SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin 

Stronger Together: An In-Depth Look at 

Selected Community-Level Approaches 

to Disaster Behavioral Health

August 2016
CONTENTS

INTRODUCTION..........................................................................................................................................1

APPROACHES TO BUILDING COMMUNITY RESILIENCE......................................................................2

Los Angeles County Community Disaster Resilience Project........................................................2

Project To Test an Approach for Building Community Resilience .................................................4

 Findings..........................................................................................................................................5

POST-DISASTER APPROACHES TO SUPPORTING 

COMMUNITY BEHAVIORAL HEALTH........................................................................................................6

Crisis Counseling Assistance and Training Program......................................................................6

 Legal Authorities and Program Structure ...................................................................................6

 Program Scope and Services ......................................................................................................7

 Data Collection and Evaluation ....................................................................................................7

 An Evaluation of the CCP: Program Reach.................................................................................7

 Another CCP Evaluation: Relationship of Aspects of Services to Outcomes .........................8

PsySTART...........................................................................................................................................10

 PsySTART in Practice: Its Use by the American Red Cross 

After Hurricane Sandy.................................................................................................................11

CONCLUSION ...........................................................................................................................................12

REFERENCES...........................................................................................................................................13

SAMHSA is not responsible for the information provided by any of the web pages, materials, or 

organizations referenced in this communication. Although the Supplemental Research Bulletin

includes valuable information and links, 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.
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INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on selected programs and approaches that can 

be used to help whole communities fare better during and after disasters in terms of behavioral health 

(mental health and substance use issues). The issue covers resilience-based approaches begun prior to 

a disaster; the Crisis Counseling Assistance and Training Program (CCP); and Psychological Simple 

Triage and Rapid Treatment (PsySTART).

Of course, this is by no means a comprehensive list of programs, approaches, and interventions that can 

be used around disasters to support behavioral health. Our goal in this issue is to look in depth at a 

subset of the rich range of approaches available, and to concentrate specifically on approaches for whole 

communities. For a list of disaster behavioral health interventions available, please refer to the issue of 

the Supplemental Research Bulletin published in May 2015: http://www.samhsa.gov/sites/default/files/

dtac/supplemental-research-bulletin-may-2015-disaster-behavioral-health-interventions.pdf. 

We chose the focus of this issue for several reasons. First, among entities within the U.S. Department of 

Health and Human Services (HHS), SAMHSA is charged with leading public health efforts to advance the 

behavioral health of the nation. The SAMHSA Disaster Technical Assistance Center (DTAC) handles one 

aspect of this mission: supporting states, territories, tribes, and localities in responding effectively to 

disasters from a behavioral health standpoint. SAMHSA DTAC is charged with work at the local level to 

improve behavioral health outcomes in the event of a disaster. Therefore, it is important that we provide 

disaster behavioral health leaders, planners, coordinators, and others with information about how to 

support communities in preparing for and responding to the behavioral health effects of disasters. 

Also, mental health and substance use issues during and after disasters constitute a major public health 

concern. As noted in an article about a resilience-based approach, “There is overwhelming evidence that 

the majority of injuries or trauma in most disaster settings are psychological, as opposed to physical, with 

ratios ranging from 4:1 to as much as 50:1—ratios consistently reflected in the National Planning 

Scenarios” (Golan, Arad, Atsmon, Shemer, & Nehama, 1992; North et al., 1999; Schlenger et al., 2002; 

U.S. Department of Homeland Security, 2006; as cited in McCabe et al., 2014). Additionally, many people 

who develop new mental disorders after disasters or other traumas do not receive treatment in time to 

reduce distress or prevent disorder, and this happens in part because they are not identified and 

assessed in a timely manner (Wang et al., 2005; Norris, Friedman, & Watson, 2002; as cited in Schreiber, 

Yin, Omaish, & Broderick, 2014). 

Conversely, community-focused approaches may be particularly effective in promoting the behavioral 

health of the public in the event of a disaster. They have certainly attracted policy focus and emphasis 

from the federal government in recent years. The U.S. government advocates a community-focused 

approach to disaster preparedness, response, and recovery. Signed in 2011, Presidential Policy Directive 

8 involves a whole-community focus for preparedness and resiliency (U.S. Department of Homeland 

Security [DHS], Federal Emergency Management Agency [FEMA], 2015). In the FEMA Strategic Plan 

2014–2018, the agency lists as a strategic imperative “a whole community approach to emergency 

management” (DHS, FEMA, 2014). And in the National Health Security Strategy and Implementation Plan 

2015–2018, designed to ensure U.S. health security in the event of public health emergencies including 

natural and human-caused disasters, the HHS Office of the Assistant Secretary for Preparedness and 

Response identifies as its first strategic objective building and sustaining healthy, resilient communities. 
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APPROACHES TO BUILDING COMMUNITY RESILIENCE

In this section, we discuss approaches that focus on fostering and enhancing community resilience, 

defined as the “ability [of a community] to withstand and recover from a disaster” (Chandra et al., 2013). 

