A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center 

the Dialogue

2017 | VOLUME 13 | ISSUE 2

Low Socioeconomic Status and Disasters
TABLE OF CONTENTS

1 In This Issue

2 Contributors

3 Recent Technical Assistance Requests

4 Data Snapshot

4 The Dialogue Reader Responses

5 A Networked Approach: How Missouri Addresses Residents’ Behavioral Health 

Needs After Disasters

8 West Virginia CCP Helps Rural Communities After Thousand-Year Flood

11 Low Socioeconomic Status (SES) Communities in Times of Disaster: Understanding 

the Challenges

14 Recommended Resources

Cover photo: Water remains on the streets after the Meramec River at Pacific, Missouri, crested more 

than 29 inches March 21, 2008. Photo by Joycelyn Augustino/Federal Emergency Management Agency.

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 behavioral health (mental health and substance 

misuse) response to disasters. To receive The Dialogue, please go to SAMHSA’s home 

page (https://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, 

enter your email address, and mark the checkbox for “SAMHSA’s Disaster Technical 

Assistance newsletter, The Dialogue,” which is listed in the Newsletters section.

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, 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 webpages, 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.

The views, opinions, and content expressed in this publication do not necessarily reflect the views, opinions, or policies of the Center for Mental 

Health Services, SAMHSA, or the U.S. Department of Health and Human Services.
2017 | VOLUME 13 | ISSUE 2 | PAGE 1

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

In This Issue

The power of socioeconomic status (SES) shapes the 

human experience by influencing access to resources 

and opportunities. SES includes a collection of qualities 

associated with a person’s standing in society such as 

education, occupation, and level of income. The SES 

of certain groups of people can vary to some degree 

across culture, place, and time. However, those with 

low SES have comparatively less access to mental 

health resources and professional treatment in the 

United States. As a result, low SES can have far-ranging 

negative effects that can be further magnified in the 

event of a disaster.

The body of literature on this topic shows that 

disasters disproportionately affect those with low SES. 

Disasters do not selectively target groups of people or 

communities. Yet those with lower SES face greater 

vulnerability and often slower recovery from a disaster 

due to preexisting factors. Socioeconomic inequality 

among communities reveals underlying risks and 

the potential for hardship from disaster. Those same 

qualities that identify people as low SES are the same 

risk factors making them more vulnerable.

The authors in this edition of The Dialogue discuss, 

based on their experiences, how the Crisis Counseling 

Assistance and Training Program (CCP) can best reach 

low SES communities, lessons learned, and barriers and 

challenges they have encountered. The three articles 

highlight programs that had to meet the needs of 

different special populations—all with low SES factors.

The first article, “A Networked Approach: How 

Missouri Addresses Residents’ Behavioral Health Needs 

After Disasters,” is an interview with Joan Keenan 

discussing her experience implementing the CCP in low 

SES populations. Next, Marcie Vaughn explains how 

the CCP program responded to the needs of survivors 

in small towns during an ongoing economic crisis in the 

article “West Virginia CCP Helps Rural Communities 

After Thousand-Year Flood.” Against a very different 

backdrop, Adrienne Fessler Belli articulates variations of 

socioeconomic distress during recovery in a more urban 

setting with the article “Low Socioeconomic Status 

(SES) Communities in Times of Disaster: Understanding 

the Challenges.”

A theme throughout the articles is the need to restore 

services and resources to those in communities with low 

SES as soon as possible to help prevent and mitigate 

negative mental health impacts. SES is only one of 

many important factors determining healthy recovery 

from a disaster. However, identifying those with low 

SES and supporting their needs may avoid or minimize 

the effects of disaster on a community. Addressing 

the inequalities in low SES populations creates more 

resilient communities by reducing underlying risks.

We hope you find the articles in this edition helpful, 

and we encourage your feedback. Please let us know if 

you have any thoughts or suggestions on how programs 

can tackle the issues surrounding low SES and disaster 

preparedness, response, and recovery. Look for an 

upcoming issue of our Supplemental Research Bulletin 

summarizing current research on the relationship 

between low SES and disaster recovery.

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

Brenda Mannix SAMHSA 

Disaster Technical 

Assistance Center Project Director dtac@

samhsa.hhs.gov
2017 | VOLUME 13 | ISSUE 2 | PAGE 2

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Contributors

Joan Keenan, M.B.A., PHR, 

SHRM-CP was appointed 

Coordinator for the Missouri 

Department of Mental Health 

(DMH) Office of Disaster 

Services in August 2015, after serving as Assistant 

Coordinator since October 2010. Her first 15 years 

working in state government were in DMH’s Office 

of Human Resources. She has worked closely with 

the DMH responses to the 2011 Joplin tornado and 

the 2016 DR-4250 winter flooding in the St. Louis 

region, working with the implementation of the 

Crisis Counseling Assistance and Training Program 

grant to assist the survivors of those disaster events. 

