SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin

Disaster Behavioral Health and 

Approaches to Community Response 

and Recovery

August 2023
CONTENTS

INTRODUCTION 3

BEHAVIORAL HEALTH IMPACTS OF DISASTER 3

Acute Stress Disorder 3

Posttraumatic Stress Disorder 4

Depression 4

Anxiety Disorders 5

Alcohol and Substance Use Disorders 5

People With Any Mental Illness, AUD, and/or SUD 5

Comorbidities 6

Suicidality and Suicide 6

Other Disaster Impacts 7

Resilience 8

Timelines of Behavioral Health Impacts 9

RISK FACTORS FOR BEHAVIORAL HEALTH IMPACTS 9

PROTECTIVE FACTORS FOR BEHAVIORAL HEALTH IMPACTS 11

APPROACHES TO SUPPORTING BEHAVIORAL HEALTH IN DISASTER-AFFECTED 

COMMUNITIES 11

Psychological First Aid 11

Benefits and Risks of Psychological First Aid 12

Evidence Informing and in Support of PFA 13

Crisis Counseling Assistance and Training Program 14

CCP Services 14

Flexibility of the CCP To Focus on Disaster-specific Special Populations 15

Evidence Informing and in Support of the CCP Service Model 15

Evidence in Support of the CCP 16

Evidence Suggesting Changes to the CCP May Be Advisable 20

CONCLUSION 22

REFERENCES 23

APPENDIX A 28

The focus of the Supplemental Research Bulletin is to provide an overview of the current literature on a specific 

topic and make it easy to understand for disaster behavioral health professionals who are not otherwise exposed 

to the research. The product aims to assist professionals and paraprofessionals involved in all-hazards planning, 

disaster behavioral health response and recovery, and/or Crisis Counseling Assistance and Training Program 

grant activities.

Would you like to see a Supplemental Research Bulletin on a topic we haven’t yet covered? Contact us with topic 

ideas and feedback via email at dtac@samhsa.hhs.gov or phone at 1–800–308–3515.
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INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on general impacts of disasters on mental 

health and substance use (behavioral health) in affected communities. It highlights mental illnesses 

linked to disaster, as well as increases in substance use and other signs of stress individuals may 

experience as they work to regain their bearings after a disaster. It looks at the typical timeline of disaster 

behavioral health reactions at the community level, as well as factors that may place people at greater 

risk of adverse behavioral health outcomes in and after a disaster. It then explores the Crisis Counseling 

Assistance and Training Program (CCP), a federal grant program to support states, territories, and tribes 

in implementing effective behavioral health responses to disasters, as well as Psychological First Aid, an 

intervention framework and approach on which parts of the CCP are based.

This issue of the Supplemental Research Bulletin is based on literature and scientific publications 

found through the National Center for Biotechnology Information and U.S. National Library of Medicine 

(PubMed) database. All research cited in this issue was published in English, and most was conducted in 

the United States (except where studies conducted outside the United States proved useful to exploration 

of the topic).

BEHAVIORAL HEALTH IMPACTS OF DISASTER

In disaster-affected populations, research has found increased rates of acute stress disorder, 

posttraumatic stress disorder (PTSD), major depressive disorder, and anxiety, as well as physical health 

problems, difficulties in functioning, and other issues. It is important to note that most people who survive 

a disaster experience some impacts, and the majority of people do not develop new post-disaster mental 

illnesses or substance use disorders (North, Oliver, & Pandya, 2012; Goldmann & Galea, 2014; Czeisler 

et al., 2020; Kwong et al., 2021; Rettie & Daniels, 2021; Ustyol et al., 2023).1

Acute Stress Disorder

Acute stress disorder occurs within 3 days to 1 month of a traumatic event. It resembles PTSD in many 

ways—a diagnosis of either disorder requires exposure to a traumatic event, and the disorders share 

several symptoms—but while a PTSD diagnosis requires having symptoms within specific areas or 

“clusters” (e.g., intrusion symptoms, avoidance symptoms), as well as presence of symptoms for more 

than 1 month, a diagnosis of acute stress disorder requires nine or more symptoms in total, across 

multiple areas (National Center for PTSD, n.d.; American Psychiatric Association, 2013). According 

to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, prevalence of acute 

stress disorder is usually less than 20 percent if the trauma is not interpersonal, but in the case of an 

interpersonal trauma such as assault or witnessing a mass shooting, rates may be higher (20 percent 