The approaches we cover focus on resilience in relation to disasters and other public health emergencies, 

but they do not focus exclusively on behavioral health. We examine them because empirical evidence has 

shown that connectedness to other people, including connection to one’s community, improves behavioral 

health during and after disasters (Hobfoll et al., 2007; Norris & Stevens, 2007). Also, research has shown 

that people may experience more severe behavioral health issues in the event of a disaster if they lose 

access to resources, including the following:

• Object resources such as homes

• Relationships such as marriage

• Personal characteristics such as self-esteem

• Energies such as time and money (Hobfoll & Lilly, 1993; Norris et al., 2002)

Community disaster resilience may help prevent such loss and ensure greater access to resources for all 

community members (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008). 

Los Angeles County Community Disaster Resilience Project

The Los Angeles County Department of Public Health (LACDPH) and several partners initiated the Los 

Angeles County Community Disaster Resilience (LACCDR) Project in 2010, with funding from a Centers 

for Disease Control and Prevention (CDC) Public Health Emergency Preparedness (PHEP) cooperative 

agreement, as well as from the National Institute of Mental Health and the Robert Wood Johnson 

Foundation. CDC’s PHEP cooperative agreement program requires awardees—which include four major 

metropolitan areas, one of which is Los Angeles County in California, as well as all 50 U.S. states and 

several territories—to comply with CDC’s public health preparedness capabilities, which were developed 

to help state and local health departments with strategic planning (HHS, CDC, 2011; Chandra et al., 2013). 

One of the six capabilities is community resilience, which includes both preparedness and recovery. 

The LACCDR Project was begun to address a knowledge gap. Although the CDC PHEP cooperative 

agreement program and many other national and even international directives present disaster 

preparedness, response, and recovery as requiring a whole-community approach, “there are few 

evidence-based methods to building community resilience in the United States” (Schoch-Spana, 

Courtney, Franco, Norwood, & Nuzzo, 2008; as cited in Eisenman et al., 2014). Project leaders have 

sought to increase resilience in communities in Los Angeles County, and to do so in such a way that 

others working to build resilience in their own communities will have more information about what works, 

and what does not work, in fostering and enhancing disaster resilience at the community level. 

The LACCDR Project is based on a conceptual model informed by previous work by several members of 

the project team. This work included a literature review and focus groups with stakeholders from 

government and nongovernmental organizations (NGOs). As shown in Figure 1, the model includes core 

components of community resilience, as well as levers, or actions to take to achieve and develop 

community resilience in terms of the core components. Please refer to Figure 1 for additional detail.
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Due to prioritization of levers based on discussions with stakeholders, the LACCDR Project focuses on 

four of the levers: education, engagement, self-sufficiency, and partnership (Chandra et al., 2013; 

Eisenman et al., 2014). 

In the first 2 years of the project, LACDPH worked with individuals and organizations in multiple sectors to 

identify ways to increase resilience in communities in Los Angeles County in California. These entities 

represented the following sectors and areas: 

• Academia (the University of California, Los Angeles; the RAND Corporation)

• Government (U.S. Geological Survey)

• Nonprofit organizations (the Emergency Network of Los Angeles, a local group of voluntary

organizations active in disaster)

• Business

• The community

For the project itself, a division of LACDPH worked with community leaders to identify 16 communities 

that met several criteria (for example, “shared identity as a ‘community’ with at least two of the following: 

local business community; school/school district; police and fire department services; community clinic/

hospital/health responsible entity; engaged community based organizations”) (Eisenman et al., 2014). 

LEVERS OF 

COMMUNITY RESILIENCE

CORE COMPONENTS OF

COMMUNITY RESILIENCE

Wellness—Promote pre- and postdisaster population health, including 

behavioral health

Access—Ensure access to high-quality 

health, behavioral health, and social 

services 

Social and economic well-being of 

the community

Physical and psychological health of 

the population

Community

context

Education—Ensure ongoing information 

to the public about preparedness, risks, 

and resources before, during, and after 

a disaster 

Engagement—Promote participatory 

decision-making in planning, response, 

and recovery activities 

Self-sufficiency—Enable and support 

individuals and communities in assuming 

responsibility for their preparedness 

Partnership—Develop strong 

partnerships within and between 

government and nongovernmental 

organizations 

Effective risk 

communication

Social 

connectedness

Integration and 

involvement of 

organizations 

(government and 

NGOs) in planning, 

response, and 

recovery

Ongoing 

Development 

of Community 

Resilience

Ongoing 

disaster 

experience

Ongoing Activities

Quality—Collect, analyze, and utilize data on building community resilience 

(affects multiple components of community resilience)

Efficiency—Leverage resources for multiple use and maximum effectiveness

Source: Chandra et al., 2013

FIGURE 1. Model of community resilience by Chandra et al.
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The communities were then paired based on demographics and risk factors, and one in each pair was 

assigned to the intervention condition, in this case community resilience, the other to the control condition. 

