs.gov.

Request: SAMHSA DTAC received a request from a

Massachusetts resident concerned about the safety of his 

congregation and place of worship. He was looking for

assistance with assessing the security of 

his congregation.

Response: SAMHSA DTAC directed him to the

FEMA web page Resources to Protect Your House of

Worship (https://www.fema.gov/faith-resources). This

web page provides links to several webinars, trainings, 

and preparedness resources for testing an emergency 

plan. It also includes resources on trauma and resilience,

and for learning about religious and cultural literacy and 

competency in disasters.

Request: SAMHSA DTAC received a request from

a survivor of Hurricane Michael looking for support

to help her recover. She wanted help with finding a

professional to talk about her experiences during and

after the disaster.

Response: SAMHSA DTAC provided her with

information on several SAMHSA resources that can

help provide disaster survivors with mental health 

and substance use support. The resources included the

following: 

 SAMHSA Disaster Distress Helpline—This 24/7,

365-day-a-year helpline provides crisis counseling

and support to people experiencing emotional distress

related to natural or human-caused disasters. Call

1–800–985–5990 or text TalkWithUs to 66746 to

connect with a trained crisis counselor. For more

information visit https://www.samhsa.gov/find-help/

disaster-distress-helpline.

 SAMHSA’s National Helpline—This helpline is a

free, confidential, 24/7, 365-day-a-year treatment

referral and information service (in English and

Spanish) for individuals and families facing mental

and/or substance use disorders. It can be reached at

1–800–662–4357, and more information can be found

at https://www.samhsa.gov/find-help/nationalhelpline.

 SAMHSA Behavioral Health Treatment Locator—

This online tool can be used to find mental health and

substance use disorder treatment services in a specific

area. The locator can be found at https://www. 

findtreatment.samhsa.gov.

Request: SAMHSA DTAC received a call from a

disaster behavioral health manager who was interested 

in training her staff so that they could be provide

services for the state’s existing CCP.

Response: SAMHSA DTAC thanked her for her

interest in CCP trainings and explained the process that

takes place when a state applies for and administers 

a CCP in response to a major disaster. SAMHSA

DTAC shared her information with the state disaster

behavioral health coordinator for her state, so she could 

be contacted to assist with future disasters. She was also

provided information on several trainings that may be of 

interest to her and her team, including the following: 

 FEMA Citizen Corps—The Citizen Corps program

brings together local government, business, 

and community leaders to harness the power of 

every individual through education, training, and 

volunteering. Its network provides services to make

communities safer, stronger, and better prepared to 

respond to the threats of terrorism, crime, public health 

issues, and disasters of all kinds. More information can

be found at https://www.ready.gov/citizen-corps. 

 Centers for Disease Control and Prevention (CDC)

Preparedness and Emergency Response Learning

Centers (PERLC)—CDC funds 14 centers across the

United States to offer disaster response-related courses

online free of charge. More information can be found

at https://www.cdc.gov/cpr/perlc.htm. ■
2019 | VOLUME 15 | ISSUE 3–4 | PAGE 29 

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