1 This statement relates to whole disaster-affected populations. In some cases, subsets of the population based on 

gender, occupation, or other variables may experience higher rates of mental illness, as was seen among youth 

during the early part of the COVID-19 pandemic (Czeisler et al., 2020). A review study also found prevalence of 

anxiety among children and youth exposed to disaster to rise to a mean of nearly 50 percent 24 months after the 

disaster (Newnham et al., 2022).
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to 50 percent) (American Psychiatric Association, 2013). In a systematic review and meta-analysis of 

research on populations after various types of trauma, investigators found a rate of acute stress disorder 

of 21.9 percent among survivors of disaster-related trauma (Geoffrion et al., 2022). 

Posttraumatic Stress Disorder

A study of survivors of the Oklahoma City bombing (1995) who had been directly exposed to the 

incident and who were assessed 6 months after the disaster found that 34.3 percent of survivors had 

PTSD (North et al., 1999). In a study of directly exposed survivors of 10 disasters of various types 

(natural disasters, technological disasters, incidents of mass violence, and a terrorist attack) 1 to 6 

months after the disaster, researchers found that 20 percent of survivors had disaster-related PTSD 

(North, Oliver, & Pandya, 2012). In a follow-up article reviewing research done with the survivors of 

the same 10 disasters, North (2016) notes that the upper limit of prevalence of disaster-related PTSD 

among highly exposed disaster survivors has typically been about one-third. Through a systematic 

review and meta-analysis of research on natural disasters, Beaglehole et al. (2018) found significant 

increases in rates of PTSD after disaster; however, this effect was limited to a small number of studies 

reporting continuous data and comparing populations with and without exposure to a disaster. In a 

study of 316 survivors of Hurricane Harvey (2017), Fitzpatrick (2021) found that, 2 months after the 

hurricane, more than one-quarter of survivors reported posttraumatic stress symptoms at levels high 

enough to meet clinical criteria for a diagnosis of PTSD.

Some reviews of research have observed variation in rates of post-disaster PTSD among disaster 

survivors (e.g., from none to as much as 70.51 percent, Lowe et al., 2019). Researchers note that this 

variation may result from differences in timing of assessment, screening and assessment tools and 

processes used, geographic location of studies, populations assessed, disaster types, and other factors 

(Goldmann & Galea, 2014; Lowe et al., 2019). 

While many studies have focused on populations within 1 year of a disaster, others have looked at 

survivors over longer periods of time. In a study of survivors with direct exposure to the Oklahoma City 

bombing, North et al. (2011) found that 7 years after the bombing, 37 percent of people with PTSD 

linked to the bombing, as assessed approximately 6 months after the incident, no longer had PTSD. 

(The percentage of survivors with bombing-related PTSD within the first 6 months of the incident was 

41 percent.) Just over one-quarter of the full sample of survivors (26 percent) had bombing-related 

PTSD 7 years after the incident. These high percentages may be related in part to the fact that the 

sample of survivors was limited to those with direct exposure to the bombing, the bombing itself was a 

deliberate and violent act, or other aspects of the disaster and its aftermath. 

Depression

Research has also found elevated rates of depression among disaster survivors. In the study of directly 

exposed survivors of 10 disasters, North, Oliver, and Pandya (2012) found that 14 percent of survivors 

developed major depression in the 6 months after a disaster. In the review of disaster behavioral health 

research, North (2016) cites prevalence of major depressive disorder among directly exposed disaster 

survivors at 14 percent to 23 percent. Data associated with the COVID-19 pandemic seems to have 

increased these proportions. A recent study reviewing disaster behavioral health research found that 
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an average of 28 percent of survivors of disasters will develop depressive symptoms (Newnham et al., 

2022). In a study of adults during the pandemic, Vahratian et al. (2021) reported a significant increase 

in people experiencing symptoms of depressive disorder, from 24.5 percent to 30.2 percent, from 

August through December 2020. Another group researching the impacts of the COVID-19 pandemic 

used a systematic review and meta-analysis to estimate change in worldwide prevalence of major 

depressive disorder owing to the COVID-19 pandemic in 2020 and found a global increase in major 

depressive disorder of 27.6 percent (COVID-19 Mental Disorders Collaborators, 2021).