She has developed a social media site to promote 

disaster behavioral health information and for general 

communication during a crisis event. Ms. Keenan 

assists with many other DMH preparedness obligations 

under the state’s contracts for the Assistant Secretary 

for Preparedness and Response grant and the Centers 

for Disease Control and Prevention’s Public Health 

Emergency Preparedness grant. Ms. Keenan has 

extensive training experience with Psychological First 

Aid, Skills for Psychological Recovery, and Mental 

Health First Aid. She holds an undergraduate degree 

from Tulane University in New Orleans, Louisiana, and 

completed her M.B.A. at William Woods University in 

Jefferson City, Missouri.

Marcie Vaughan, M.A. is a 

licensed psychologist and CEO 

of Seneca Health Services. She 

is serving as a member of PRO 

WV (West Virginia Bureau for 

Behavioral Health & Health Facilities).

Adrienne Fessler Belli, Ph.D., 

LCSW is a psychologist 

and licensed clinical social 

worker and is the Director of 

the Disaster and Terrorism 

Branch within the New Jersey 

Department of Human Services’ Division of Mental 

Health and Addiction Services. She served as a New 

Jersey Disaster Field Operations Specialist for the 

Federal Emergency Management Agency-funded 

mental health response to the 9/11 World Trade Center 

attack. As Director, she is in charge of overseeing and 

coordinating disaster behavioral health preparedness, 

response, and recovery efforts statewide. She has 

managed responses to several disasters, including 

Tropical Storm Irene and Superstorm Sandy, and she 

oversees a program that trains and certifies disaster 

response crisis counselors. Her background includes 

35 years of providing health and trauma-related mental 

health services. She received her master’s of social work 

from Rutgers University and Ph.D. in psychology from 

Walden University.
2017 | VOLUME 13 | ISSUE 2 | PAGE 3

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Recent Technical Assistance Requests

In this section, read about recent questions SAMHSA Disaster Technical Assistance Center (DTAC) staff have 

answered and technical assistance requests to which they have responded. Send your questions and comments to 

dtac@samhsa.hhs.gov.

Request: Crisis counselors working in a state with an 

up and running Crisis Counseling Assistance and Training 

Program (CCP) were facing issues that go beyond the 

scope of the CCP with the potential to impact staff morale.

Response: SAMHSA DTAC sent the state and the 

providers resources on self-care and tips for working with 

survivors. The following is a list of the resources sent to 

the state by SAMHSA DTAC.

Self-care and stress management resources

• A Guide to Managing Stress in Crisis Response 

Professions—This SAMHSA pocket guide provides 

first responders with information on signs and 

symptoms of stress and offers simple, practical 

techniques for minimizing stress responses prior to and 

during disaster response. http://store.samhsa.gov/shin/

content/SMA05-4113/SMA05-4113.pdf

• Tips for Disaster Responders: Preventing and 

Managing Stress—This SAMHSA tip sheet helps 

disaster response workers prevent and manage stress. It 

includes strategies to help responders prepare for their 

assignment, use stress-reducing precautions during the 

assignment, and manage stress in the recovery phase 

of the assignment. http://store.samhsa.gov/shin/

content/SMA14-4873/SMA14-4873.pdf. This tip 

sheet is available in Spanish at http://store.samhsa.

gov/shin/content/SMA14-4873SPANISH/SMA14-

4873SPANISH.pdf.

• Tips for Disaster Responders: Understanding 

Compassion Fatigue—Explains the causes and signs of 

compassion fatigue, the burnout and secondary trauma 

a disaster response worker can experience. Offers 

self-care tips for coping with compassion fatigue and 

discusses compassion satisfaction as a protective tool. 

http://store.samhsa.gov/product/UnderstandingCompassion-Fatigue/SMA14-4869

• Responder Stress and Self-care During a Disaster or 

Emergency—This fact sheet by Alberta Health Services 

presents possible sources of stress, signs of stress, and 

tips for self-care. http://www.albertahealthservices.ca/

assets/healthinfo/mh/hi-amh-prov-mhpip-disasterresponders-stress-and-self-care.pdf

Tools and tips for working with survivors

• Psychological First Aid: How You Can Support WellBeing in Disaster Victims—This fact sheet by the 

Center for the Study of Traumatic Stress explains how 

disaster response workers can use Psychological First 

Aid to help people in distress after a disaster. https://

www.cstsonline.org/assets/media/documents/CSTS_

psychological_first_aid.pdf

Request: A flood survivor in a state with a CCP grant 

contacted SAMHSA DTAC for assistance. The survivor 

had been given SAMHSA DTAC materials at a recent 

community event.

Response: SAMHSA DTAC forwarded the survivor’s 

contact information to the appropriate provider who 

reached out to the survivor.■

ONLINE TRAINING

Creating Safe Scenes is a free online training course 

that helps first responders—police, fire, and emergency 

medical services—work with individuals experiencing a 

mental health and/or substance use crisis.