Each community in the community resilience condition was assigned a public health nurse, who helped 

the community develop a community resilience coalition. These communities also had access to a 

community resilience toolkit, which included sections on Psychological First Aid, community mapping, and 

community engagement principles for resilience, as well as open source risk and resilience mapping 

software. Community resilience coalitions met monthly, with the public health nurses providing training on 

how to use the toolkit, and, based on this process, developed a community resilience work plan. Each 

community was given $15,000 for implementation of the work plan after the plan had been approved by 

LACDPH (Eisenman et al., 2014). 

In the communities in the control condition, a public health nurse or health educator was assigned to 

develop a preparedness coalition. The public health nurse or health educator then trained the coalitions to 

increase disaster preparedness, which in the project focuses mainly on individual and family/household 

levels. These coalitions also developed work plans, and each also had $15,000 to implement the plan 

after the plan was approved (Eisenman et al., 2014).

The LACCDR Project involves several types of evaluation to see whether communities in the different 

conditions are proceeding differently in terms of developing and increasing resilience—and, if so, how: 

• Organizational network analysis, or assessment of changes over time in linkages 

between community coalitions and NGOs in the 16 communities 

• Household and neighborhood-level preparedness and resilience, and changes in these 

factors over time, as assessed via a population-based community resident survey 

administered at least twice across all 16 communities

• Tabletop exercises across all 16 coalitions

• Process evaluation to identify factors that promote the development and impact of community 

coalitions as fostering and fomenting development of resilience (Eisenman et al., 2014) 

The LACCDR Project is still in process. Its website, http://www.laresilience.org, offers project materials 

including published research, a description of the conceptual model for the project, a listing of the 16 

coalitions and an overview of their accomplishments, and the community resilience and preparedness 

toolkits they have used. Findings from evaluations have not yet been published. 

Project To Test an Approach for Building Community Resilience 

In this project, the Johns Hopkins Preparedness and Emergency Response Research Center (JH-PERRC) 

tested a model in which an academic center (JH-PERRC is part of the Johns Hopkins University 

Bloomberg School of Public Health) and its affiliates worked with local health departments (LHDs) and 

faith-based organizations (FBOs) to build capacity in communities to provide public mental health support 

after disasters and increase community disaster resilience. The project was conducted in part to 

determine whether an academic health center could engage LHDs and FBOs in collaboration, as well as 

whether LHDs could come up with ways to continue preparedness efforts with FBOs with which they had 

worked in the project. Essentially, project leaders wanted to examine whether this model could be used 

after this project to help communities increase their own mental health preparedness and overall 

resilience (McCabe et al., 2014). 
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The project was conducted in three phases:

• In the first phase, a pilot study was conducted in which early versions of Psychological First 

Aid (PFA) and Guided Preparedness Planning (GPP) training were provided to urban 

residents in Maryland. This phase did not involve LHD collaboration. The only assessment 

conducted was of participants’ reactions to the training. 

• In the second phase, revised versions of PFA and GPP training were provided to rural 

residents in Maryland, with collaboration of LHDs. Again, the only assessment was of 

participant reactions to the training. 

• Phase 3 consisted of provision of final versions of PFA and GPP trainings provided to 

people in Maryland and two other states (Illinois and Iowa). Assessment in this phase 

included “assessments of pre- and post-training self-reports, objective tests, and behavioral 

indices of change in relevant knowledge, skills, and attitudes (KSAs)” (McCabe et al., 2014). 

In each phase, PFA training was provided before GPP training. 

FINDINGS

Researchers found that the partnership model central to the project was indeed viable—that is, many 

LHDs and FBOs in all phases participated (McCabe, Mosley et al., 2007; McCabe, Lating et al., 2007; 

McCabe et al., 2012; McCabe et al., 2011; McCabe et al., 2013; as cited in McCabe et al., 2014). They 

also found that the different types of organizations were able to define their roles in the project in early 

phases and work within these roles in later phases (McCabe et al., 2014).