Anxiety Disorders

In a review of disaster behavioral health research, Goldmann and Galea (2014) relate that panic 

disorder has been reported among disaster survivors, as have increases in prevalence of generalized 

anxiety disorder. In their review of data from survivors of 10 different disasters with direct exposure to 

the disasters, North, Oliver, and Pandya noted a 1 percent increase in prevalence of panic disorder 

from before to after the disasters, with post-disaster incidence of 1 percent (2012). They found similarly 

low levels of generalized anxiety disorder, which did not increase at all in prevalence from before to 

after the disasters, and which also had a post-disaster prevalence of 1 percent.

Alcohol and Substance Use Disorders

Some research seems to indicate that people rarely develop new alcohol use disorder (AUD) or 

substance use disorder (SUD) after a disaster. Instead, research has found the prevalence in disasteraffected populations is roughly equal to prevalence in the same populations before the disaster. For 

example, in the article about survivors of 10 disasters, the authors write, “Virtually no incident (new) 

postdisaster cases of substance use disorders were identified, as previously described for disasterrelated alcohol use disorders” (North, Oliver, & Pandya, 2012, p. e44). In their review, Goldmann 

and Galea (2014) observe that some research has found increases in use, but not use disorders, of 

alcohol and drugs after disaster, but they also observe that research has found SUDs do not increase 

substantially in prevalence after disasters and that people experiencing maladaptive substance use 

tend to be those with prior substance use issues and conditions or those with other mental illness that 

has developed in response to the disaster. In a landmark review of 20 years of disaster behavioral 

health research—which included investigations published in about 250 articles, chapters, and books 

and involved 160 samples of disaster-affected populations—Norris, Friedman, Watson, Byrne, et 

al. (2002) report that health problems and concerns were identified in 23 percent of the sample 

populations from studies included in their review; they include increased use and misuse of substances 

within this category. In Beaglehole et al.’s (2018) systematic review and meta-analysis of the effects of 

natural disasters, they found an insignificant change in alcohol misuse and dependence.

People With Any Mental Illness, AUD, and/or SUD

In their review of 20 years of disaster behavioral health research, Norris, Friedman, Watson, Byrne, 

et al. (2002) note that what they refer to as “specific psychological problems” were identified in 121 of 

the samples, or 77 percent. They explain that “this set includes continua of symptoms of posttraumatic 

stress, depression, and anxiety, and other psychiatric problems, as well as criterion-based conditions of 

posttraumatic stress disorder (PTSD), major depression disorder (MDD), generalized anxiety disorder 
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(GAD), and panic disorder (PD)” (p. 211). In the study of directly exposed survivors of 10 disasters, 

North, Oliver, and Pandya report that one-third of survivors experienced some sort of post-disaster 

disorder (2012). Percentages may be higher for particular incidents or disaster types; North et al. 

(1999) report a rate of 45 percent with a psychiatric disorder among directly exposed survivors of the 

Oklahoma City bombing.

Comorbidities

People with one behavioral health issue or condition following a disaster may have more than one such 

issue or condition. In a review of 1 year of research on environmental disasters—a category including 

natural disasters as well as technological disasters that affect the environment—Lowe et al. (2019) 

report that people with PTSD were more likely also to have depression following a disaster, and people 

with depression were more likely to have PTSD. In addition, people with both conditions were more 

likely to have anxiety, sleep problems, and physical health problems (Lowe et al., 2019). Goldmann 

and Galea (2014) write that “disaster-related PTSD is often accompanied by symptoms of other anxiety 

disorders, MDD [major depressive disorder], and substance use disorders” (p. 173).

Suicidality and Suicide

Although suicide is of concern after a disaster and as a public health issue at all times, research on 

U.S. populations affected by disasters apart from the COVID-19 pandemic typically has not found 

significant increases in suicide. For example, in research on highly exposed survivors of the 9/11 

attacks on the World Trade Center (2001), Xue et al. (2022) found that 7 percent experienced postdisaster suicidal thoughts or behavior, but only 1 percent of people experienced suicidal thoughts 

or behavior for the first time after the disaster. They found a significant association of post-disaster 

psychiatric disorder (9/11-related PTSD and post-disaster major depressive disorder, panic disorder, 

generalized anxiety disorder, and AUD) and suicide risk, but no significant association of disaster 

trauma exposure and risk of suicide. 