For more information, visit https://www.samhsa.gov/

dtac/creating-safe-scenes-training.
2017 | VOLUME 13 | ISSUE 2 | PAGE 4

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

DATA SNAPSHOT

Top Risk Factors 

Experienced by 

Survivors Served 

by the CCP

For all grants in the SAMHSA DTAC 

Online Data Collection and Evaluation 

System 2.0 from 1/1/2016 through 

12/31/2016.

(Responses: 17,521)

The Dialogue Reader Responses

In this section, read selected responses from readers about their thoughts on previous issues of The Dialogue. Find 

past issues at https://www.samhsa.gov/dtac/resources/dialogue. If you have a comment about an article, send it to 

dtac@samhsa.hhs.gov.

In response to a previous issue, “The Role of 

Disaster Memorials,” Shelly Bradbury shared 

with SAMHSA DTAC a project that she just 

completed.

Ms. Bradbury, a sculptor from Massachusetts, unveiled 

Dedication Plaza on September 11, 2016, at Endicott 

College in Beverly, Massachusetts. The memorial was 

created to honor the five branches of the military and first 

responders. Her inspiration for the memorial came from 

learning about the experiences of the college’s Reserve 

Officers’ Training Corps students; men and women 

serving in the military; and local firefighters, police 

officers, and emergency medical technicians.

If you are interested in the full issue of The Dialogue 

about disaster memorials, visit http://www.samhsa.gov/

sites/default/files/dtac/dialogue-vol-12-issue-2.pdf.
2017 | VOLUME 13 | ISSUE 2 | PAGE 5

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

INTERVIEW

A Networked Approach: 

How Missouri Addresses Residents’ 

Behavioral Health Needs After Disasters

Joan Keenan, M.B.A., PHR, SHRM-CP, Coordinator, Office of Disaster Services, Missouri Department of 

Mental Health, talks about her experience with disasters in Missouri, as well as her state’s practices to 

reach people of low socioeconomic status (SES) and other special populations.

Missourians are no strangers to 

disaster. To reach individuals across 

the state after disasters, Missouri 

has some distinctive practices that 

may work well in other states, 

territories, and tribes. The Dialogue 

recently interviewed Joan Keenan 

of Missouri’s Department of Mental 

Health (DMH) to learn more about 

how the state approaches behavioral 

health response to disasters in ways 

designed to reach all its residents.

Please describe Missouri’s 

current Crisis Counseling 

Assistance and Training 

Program

We had flooding between Christmas 

and New Year’s in 2015 that affected 

more than 30 counties across the 

state. Missouri is known for its 

many rivers and creeks; we are 

used to springtime flooding, but not 

Christmas flooding.

Although I was traveling out of 

state during the holidays when the 

flooding began, I soon realized this 

disaster would probably qualify 

for a federal declaration. I started 

reaching out to our DMH service 

providers in the areas affected by the 

flooding. Most indicated confidence 

in their ability to support the behavioral health needs of their communities with existing resources. In the 

St. Louis region, three providers 

agreed that they would welcome the 

additional funding assistance a CCP 

grant would provide. Those agencies—Crider, COMTREA, and Places for People—agreed to administer 

CCP grant operations for the “Show 

Me Hope” program covering the five 

counties of St. Charles, St. Louis, 

Jefferson, Franklin, and Lincoln. 

Fortunately, two of the three provider agencies had previous experience 

administering a CCP grant.

SOURCES: Missouri Association for Community Action, 2016 State of the State: Poverty in Missouri, http://www.communityaction.org/poverty-reports; 

Proctor, Semega, & Kollar, 2016, https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-256.pdf

Does your office engage 

in specific efforts to reach 

people of low SES?

Almost everyone we meet in 

CCP outreach experiences some 

degree of poverty. We keep an 

eye on where people show up for 

other services. Negative attitudes 

and misperceptions about mental 

health often keep people from 

seeking behavioral health support. 

However, they will seek assistance 

to get clothes for their kids or go 

to a food pantry to make sure they 

can feed their families. After the 

2011 Joplin tornado and the 2015 

winter flooding, CCP teams engaged 
2017 | VOLUME 13 | ISSUE 2 | PAGE 6

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

with other services, such as Meals 

on Wheels. Outreach workers rode 

on public transportation looking 

for opportunities to engage with 

community members. When there are 

community events, “Show Me Hope” 

providers make sure that CCP teams 

are a visible presence, providing 

resource materials and information 

about available services in the 

communities. “Show Me Hope” 

workers offer outreach wherever 

residents of the community naturally 

congregate, such as at school events 

and in public libraries.

In Missouri, many faith-based 

organizations and nongovernmental 

organizations (NGOs) regularly 

respond to disasters. Following 

the “Great Flood of 1993,” thenGovernor Carnahan issued an 

executive order to establish the 

Governor’s Faith-Based and 

Community Service Partnership 

for Disaster Recovery (also 

known as The Partnership), which 

continues to operate today. Members 

of The Partnership include disaster 

response partners from state agencies 

and many NGOs like the Red Cross 

and Salvation Army, and faith-based 

organizations like Catholic Charities, 

the Southern Baptists, and the United 

Methodist Conference. We meet 

face to face on a quarterly basis and 

by conference call as needed. We 

know each other by name, and we 

know what resources we each bring 

to disaster response, recovery, and 

unmet needs or issues.