Additionally, researchers found that several efforts were often necessary before FBOs agreed to 

participate in the project. They also found that it was important to have someone within the FBO who 

could serve as an advocate for participation: “Critical to securing leadership buy-in and ultimate approval 

for partnering was finding at least one advocate in the organization who could voice and model 

enthusiasm for the coventure” (McCabe et al., 2014). They note that traditional marketing and promotional 

strategies were useful with FBOs (e.g., email messages, bulletin inserts, flyers), but that “it was necessary 

to follow up on these activities with numerous personal contacts” (McCabe et al., 2014). They report 

encountering similar challenges in recruiting and retaining partners from LHDs. 

In all phases of the project, most participants thought that it was beneficial to be trained first in PFA and 

then in GPP. According to a journal article describing the project, they “indicated that not only was PFA a 

critical hook that pulled them into the project in the first place, but it also raised their consciousness about 

the lack of preparedness planning in their community” (McCabe et al., 2014). 

Beginning in the third phase of the project, when evaluation became more extensive, researchers 

assessed PFA and GPP training in part by comparing participants’ responses to questions about training 

content; questions were presented before and after training. In this assessment, of 14 items to assess 

acquisition of PFA training content, 11 showed significant improvement in participant scores after the 

training. Of the 15 items to assess GPP content acquisition, there were significant improvements on eight 

of the items. Additionally, more than 90 percent of planning teams made disaster plans for their 

communities with the guidance of GPP training (McCabe et al., 2014).

Early in the project, researchers realized that LHDs and FBOs would benefit from guidance in continuing 

to work together after the project was complete. To provide some of this guidance, they asked LHD 
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partners to list ways to support ongoing contact between them and FBOs. Researchers used this list to 

create a checklist tool, which is now used at the end of the GPP workshop: LHD and FBO leaders review 

the checklist and identify the items they are willing to implement together in the year after the workshop. 

There were also “translational impacts” of the project, with arrangements and changes to ensure ongoing 

collaboration between and among LHDs, FBOs, and the community at large in disaster preparedness and 

planning—and in other efforts. For example, “At the local level, one LHD leader (author Charlene Perry) 

now has in place a durable arrangement by which FBOs in her jurisdiction make their facilities accessible 

to disseminate public health messages and guidelines. During pandemic influenza A (H1N1), 22 FBOs 

operated as points of dispensing, where 536 people were vaccinated” (McCabe et al., 2014). 

POST-DISASTER APPROACHES TO SUPPORTING COMMUNITY BEHAVIORAL HEALTH

In the sections that follow, we look in depth at approaches that assess and address behavioral health 

needs in communities affected by disaster. Both approaches take into account limited resources for 

behavioral health and other types of response.

Crisis Counseling Assistance and Training Program

The Crisis Counseling Assistance and Training Program (CCP) is a U.S. government program to help 

individuals and communities recover from the challenging effects of natural and human-caused disasters. 

To that end, the CCP funds community-based individual crisis counseling, outreach, and psychoeducational services (HHS, SAMHSA, DTAC, 2016).

While states, territories, and federally recognized tribal organizations receive CCP grants after disasters, 

they use the CCP grant funding to support work done by providers at the local, community level. 

Therefore, the CCP is fundamentally a community-level approach to disaster behavioral health.

LEGAL AUTHORITIES AND PROGRAM STRUCTURE

Authorized in 1974 by the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 

93-288, as amended, 42 U.S.C. 5121 et seq.), the CCP is funded by FEMA and administered primarily by 

SAMHSA’s Center for Mental Health Services (CMHS)—and, specifically, SAMHSA DTAC, which is part 

of CMHS (Norris & Bellamy, 2009; The Stafford Act, as Amended, 2013).

After a Presidential disaster declaration that includes individual assistance, a state, territory, or federally 

recognized tribe can apply for a CCP grant. The CCP comprises two grant programs: the Immediate 

Services Program (ISP), which runs for 60 days and is intended to provide support in the acute postdisaster phase, and the Regular Services Program (RSP), in which grants last for up to 9 months (HHS, 

SAMHSA, DTAC, 2016a, 2016b). Once a state, territory, or tribe has received an ISP or RSP grant, local 

provider organizations deliver program services, through behavioral health professional as well as 

paraprofessional employees (Norris, Hamblen, & Rosen, 2009). Specific trainings are required during the 

ISP and the RSP so that CCP employees understand the program philosophy and goals and are aware of 

techniques to promote the behavioral health of individuals and groups they serve, as well as to manage 

their own stress during their work (HHS, SAMHSA, DTAC, 2016b).
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PROGRAM SCOPE AND SERVICES 

CCPs provide a broad range of services, including brief educational or supportive contact; individual, 

family, and group crisis counseling; and assessment, referral, and resource linkage (HHS, SAMHSA, 

DTAC, 2016b). Services are provided where survivors live, work, worship, and take part in recreational 

and community activities (Norris & Bellamy, 2009). 