Early in the COVID-19 pandemic, several leaders in mental health and suicidology expressed concern 

that the pandemic could lead to an increase in suicide, as it did or could involve increases in several 

known risk factors, including social isolation, economic difficulties, and unemployment (Moutier, 2020; 

Sher, 2020; Asper et al., 2022). There were also early reports of an increase in serious consideration 

of suicide (Czeisler et al., 2020), although the U.S. suicide rate declined in 2019 and 2020 (Curtin, 

Garnett, & Ahmad, 2022). Research reviews and meta-analyses from the early to mid-pandemic period 

(including research published as late as 2021) have had complex findings, with reports of increases in 

rates of suicidal ideation and suicide attempts during the pandemic (Dubé et al., 2021; Farooq et al., 

2021; Pathirathna et al., 2022), but suicide rates that either decreased or remained the same during the 

pandemic (Asper et al., 2022; Angus et al., 2023). In a recent systematic review and meta-analysis of 

research published through December 2022, Yan et al. (2023) observe a significant increase in suicidal 

ideation from before to during the pandemic, as well as increases in suicide attempts, but a fairly stable 

suicide rate. In the United States, according to the Centers for Disease Control and Prevention (CDC), 

suicide rates increased by 30 percent from 2000 to 2018, and so the decline in 2019 and 2020 should 

be considered in that context (CDC, n.d.). From 2020 to 2021, the rate of suicides in the United States 

increased by 4 percent (Curtin, Garnett, & Ahmad, 2022). In a report on 2021 results of its National 
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Survey on Drug Use and Health, the Substance Abuse and Mental Health Services Administration 

(SAMHSA) estimates that, in the past year, 4.8 percent of adults had serious thoughts about trying to 

kill themselves, 1.4 percent made suicide plans, and 0.7 percent attempted suicide (SAMHSA, 2022). 

However, of these groups, proportions no greater than 16 percent attributed their suicidal thinking, 

planning, and attempts to the COVID-19 pandemic (15.8 percent of those who had serious thoughts 

about suicide, 13.7 percent of those who made suicide plans, and 1.7 percent of those who attempted 

suicide). Among adolescents ages 12 to 17 years, 12.7 percent had serious thoughts about trying to kill 

themselves, 5.9 percent made suicide plans, and 3.4 percent attempted suicide, and, as among adults, 

less than 16 percent of each group attributed their thinking, planning, and behavior to the pandemic 

(15.1 percent of those who had serious thoughts of suicide, 12.0 percent of those who made suicide 

plans, and 8.4 percent of those who attempted suicide) (SAMHSA, 2022). 

Research has also found increases associated with the pandemic in suicidal thinking, behavior, and 

attempts among various subsets of the population. For example, Madigan et al. (2023) reviewed data 

on child and adolescent emergency department visits for suicidal ideation, suicide attempts, and selfharm during the pandemic and found evidence of increases in visits for suicide attempts and modest 

evidence for increases in visits for suicidal ideation—in contrast to reductions in pediatric emergency 

department and general healthcare visits during the pandemic. 

The overall impacts of the pandemic on suicidal thinking, planning, and attempts will likely become 

clearer over time, given the lag time between phenomena and publication of research, as well as 

potentially delayed impacts in the area of behavioral health. 

Other Disaster Impacts

Several review studies have found psychological distress or nonspecific distress to be a common 

behavioral health impact of disasters of all kinds (Beaglehole et al., 2018; Norris, Friedman, Watson, 

Byrne, et al., 2002; Goldmann & Galea, 2014). Norris, Friedman, Watson, Byrne, et al. describe 

nonspecific distress as “elevation of various stress-related psychological and psychosomatic symptoms 

rather than . . . a particular syndrome, such as anxiety or depression” (2002, p. 216) and note it was 

identified in 39 percent of the sample populations included in their review. Some research has found 

elevations specifically in posttraumatic stress symptoms in disaster-affected populations. In a review of 

research, North (2016) reports that some survivors of the Oklahoma City bombing who did not develop 

PTSD continued to experience posttraumatic stress symptoms 7 years after that disaster. A review 

study found that, across research included in the study, an average of 24 percent of disaster survivors 

developed clinically significant posttraumatic stress symptoms within the 6 months after the disaster 

(Newnham et al., 2022). 