Internally, the DMH Central Office 

has a team of representatives from 

different offices and divisions. 

The DMH READI Team helps 

share preparedness and response 

information with service providers 

and facilities around the state. This 

team provides staff support during 

activation of our state emergency 

operations center. The department 

supports the state’s mass care and 

public health/medical operations 

during emergency events.

Most of what we rely on is the 

nurturing of these networks and 

making sure there is two-way communication. Relationships are key to 

disaster response. If you have strong 

relationships, you have connectivity 

to the community where and when 

the events happen. We use those 

connections to reach other agencies 

that can support behavioral health at 

a community fair or holiday event 

and be a visible presence in the 

community. Collectively, we have 

quite an impact combating negative 

attitudes and misperceptions about 

mental health services. The fact is 

everyone needs a little help now and 

then.

Another successful Missouri concept 

is the Multi-Agency Resource 

Center, or MARC. This began 

in response to the Joplin tornado. 

After a disaster event, the Red 

Cross or Missouri State Emergency 

Management Agency may ask a 

community if they would like to host 

a MARC. Similar to a health fair, a 

MARC is set up in a large venue such 

as a school gymnasium or a church. 

Various agencies set up booths or 

tables to present their resources and 

information about available services. 

This allows people in disasteraffected communities a “one-stopshop” experience in a central location 

where they can easily learn about and 

select services and supports available 

from state agencies, volunteer 

organizations, and the NGOs. Part 

of the beauty of the MARC is that 

people are free to select from the 

Missouri 

ranks 18th 

in the nation for declared disasters, 

and fourth for disaster-related 

property losses in recent years.

SOURCES: U.S. Department of Homeland 

Security, Federal Emergency Management 

Agency, https://www.fema.gov/disasters/grid/

state-tribal-government; Kiplinger’s Personal 

Finance, 2015, http://www.kiplinger.com/

slideshow/insurance/T028-S001-10-statesmost-at-risk-of-disaster/index.html

It’s among the top 10 

states in the country 

in numbers of natural disasters.

SOURCE: Whiteman, 2013, http://www.

nbcnews.com/business/10-states-mostnatural-disasters-6C10088195
2017 | VOLUME 13 | ISSUE 2 | PAGE 7

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

array of available services and 

resource materials, and they decide 

what their families need. It gives 

ownership back to disaster survivors 

to begin to address their own 

problems and consider options they 

may not have thought about before. 

The MARC allows volunteer and 

faith-based agencies to help people 

in a way that is organized, uniform, 

and supportive of the community.

What barriers or challenges 

have you encountered in 

trying to provide services 

to people of low SES and 

other special and hard-toreach populations? How 

has your team worked to 

overcome these barriers 

and challenges?

Communication and transportation 

are often challenges following disasters. In the behavioral health world, 

there are negative and inaccurate 

ideas rooted in prejudice toward 

people with mental and/or substance 

use disorders. As people contend 

with this, it can create hurdles for 

crisis counseling work.

We run into a lot of barriers with 

older adults. As a group, they’re less 

likely to reach out for help. They 

figure they’ve made it this far in life; 

they can handle whatever comes 

their way. There may be reluctance 

to admit they’re vulnerable and need 

help. Some may worry that their 

kids will see it as an opportunity to 

put them in a nursing home, or they 

wonder what a crisis counselor or 

outreach worker can offer. It takes 

time to develop trust and rapport, 

which means multiple visits and lots 

of patience.

Similar to other states, Missouri’s 

population has a wide range of 

cultural and ethnic backgrounds. 

To reach these various groups 

of residents, we coordinate with 

local organizations that are already 

working within the groups’ 

communities, schools, and places of 

faith. We find meeting places, where 

people show up for building supplies 

or groceries, and other types of 

services in a community. We often 

call SAMHSA DTAC for resource 

materials in appropriate languages.

Thanks to our partners, we have 

local experience and awareness 

to help guide us as we reach 

out to individuals and families 

experiencing homelessness and 

those with special needs. To reach 

children, we work with schools, day 

care centers, after-school programs, 

and libraries.

What, if anything, is key 

to Missouri’s success 

in providing disaster 

behavioral health services?

After the tornado, Joplin was 

swamped by people who came to 

help in any way they could. It was 

like watching young children first 

learning to play soccer—everyone 

is just chasing the ball! By the time 

kids get to middle school, they learn 

how to play their zone and work 

together as a team. It’s similar with 

disaster response. We all want to 

get the ball down the field, but not 

every player gets to make the goal. 