In a commentary on a paper in which Hobfoll and colleagues identified five key evidence-based elements 

of post-disaster intervention, Norris and Stevens write, “If we were to design, from scratch, a program that 

conformed to Hobfoll and colleagues’ framework in the United States, it might well resemble the Crisis 

Counseling Assistance and Training Program” (Norris & Stevens, 2007). (Hobfoll et al. [2007] identified the 

key elements as promoting a sense of safety, calm, self- and community efficacy, connectedness, and hope.) 

The CCP is intended to address short-term needs of survivors (Norris, Hamblen, & Rosen, 2009). 

Services are strengths based—i.e., the CCP assumes that most survivors are naturally resilient—and 

provider organizations and employees are taught that crisis counseling within the context of a CCP differs 

from traditional psychotherapy in many ways (Norris & Bellamy, 2009; HHS, SAMHSA, DTAC, 2016b). 

Programs are encouraged to link to behavioral health professionals and organizations to which they can 

refer survivors who are experiencing serious distress and diagnosable disorders (DHS, FEMA, & HHS, 

SAMHSA, CMHS, 2013). “As an essentially preventative approach, the CCP is not designed to deliver 

treatment,” write Norris and Bellamy, in a report on evaluation across CCPs after Hurricane Katrina, “but 

there is an increasing effort to infuse evidence-based practices into CCP services. Policy-makers should 

consider wider implementation of specialized services in the aftermath of extreme events that have 

severe consequences for public mental health” (Norris & Bellamy, 2009). 

DATA COLLECTION AND EVALUATION

Soon after Hurricane Katrina, SAMHSA CMHS implemented a standardized data collection system for 

CCPs (Norris & Bellamy, 2009). Designed to assess program reach, quality, and consistency, this system 

comprises several forms for tracking details of specific types of services provided, an online database for 

collection and aggregation of information, and a mobile app that has recently been launched for data 

collection in the field (HHS, SAMHSA, DTAC, 2016b). Individual CCP grant programs can use the 

evaluation tools to tailor their services over time to better meet the needs of their communities. FEMA, 

SAMHSA CMHS, and other entities use them to understand how the program is working as a whole, 

across sites and over time. 

AN EVALUATION OF THE CCP: PROGRAM REACH

In 2009, Norris and Bellamy evaluated the reach of CCPs that were part of the response to Hurricane 

Katrina. In their paper describing the evaluation, they explain that after Hurricane Katrina, because of the 

intensity of the disaster and how many people it displaced, the federal government relaxed the CCP 

application requirement of a Presidential disaster declaration that includes individual assistance. More 

than 30 states applied for and received CCP ISP grants, and 18 applied for and received RSP grants.

Norris and Bellamy reviewed data from 19 CCPs over 16 months after Hurricane Katrina (from November 

1, 2005, to February 28, 2007). They worked with data from 1.2 million encounters, including individual 

crisis counseling, group crisis counseling, and public education encounters. “Crisis counseling was 

defined as an encounter that lasted at least 15 minutes and involves participant engagement or disclosure,” 
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they write (Norris & Bellamy, 2009). They also describe encounters defined in these CCPs as group crisis 

counseling and public education: “Group crisis counseling (in which participants do most of the talking) 

and public education activities (in which counselors do most of the talking) were defined as interactions at 

least 15 minutes in length with two or more unrelated individuals” (Norris & Bellamy, 2009). Three CCPs 

were in states with disaster declarations, and 80 percent of total encounters in this study (936,000) came 

from these CCPs. Sixteen CCPs were in states without disaster declarations, and 20 percent of total 

encounters included in the study (237,000) came from these programs.

To understand program reach, Norris and Bellamy compared FEMA registrations for individual assistance 

by state (as a way to determine need) to the number of encounters in that state. While the relationship of 

FEMA registrations to encounters varied by state, Norris and Bellamy report that “in general, the 

distribution of encounters across states was highly consistent with the distribution of registrations (or 

need). Altogether, there were 1.2 CCP encounters for each FEMA application” (2009).

They found that service mix varied widely across CCPs. For example, across all programs, 56 percent of 

encounters were individual crisis counseling, but, among declared programs, percentages of individual 

crisis counseling ranged from 38 percent in Alabama to 76 percent in Mississippi. 

Norris and Bellamy compared racial and ethnic data from individual CCP encounters (these data were not 

collected for group encounters) to census data to examine to what extent the race and ethnicity of those 

served by CCPs was proportional to racial and ethnic makeup of the communities where they were 

serving. They found that whites were underrepresented in the encounter data, and African American 

people were overrepresented. However, they point out, “this likely reflects the demographics of persons 

displaced by the flooding of New Orleans.” 

Additionally, they looked at risk factors: exposure to potentially traumatic events and experiences of loss. 