Forbes and McHugh (2021) call attention to growing evidence of the presence of anger in disaster 

survivors, including dysfunctional anger. The writers note that evidence has been found of anger in 

survivors of both natural and intentional, human-caused disasters. They also cite evidence of anger 

shortly after disaster as predictive of development of PTSD 1 year later (Jayasinghe et al., 2008, as 

cited in Forbes & McHugh, 2021).

Health problems were also identified across studies as a consequence of disaster exposure. Norris, 

Friedman, Watson, Byrne, et al. (2002) write that health problems and concerns were found in 23 
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percent of the samples included in their study. Goldmann and Galea (2014) note that some disaster 

research reports that survivors of disaster experience physical problems and symptoms including 

headache, fatigue, abdominal pain, shortness of breath, and sleep problems. They write that research 

has found varying levels of these concerns and symptoms, ranging from 3 percent to 78 percent in 

one review. 

Norris, Friedman, Watson, Byrne, et al. (2002) highlight psychosocial resource loss as a potential 

concern, which they define as declines in perceived social support, social embeddedness, self-efficacy, 

optimism, and perceived control. They note that these issues appeared in 9 percent of the samples in 

their study.

Finally, two recent studies (Rijnink et al., 2022; Abadie et al., 2022) found that disasters can impact 

access to and use of harm reduction supplies and practices for people with SUD. (Adaptations for 

delivering harm reduction services during and after the disruption caused by a disaster can be found in 

the August 2022 Supplemental Research Bulletin.)

Resilience 

As noted in earlier sections of this bulletin, subsets of people (typically less than 40 percent of disasterexposed populations) develop new mental illness after disaster, and people with preexisting mental 

illness, AUD, or SUD may experience worsening of symptoms. In addition, people without diagnosable 

disorders may experience issues in mood, functioning, and quality of life. 

With these considerations in mind, it is also important to acknowledge that research seems to show 

that a majority of survivors will not develop new mental illness, AUD, or SUD. In the review study by 

North, Oliver, and Pandya (2012), the researchers point out that while one-third of their sample of 

directly exposed disaster survivors met criteria for a post-disaster diagnosis (PTSD, major depression, 

panic disorder, generalized anxiety disorder, AUD, or SUD), two-thirds did not. Similarly, Goldmann and 

Galea (2014) note that most people who experience a disaster do not develop psychopathology.

However, absence of a diagnosable disorder is not absence of impact and response—for example, 

the psychological distress, health problems, and psychosocial resource loss described in the previous 

section. In discussing resilience among disaster survivors, Goldmann and Galea (2014) describe it as a 

complex, dynamic process: 

There is a growing consensus . . . that resilience does not indicate the complete absence of any 

psychological symptoms after traumatic event exposure; rather, it describes the ability to ‘bounce 

back’ . . . . Resilient individuals generally experience distress for a short period and quickly return to 

pre-disaster levels of functioning, distinguishing them from those who experience a longer period of 

dysfunction and a more gradual return to baseline functioning (“recovery”). (p. 171) 

In her disaster behavioral health research review, North (2016) also points out that absence of disorder 

is not absence of impact and response:

Even resilient people . . . are likely to experience strong emotional reactions to being in a disaster. 

These ubiquitous emotional reactions to disaster should not be confused with or assumed 

to represent a lack of resilience or psychopathology, because most people who report such 

psychological reactions do not develop psychiatric disorders (North et al., 1999; North, Abbacchi, & 

Cloninger, 2012). (p. 138). 
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Layne and colleagues (2021) build on the conservation of resources theory (Hobfoll et al., 1991, as 

cited in Layne et al., 2021) that suggests traumatic stress is due to loss of resources, further suggesting 

that resiliency is not an individual characteristic as much as it is that individual’s access to physical or 

emotional resources that can support recovery (such as physical safety, social support, or collective 

efficacy). Approaches to support behavioral health before, during, and after a disaster should recognize 

that individuals go into a disaster situation with varying levels of access to resources, including the 

expectation that assistance is available or valuable to them.