Everyone must learn to play together 

within their respective zones, 

understanding when and to whom 

to pass. It takes dedicated effort to 

build and maintain those important 

working relationships. In Missouri, 

we are proud of the relationships 

that have been built and are so 

critical for a successful, coordinated 

response that respectfully blends in 

with the unique character of each 

community.■

Missouri ranks 

seventh nationally 

for food insecurity,

or percentage of households 

where people have lower quality 

and less varied diets than are 

needed for good health, and in 

some cases not enough to eat.

SOURCE: U.S. Department of Agriculture, Economic Research Service. (2016). Definitions of food security. 

https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-foodsecurity
2017 | VOLUME 13 | ISSUE 2 | PAGE 8

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

West Virginia CCP Helps Rural Communities 

After Thousand-Year Flood

By Marcie Vaughan, M.A., Licensed Psychologist and CEO, Seneca Health Services, and People Reaching Out 

in West Virginia (PRO WV) Crisis Counseling Assistance and Training Program Team, West Virginia Bureau for 

Behavioral Health & Health Facilities

The Disaster

On June 23 and 24, 2016, West Virginia experienced a “thousand-year 

flood”—so called because the chances of its happening in a year are 

extremely low—only 1 in 1,000 (Breslin, 2016). The flooding stranded 

state residents, destroyed over 100 homes, damaged infrastructure, 

and claimed at least 23 lives (Pérez-Peña, 2016).

West Virginia has 

a median household 

income of $41,751, 

more than $10,000 less than the 

national median income.

SOURCE: United States Census Bureau, 2015, Quick facts for the state of West Virginia and the United 

States, 2010-2015. Retrieved from https://www.census.gov/quickfacts/table/PST045216/00,54

In the midst of an economic crisis, 

disaster struck, and its effects 

lingered. June 2016 brought what is 

being referred to as the “ThousandYear Flood” to West Virginia.

Backdrop of Economic Crisis

Small towns across West Virginia 

have suffered as the coal industry 

has slowed. Communities have 

become impoverished, with residents 

experiencing one of the highest 

unemployment rates of all time. 

Not only have individuals faced 

difficult times, but municipalities 

and county governments have also 

been dealing with financial woes 

as tax revenues have plummeted. 

The lack of tax revenue has forced 

governmental entities to cut services 

and personnel.

Disaster Impacts on 

Communities

The natural disaster—ThousandYear Flood—that hit small towns 

in West Virginia during June 2016 

left behind a path of destruction 

and a mound of debt for small 

towns that were already struggling 

to meet the needs of their citizens. 

Municipalities lost street sweepers, 

lawnmowers, snow removal trucks, 

and other equipment vital to 

maintenance. Water supply systems 
2017 | VOLUME 13 | ISSUE 2 | PAGE 9

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

supported by loans were damaged 

during the flooding and its aftermath, 

requiring repair to restore a clean 

water supply. Coupled with massive 

shutoffs due to vacant housing, this 

situation means that loan repayment 

will be difficult. The small towns 

were not financially able to support 

recovery for their citizens.

Financial Impacts on 

Individuals

The flood damaged or destroyed 

over 80 percent of homes in small 

communities. The rural areas do 

not have an abundance of public 

housing, so families were displaced 

to areas outside of their community 

or to homes where they live with 

multiple families under one roof. 

Citizens have reported that recovery 

monies they have received are 

not enough to cover replacement 

of items they need to remain in 

the homes they lived in before 

the flooding. For example, many 

individuals heated their homes by 

burning wood due to the low cost 

in comparison to electric heating or 

heating oil. In the flooding, these 

individuals lost chainsaws, wood 

splitters, and/or four-wheelers used 

to harvest wood, and the recovery 

money they received didn’t cover 

replacement of those items.

Public transportation is nonexistent. 

Individuals who lost their vehicles in 

the flood found themselves without 

means to travel to grocery stores or 

medical appointments. In some rural 

areas of West Virginia, the sole grocery stores closed as a result of flood 

damage, forcing residents on a fixed 

Local grocery store cleanup continues after flash flooding strikes West Virginia on May 2, 2002. Photo by 

Bob McMillan/Federal Emergency Management Agency News Photo.

SOURCE: 2015 Overall County Food 

Insecurity in West Virginia, Feeding America. 

Retrieved from http://map.feedingamerica.

org/county/2015/overall/west-virginia
2017 | VOLUME 13 | ISSUE 2 | PAGE 10

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

income to travel over 20 miles for 

essentials such as milk and bread. 

The community members who had 

remained employed during the financial crises were faced with rebuilding their homes and businesses—

significantly limiting assistance they 

could offer to the community. Older 

adults on fixed incomes refused the 

offer of low-interest loans, stating 

that they did not want to pass debt 

on to their children.