Because of how collection of these data works in the CCP—they are recorded only for individual 

encounters, and based on revelations during discussions; counselors are not supposed to ask about 

these factors—they are probably underestimated. Across programs, the researchers found that fully 

one-fifth of people had experienced one or more potentially traumatic events (e.g., family missing or dead, 

witnessed death or injury), and nearly 83 percent had experienced two or more losses (e.g., separation 

from loved one, displacement). 

Norris and Bellamy conclude that “by the criteria used in these analyses, the reach of the national CCP 

was appropriately wide.” They conclude this because of their findings in several areas, including service 

volume and penetration (FEMA registrations relative to encounters), service capacity that peaked at 

100,000 encounters per month, balance between individual and group encounters, representation of 

children and older adults in the data, and data on the need of survivors for crisis counseling services due 

to potential trauma and disaster-related losses. 

Another CCP Evaluation: Relationship of Aspects of Services to Outcomes

In another study of CCPs related to the 2005 hurricane season (with Hurricanes Katrina, Rita, and 

Wilma), researchers also reviewed data from multiple CCPs, as well as archival and census data, in this 

case to understand how aspects of program services, including service intensity, service intimacy, and 

frequency of psychological referrals, related to participants’ perceptions of having benefited from services. 
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Researchers defined service intensity as how long encounters lasted and how many of the encounters 

were second or later visits. They defined service intimacy as the percentage of encounters occurring in 

homes (Norris, Hamblen, & Rosen, 2009).

Forms for tracking data across CCPs include an individual crisis counseling services encounter log, 

participant surveys, and service provider feedback surveys. The researchers used data from 132,733 

individual crisis counseling services encounter logs, 2,850 participant surveys, and 805 provider surveys. 

The participant survey, which gauges survivors’ experiences of and satisfaction with CCP services, included 

items from an instrument called the Counseling Outcomes and Experiences Scale (COES), which, the 

researchers explain, “assess[ed] the extent to which the counselor (a) created an encounter characterized by 

respect, cultural sensitivity, and sense of privacy and (b) achieved realistic immediate outcomes (e.g., reducing 

stigma of help-seeking, normalization of reactions, increased coping skills) as perceived by the participant” 

(Norris, Hamblen, & Rosen, 2009).

Researchers found pronounced variability across counties in terms of the following:

• How long encounters lasted

• How many of the encounters were subsequent visits following an initial one

• Service locations

• Percentages of providers with advanced degrees

• Provider stress

• Participants’ perceived benefits, as indicated by average COES scores 

The average COES score across counties was 87, which the researchers note was good (Norris, 

Hamblen, & Rosen, 2009).

Researchers also found that participants rated their benefits from CCP services more positively in 

counties with greater service intensity and intimacy. Although the finding about service intimacy suggests 

that home visits may be better for individual crisis counseling than visits in other locations, the researchers 

point out that “it may not actually be the place that matters but rather how well the setting elicits privacy, 

empathy, sharing of reactions, and attention to the information that is being provided” (Norris, Hamblen, & 

Rosen, 2009).

People also rated their benefits from CCP services more positively in counties with higher frequency of 

psychological referrals. In their discussion of this finding, the researchers note that very few of the 

participants in services in the CCP data they examined were referred for more intensive intervention—on 

average, 3 percent—in spite of the fact that research on Hurricane Katrina had found that many survivors 

experienced posttraumatic stress disorder and depression. The researchers discuss these findings in 

relation both to the CCP and also to national policy:

The reach and quality of the CCP must be judged according to what the program is designed to 

do, and it is not charged with delivering treatment. However, as leaders in disaster mental health, 

the national program can call attention to this gap in the federal response plan, and ensure that 

local providers are skilled at making referrals to mental health care when appropriate. This 

recommendation is not meant to imply that all or even the majority of crisis counseling participants 

should be referred for treatment, and in fact, the maximum frequency across these counties was 
| Page 10

17 percent. Most people are resilient, but counselors can do a better job of identifying and meeting 

the psychological needs of participants who need more than crisis counseling to get by (Norris, 

Hamblen, & Rosen, 2009).

Additionally, researchers noted, participants’ perceived benefits were lower when providers’ stress levels 

were higher. They add that providers’ levels of stress were significantly correlated with severity of losses 

in their county. To help manage provider stress levels, the CCP now requires a training that focuses on 

provider morale and stress management, suggests in its guidance a program management plan that 

addresses staff stress management, and offers related tip sheets and webcasts on stress management 

for responders (DHS, FEMA, & HHS, SAMHSA, CMHS, 2013; HHS, SAMHSA, DTAC, 2016c). 

PsySTART

The CCP is a federal grant program that is implemented under specific statute and incorporates evidenceinformed practices; other interventions, such as PsySTART, may be implemented in and after disasters 

even without CCP grant funding. Psychological Simple Triage and Rapid Treatment (PsySTART) is 

appropriate for individual and multiple communities affected by large-scale disasters. PsySTART is used 

by the American Red Cross, the Los Angeles County Emergency Medical Services Agency, more than 80 

hospitals in the Los Angeles Hospital Disaster Resource Center System, and the State of Minnesota 

(University of California, Irvine [UCI], School of Medicine, Center for Disaster Medical Sciences [CDMS], 

2016). It provides ways for individual responders to collect survivor mental health risk data, which is then 

aggregated and analyzed to help with identification of high-risk areas, which in turn can help 

organizations allocate limited resources where they are most needed. It enables a more effective 

response at the individual responder, organizational, and regional or even national levels. 

At its main website, PsySTART is defined as “a strategy for rapid mental health triage and incident 

management during large-scale disasters and terrorism events” (UCI, School of Medicine, CDMS, 2016). 

PsySTART consists of three components: “community resilience via linkage between community ‘disaster 

systems of care,’ an evidence-based rapid triage ‘tag’ designed for field use by responders without mental 

health experience, and an information technology platform to manage the collection and analysis of triage 

needs in near real time” (UCI, School of Medicine, CDMS, 2016). 

The evidence-based rapid triage tag is used by responders to record traumatic exposures, losses, health 

factors, and mental health care or disaster experience that an individual had prior to the most recent 

disaster. It helps responders in providing Psychological First Aid and referring individuals who need more 

comprehensive assessment or mental health intervention to these services (Schreiber, Yin, Omaish, & 

Broderick, 2014). As explained in a monograph about the strategy, “Rapid mental health triage is critical 

because, just as in emergency medicine where there is the ‘golden hour’ to get care, in disaster mental 

health, there is increasing evidence of a ‘golden month’ for the high-risk subset to be matched to brief, 

evidence-based case (Foa, Hearst-Ikeda, & Perry, 1995; Sijbrandij et al., 2007; as cited in Schreiber, 

2010). Evidence on which the rapid triage tag risk factors are based includes some obtained through 

international responses to tsunami disasters. As noted in a paper on the use of PsySTART in the 

American Red Cross response in lower New York State after Hurricane Sandy:

Two large disaster operations coordinated by the Centers for Disease Control and Prevention, the 

U.S. Public Health Service, and other federal and international offices used PsySTART to conduct 

psychological risk surveillance and to improve mental health recovery efforts in Thailand and American 
| Page 11

Samoa (Thienkrua et al., 2006; King et al., 2013; as cited in Schreiber et al., 2014). Longitudinal 

assessment of survivors confirmed the increased risk for posttraumatic stress disorder and 

depression in the months after the disaster among survivors testing positive for PsySTART 

factors (van den Berg, Wong, van der Velden, Boshuizen, & Grievink, 2012; Marshall, Schell, 

Elliott, Rayburn, & Jaycox, 2007; as cited in Schreiber et al., 2014).

PsySTART is a key component of the National Children’s Disaster Mental Health (NCDMH) Concept of 

Operations (CONOPS) (UCI, School of Medicine, CDMS, 2016). In an article explaining PsySTART as 

part of the NCDMH CONOPS, Schreiber, Pfefferbaum, and Sayegh (2012) write that the approach 

involves use of the evidence-based rapid triage tag by responders in a range of key disaster systems of 

care organizations, including “hospitals, clinics, schools, decontamination sites, mass casualty collection 

points, and disaster relief settings, such as American Red Cross shelters.” They go on to explain how 

these individual assessments are aggregated and used within the NCDMH CONOPS; the same methods 

can be used in response efforts with populations of all ages.

This system allows for aggregation of individual-level triage data to generate an estimate of the 

population-level impact of a disaster or terrorism incident across sentinel sites. This system also 

permits aggregated triage-risk data to be shared across children’s disaster systems of care in near 

real time, permitting shared situational awareness of triage levels and specific risk indicators. This 

information can then be used to determine levels, types, and locations of children’s mental health 

needs. The incident action plan and planning and operations functions within a local, state, or 

national incident command system are then informed, in turn (Schreiber, Pfefferbaum, & Sayegh, 2012).

PsySTART IN PRACTICE: ITS USE BY THE AMERICAN RED CROSS AFTER HURRICANE SANDY

After Hurricane Sandy hit the eastern seaboard in fall 2012, the American Red Cross used PsySTART as 

part of its response. Researchers reviewed data from the use of PsySTART as part of the American Red 

Cross response in eight counties in lower New York State in the first 3 weeks of response (October 30 to 

November 23, 2012). They were evaluating feasibility of the use of PsySTART, as well as the utility of the 

approach. The data that researchers examined came from 18,823 disaster mental health contacts. 