Support From Volunteers

The devastation of the recent 

flooding has been great—the 

positive response of volunteers, 

greater. As communities have 

worked to recover, small-town 

citizens have found people with 

no previous ties to their small 

community willing to get in and 

get dirty. These volunteers have 

taken on jobs no one wanted to do 

. . . pulling up wet, muddy carpet; 

shoveling debris out of homes; and 

lifting waterlogged furniture out of 

homes and onto streets. They have 

distributed cleaning supplies and 

food, and they have left sweat, tears, 

and most of all hope.

People Reaching Out in West 

Virginia (PRO WV) CCP

In addition to being present in 

Disaster Response Centers during 

the initial response, PRO WV 

CCP teams took to the streets to 

share information about common 

responses to disaster, ways to cope 

with additional stress, and when 

and where to find help, as well as 

providing information on local 

supply distribution sites. While 

teams did make door-to-door visits, 

they were often limited in their 

success through this approach, due 

to the relocation of survivors outside 

of the community. Instead, PRO WV 

teams made contact with survivors 

at furniture and building supply 

distribution sites, hardware stores, 

flea markets, community fairs, 

and local sporting events such as 

Little League and middle and high 

school football games. Individuals 

displaced due to lack of housing 

often returned to the community for 

these types of events.

Many flood victims have expressed 

appreciation for PRO WV team 

members’ interest in their wellbeing and for the information they 

provided about whom to contact 

for hazard mitigation, furniture, or 

other needs. One flood survivor, 

in particular, was very glad to see 

them at his door. It was the first 

of September, 2 months after the 

flood, when PRO WV made their 

way to his home to find he had not 

been in contact with anyone. The 

team provided information about 

a veterans’ and community action 

program and a contact number 

for the long-term recovery case 

management team. As a result, a 

new heating system was installed 

in his home before winter weather 

moved in. The PRO WV teams 

have been able to encourage many 

individuals in their journey back to 

their homes.

The PRO WV teams and survivors 

have encountered numerous 

obstacles on the road to recovery; 

however, they continue to work 

toward returning to a more stable 

way of life.■

Breslin, S. (2016, August 3). America’s ‘one-in1,000-year’ flood events in 2016. Weather.com. 

Retrieved from https://weather.com/safety/floods/

news/1-in-1000-year-flood-events

Pérez-Peña, R. (2016, June 24). West Virginia 

floods cause 23 deaths and vast wreckage. The 

New York Times. Retrieved from http://www.

nytimes.com/2016/06/25/us/west-virginia-floods.

html?_r=1

In the United States, 19.3% of the 

population live in rural areas.

In West Virginia 51.28% of the 

population lives in rural 

areas (second highest state 

percentage in the United States).

SOURCE: United State Census Bureau, 2010. Retrieved from 

https://www.census.gov/geo/reference/ua/urban-rural-2010.html
2017 | VOLUME 13 | ISSUE 2 | PAGE 11

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Low Socioeconomic Status Communities 

in Times of Disaster: Understanding the 

Challenges

By Adrienne Fessler Belli, Ph.D., LCSW, Director of the Disaster and Terrorism Branch, Division of Mental 

Health and Addiction Services, New Jersey Department of Human Services

In 2011, Hurricane Irene caused 

nearly $1 billion in damage to 

200,000 homes and buildings in 

New Jersey, and just 1 year later, 

the state was slammed again, this 

time by Superstorm Sandy, which 

resulted in economic losses to 

businesses of up to $30 billion. Over 

2 million households in the state lost 

power in the storm, 346,000 homes 

were damaged or destroyed, and 37 

people were killed. In responding 

to affected residents, it became 

clear that crisis counselors needed 

to understand and anticipate three 

variations of socioeconomic distress 

in the early stages of recovery.

First, there were many individuals 

seeking refuge in disaster 

shelters who lived with chronic 

socioeconomic hardship and had 

prior or current connections to 

public assistance programs for 

housing, food, and other services. 

Their distress frequently arose more 

from disruption of their services and 

support than from the shock of the 

storm. It was critical for counselors 

to be knowledgeable about local 

social service networks and to 

rapidly form relationships with 

representatives from those agencies 

who were present in the shelters 

or working in the community. 

The principal task was often 

reconnecting such individuals with 

systems of care and support to which 

they were already known, but whose 

connections had been severed by 

displacement. Many shelter residents 

were not from the immediate area, 

so it was challenging to reestablish 

these connections, particularly at a 

time when communications were 

compromised and systems were 

overwhelmed.

A second type of socioeconomic 

distress commonly encountered by 

counselors was in those individuals 

and families who had greater predisaster stability and security, but 

no buffer for devastating or disruptive events. In most instances, these 

individuals and families had consistent job, housing, and food security, 

but no reserves to protect against 

the effects of adverse life events. 

The combination of increased costs 

(such as hotel stays, damage to 

homes and vehicles) and decreased 

income due to lost time and wages, 

or outright economic displacement, 

often resulted in a second “perfect 

storm” of hardship for this type 

of survivor. Individuals and famiDue to the impact of Hurricane Sandy, hungry kids get help with hot food and supplies in 

Queens, New York. Photo by FashionStock.com / Shutterstock.com.

One in three American 

families reports having no 

savings to protect themselves 

from the unexpected.

SOURCE: The Pew Charitable Trusts. (2015, November 18). What resources 

do families have for financial emergencies? The role of emergency savings in 

family financial security. Retrived from http://www.pewtrusts.org/en/researchand-analysis/issue-briefs/2015/11/emergency-savings-what-resources-dofamilies-have-for-financial-emergencies.
2017 | VOLUME 13 | ISSUE 2 | PAGE 12

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

lies in this situation were typically 

unfamiliar with and not previously 

connected to local human service or 

social service supports. Even though 

they went into the disaster in a better position than those with chronic 

socioeconomic distress, they often 

found themselves in worse shape 

financially and emotionally. Anxiety, 

sadness, and often self-blame were 

dominant themes in crisis counseling 

for this group.

The residents’ geographic 

environment was the third factor 

impacting individuals with low 

SES after the disaster. Urban 

environments involved additional 

challenges. For example, areas 

characterized by lower SES levels 

often lacked shopping options for 

groceries and other basic needs. In 

those neighborhoods badly affected 

by the storms, the few local grocery 

stores were often damaged and 

closed. Public transportation was 

damaged and limited by the storms, 

especially during Superstorm Sandy, 

with floodwaters that damaged or 

destroyed 273 NJ TRANSIT railcars 

and 70 engines. Residents reliant 

on mass transit often could not use 

public transportation options to go 

beyond their immediate areas to 

access alternative shopping places.

Response to Superstorm Sandy

In New Jersey, the Division of 

Mental Health and Addiction 

Services, part of the New Jersey 

Department of Human Services, 

houses a highly specialized mental 

health Disaster and Terrorism 

Branch (DTB). The branch is 

responsible for administering as well 

as directly providing emergency 

response behavioral health programs 

to assist the citizens of New Jersey. 

Services available through the 

DTB include crisis counseling, 

Psychological First Aid, psychoeducational information focusing 

on disaster stress management, 

consultation, training, and 

information and referral services.

DTB has a seat at the State 

Emergency Operations Center 

to keep a finger on the pulse of 

changing needs throughout the 

state. Crisis counselors were 

activated immediately and were 

deployed statewide to provide crisis 

counseling, emotional support, and 

services for shelter occupants, as 

well as information and referral to 

other services. Many individuals in 

shelters were at risk and already had 

an array of service needs that could 

become more complicated due to the 

effects of the disaster. Counselors 

provided information regarding local 

resources and emotional support.

As the response progressed, 

counselors provided outreach in 

low-income housing and transitional 

shelters to disseminate information 

regarding the availability of 

services and Office of Emergency 

Management contact information, 

all the while providing emotional 

support and establishing rapport 

and trust. The Crisis Counseling 

Assistance and Training Program 

was named New Jersey Hope and 

Healing, and because of its efforts 

at the shelters, as well as numerous 

partnerships and outreach activities, 

communities became familiar with 

the program as it moved through the 

different phases of response.

DTB hired a staff member who 

was specifically assigned to 

develop strategies for working with 

disadvantaged communities—to 

assess their unique needs and 

provide support, referrals, and 

resources. One of the providers 

who participated in the response to 

Superstorm Sandy had also been 

a provider during the response to 

Hurricane Irene. This provider 

had a long and successful history 

of serving several urban, diverse 

communities and was experienced 

and available to conduct outreach 

to these populations in response to 

Superstorm Sandy. They were also 

affiliated with the largest provider 

of low-income housing in the 

area and known in the community 

from their work providing services 

to individuals with mental and 

substance use problems and other 

outlying populations.

Only 37% of Americans had 

enough savings to pay for a 

$500 to $1,000 emergency.

SOURCE: Bankrate Money Pulse Survey. 

December 17-20, 2015.
2017 | VOLUME 13 | ISSUE 2 | PAGE 13

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

The other strategy we used in 

response to the storm was to work 

with faith-based entities to develop 

partnerships. This was vital to 

reaching individuals who felt 

disenfranchised and were less likely 

to respond to people they perceived 

to be in authority or outside of their 

community area.

The training given to providers and 

disaster response crisis counselors 

before the disaster familiarized them 

with the SAMHSA and Federal 

Emergency Management Agency 

(FEMA) crisis counseling model. 