Through the use of the rapid triage tag in these contacts, 17,979 risk factors were recorded (Schreiber, 

Yin, Omaish, & Broderick, 2014).

In this response, the rapid triage tag was used to collect data in ways that are somewhat similar to the 

ways in which CCP crisis counselors use the individual crisis counseling services encounter log. American 

Red Cross disaster mental health volunteers received training in PsySTART prior to beginning their work. 

Each day as they worked with survivors, they would carry a PsySTART recording sheet with them. After 

an encounter considered meaningful, generally 15 minutes or more, they would spend 1 minute or less 

checking off risk factors on the rapid triage tag, as well as indicating whether the individual was a child or 

an adult. Like CCP counselors, they did not ask questions to assess risk; instead, they entered the 

information they had learned in their conversation with the survivor. At the end of the worker’s shift, he or she 

would report the data to a central operations center by phone or give the data to a supervisor. Data from 

individual workers were aggregated on a daily basis to the county level, as that level matched the primary 

operations management level for the emergency response (Schreiber, Yin, Omaish, & Broderick, 2014). 

Risk ratios were calculated for counties by finding the total number of risk factors reported across all 

survivor contacts and dividing the total by the number of survivor contacts. For the full study period, the 
| Page 12

ratios ranged from 0.67 (Suffolk County) to 2.00 (Bronx County). The researchers found significant 

differences in some of the risk factors between these two counties. Importantly, across counties, they also 

found that the risk ratios sometimes indicated greater mental health risk in areas that were less physically 

affected by the disaster (i.e., farther from the storm surge). As they explain, 

Another finding was the number of contacts and the level of observed risk in contacts in the Bronx 

and Westchester areas that are geographically away from the water surge. The survivors being 

served in those areas had been evacuated north away from the flood zones or had experienced 

severe home damage or deaths because of wind damage in areas above the city. Thus, although 

the contacts were relatively far from the areas with the most severe physical effect, PsySTART 

alerted the disaster operations leadership to locations of significant psychological injury and need 

(Schreiber, Yin, Omaish, & Broderick, 2014).

This highlights the potential of PsySTART to guide deployment of disaster behavioral health responders to 

areas of greatest psychological risk, as well as to help individual responders to interact with survivors in 

ways that better meet their needs (Schreiber, Yin, Omaish, & Broderick, 2014).

The researchers note that PsySTART is not intended as tool for providing behavioral health diagnoses for 

survivors or for providing a “yes or no answer” (independent of confirmation by other means) to the 

question of whether a specific survivor needs clinical mental health care. Also, because its triage tool 

does not identify survivors, except for children, as part of special populations—those who may have 

higher levels of risk and/or special considerations after disasters—it cannot be used to highlight 

populations at particular mental health risk after a disaster (Schreiber, Yin, Omaish, & Broderick, 2014). 

Instead, it is intended as a strategy that can help individual, paraprofessional mental health volunteers; 

disaster response organizations; coalitions of organizations; and local, state, territorial, and tribal 

governments provide a mental health response to disasters guided by rapid identification of risk, triage to 

appropriate care, and management of resources to best meet the needs of disaster-affected populations. 

CONCLUSION

“Disasters are by their very nature devastating to communities, often having significant and long-lasting 

individual- and population-level effects on physical, mental, and social well-being,” begins a report from 

the Institute of Medicine (2015). As such, it makes sense that a set of approaches focuses on building and 

enhancing community resilience in advance of a disaster, to mitigate the effects of disaster impact and 

help community members manage post-disaster distress, experience better post-disaster behavioral 

health, and enjoy enhanced community resilience over time. These approaches and their evaluation 

make up a relatively new area of disaster behavioral health; as evidence accumulates, the field as a 

whole will have a better sense of best practices in building community resilience and helping it flourish.

Other approaches like the CCP and PsySTART tap into and fortify dimensions of community resilience—e.g., 

networks between and among individual community members, community organizations, and sectors—in 

meeting the needs of disaster-affected communities. Although, as noted, these approaches do not include 

intensive services, they do help with meeting the needs of the majority of people in most disaster-affected 

communities, and they also help with identifying people to be referred for intensive interventions. They 

address the resource limitations that confront disaster-affected communities, in that their interventions are 

designed to be delivered by paraprofessionals and their data collection activities to support scaling of 
| Page 13

services to the level of need in the community. They also are based on acknowledgment of the innate 

resilience of most individuals; while most people in a disaster-affected community will experience some 

distress, particularly in the first 2 to 4 weeks after the disaster, most will also return to their customary 

level of functioning and well-being over time—and relatively simple interventions at the community level 

can support them in the process of getting there. 
| Page 14

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