Many of these providers and crisis 

counselors responded to Superstorm 

Sandy and then later participated in 

the NJ Hope and Healing CCP. As a 

result, they understood not only the 

SAMHSA/FEMA model, but also 

the importance of disenfranchised 

populations and the unique issues 

they face, which their training 

also emphasized. A major factor 

in ensuring successful provision 

of services to low SES individuals 

was to establish a strong presence 

in the affected communities where 

people lived and worked. With over 

200 crisis counselors, teams were 

embedded within communities to 

locate pockets of survivors. This 

effort facilitated the development of 

support groups that eventually were 

partnered with long-term recovery 

groups and other community 

partners and institutions such as 

schools, restaurants, neighborhood 

stores, senior centers, food banks, 

supermarkets, banks, and hardware 

stores. Counselors reached out to 

faith-based organizations, retail 

establishments, rental centers, 

and social service agencies and 

at community events. Crisis 

counselors were recruited who 

came from and had ties to local 

municipalities. During the NJ 

Hope and Healing program, 

counselors became immersed in 

the communities they served and 

provided services that included 

door-to-door outreach, resource 

tables at different community 

locations such as shopping centers 

and churches, individual and group 

crisis counseling, educational 

presentations, and information and 

referral services. In addition, the 

referral process for NJ Hope and 

Healing was supported by a toll-free 

mental health helpline that provided 

warm transfers and direct linkages to 

services across the state.

In low SES communities more 

than in the general population, 

people may mistrust officials, and 

this mistrust can decrease their 

likelihood to seek services during 

a disaster. Instead, they may rely 

on known, trusted services such 

as health care providers including 

hospitals, emergency rooms, local 

health care settings, physicians’ 

offices, and primary care facilities. 

DTB has a longstanding relationship 

with the New Jersey Department 

of Health (DOH). Through the 

preparedness phase, DTB worked 

very closely with the New Jersey 

DOH and other county and local 

health entities, forming strong 

partnerships. During Superstorm 

Sandy, NJ Hope and Healing 

capitalized on those partnerships, 

and the counselors benefitted 

from these relationships to access 

the affected communities. We 

understood that it is difficult for 

individuals to focus on taking time 

to address behavioral health needs 

when their basic needs are a struggle 

to meet. To address that problem, 

counselors provided outreach in 

settings where survivors would be 

present daily such as at medical 

appointments, food markets, 

shopping centers, and day care 

centers.

Lessons Learned From 

Superstorm Sandy

Urban settings pose unique 

challenges, and even within those 

settings each city has its own 

distinctive strengths and problems. 

It is important to remember that 

the CCP is not a one-size-fits-all 

program. It requires a study of the 

different community characteristics 

and challenges, which leads to the 

development of a plan that will help 

each unique community recover and 

enhance its resiliency.

Preparedness activities go a long 

way with helping to promote a more 

comprehensive disaster response 

that fits the needs of diverse communities. Developing partnerships 

before the chaos of a disaster builds 

credibility and increases access 

to groups who may resist the assistance they need after a disaster. 

Each disaster brings new challenges 

and more lessons learned, and the 

planning process must be fluid and 

change with the distinctive needs of 

the communities to be served.■
2017 | VOLUME 13 | ISSUE 2 | PAGE 14

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

RECOMMENDED RESOURCES

Preparedness Tip Sheet: 

Assembling a Cost-Friendly 

Emergency Supply Kit

FEMA developed this tip sheet to help people on tight 

budgets to put together supply kits for disasters and 

other emergencies. The tip sheet features ideas for 

stocking up on items without breaking the bank, as well 

as links to related resources.

View and download the tip sheet at http://www.dhhr.

wv.gov/healthprep/plan/howtoprepare/familyprep/

Documents/FEMA%20-%20Preparedness%20

Tip%20Sheet.pdf.

Economic Stress

The National Child Traumatic Stress Network (NCTSN) 

provides information about economic changes 

and stressors and their effects on parents and other 

caregivers, communities, and children. Also provided 

are links to related resources, including guidance on 

building resilience and a series of fact sheets about 

coping with difficult economic times.

Access this part of NCTSN’s website at http://www.

nctsn.org/resources/topics/economic-stress.

When Disaster Strikes: Promising 

Practices—Low-Income Families and 

Communities

In this 7-page booklet, MDC, an organization based 

in North Carolina, explains factors and conditions that 

place low-income people and communities at particular 

risk in disasters. It then recommends strategies and 

steps that officials, organizations, and individuals can 

take to build capacity in low-income communities. Also 

included are case studies in which organizations helped 

to increase preparedness in low-income communities 

and ensure that recovery and rebuilding efforts included 

people with low incomes.

Learn more and access and download the booklet at 

http://www.mdcinc.org/resources/publications/whendisaster-strikes-promising-practices-low-incomefamilies-and-communities.■

https://www.samhsa.gov
Behavioral Health is Essential To Health

Prevention Works • Treatment is Effective • People Recover

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The SAMHSA Disaster Behavioral Health Information Series contains resource 

collections and toolkits pertinent to disaster behavioral health. Installments focus 

on specific populations, specific types of disasters, and other topics related to allhazards disaster behavioral health preparedness and response. Visit the SAMHSA 

DTAC website at https://www.samhsa.gov/dtac/dbhis-collections to access these 

CONTACT US materials.

SAMHSA Disaster Technical 

Assistance Center

Toll-Free: 1-800-308-3515 

dtac@samhsa.hhs.gov

https://www.samhsa.gov/dtac