Timelines of Behavioral Health Impacts 

Across all types of behavioral health impacts, Norris, Friedman, Watson, Byrne, et al. report that “in 

general, the longitudinal data suggested that the first year is the time of peak symptoms or effects 

(Bromet, Parkinson, and Dunn 1990; Carr et al. 1997a; McFarlane 1989; Nader, Pynoos, Fairbanks, 

and Frederick 1990; Phifer and Norris 1989; Phifer, Kaniasty, and Norris 1988; Shaw et al. 1996; 

Steinglass and Gerrity 1990; Thompson et al. 1993; Ursano, Fullerton, Kao, and Bhartiya 1995)” (2002, 

p. 224). They also report that across samples, symptoms generally improved over time, though often 

not in a linear fashion (i.e., people were sometimes faring more poorly before feeling better, or people 

were sometimes faring better and then doing more poorly, even though their trajectory was overall 

toward improvement). Goldmann and Galea similarly highlight the first year after a disaster as the time 

when mental health issues and conditions are at their most severe, followed by improvement, though 

they add that in some studies symptoms have persisted for months or years (2014). In a systematic 

review, Newnham et al. found that across studies included in their research, disaster survivors 

experiencing posttraumatic stress symptoms had improvement in those symptoms over time, whereas 

symptoms of depression and anxiety held steady over months and years after the disaster event 

(2022). In a study involving 885 low-income women affected by Hurricane Katrina (2005), Lowe and 

colleagues (2020) found that most of the women in their study experienced moderate symptoms that 

decreased over time (69.3 percent), a smaller percentage (23.1 percent) experienced severe symptoms 

that also decreased, and a small minority experienced severe symptoms that remained consistent over 

time (7.6 percent).

RISK FACTORS FOR BEHAVIORAL HEALTH IMPACTS 

Several factors seem to place survivors at greater risk of behavioral health impacts or more severe 

behavioral health impacts after disaster. Some of these factors correspond to what people in disaster 

behavioral health sometimes refer to as “special populations,” including the following:

• Female gender (corresponding to the special population of girls, women, and others with female 

identities) (Lowe et al., 2019; Norris, Friedman, Watson, Byrne, et al., 2002; Goldmann and Galea, 

2014)

• Middle age among adults (Norris, Friedman, Watson, Byrne, et al., 2002)

• Younger age (children or adolescents) (Goldmann and Galea, 2014)

• Lower socioeconomic status (people with lower incomes and fewer financial resources available 

to them in a disaster) (Norris, Friedman, Watson, Byrne, et al., 2002; Lowe et al., 2019; Goldmann 

and Galea, 2014)
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• Historically marginalized race or ethnicity (Goldmann & Galea, 2014; Newnham et al., 2022)

• Preexisting mental illness, AUD, or SUD (people with preexisting behavioral health conditions) 

(Norris, Friedman, Watson, Byrne, et al., 2002; Goldmann and Galea, 2014; North, Oliver, & 

Pandya, 2012; Lowe et al., 2020)

• Differences in abilities or access or functional needs, relative to the majority of the population 

(Sherman et al., 2017)2 

Several of these factors may involve having less access to power, and therefore less access to 

resources. They may also involve responsibility for others, including younger and older family members 

and loved ones (i.e., middle age among adults). As a result, people with these factors may be more 

likely to experience greater disaster exposure, or exposure to more disaster-related adversity, which in 

turn may place them at greater behavioral health risk.

Research has also found multiple aspects of experience—prior to, during, and after a disaster—that 

may place people at greater risk after a disaster. These factors include the following:

• Pre-disaster trauma or adversity (Goldmann & Galea, 2014)

• High degree or severity of exposure to the disaster (Goldmann & Galea, 2014), including, for 

emergency responders, encountering human remains (Beidel et al., 2023)

• Exposure to more disaster-related stressors and traumatic events (Lowe et al., 2019; Goldmann & 

Galea, 2014)

• Injury to yourself or to a family member, or death of a family member, in the disaster (Norris, 

Friedman, Watson, Byrne, et al., 2002)

• Threat to your life or panic during the disaster (Norris, Friedman, Watson, Byrne, et al., 2002)

• Property damage or financial loss (Norris, Friedman, Watson, Byrne, et al., 2002)

• Relocation (Norris, Friedman, Watson, Byrne, et al., 2002)

• Greater resource loss (with resources defined broadly to include objects, conditions such as 

marriage, personal characteristics such as self-esteem, and energies such as time and money) 

(Norris, Friedman, Watson, Byrne, et al., 2002)

• Having children (Goldmann & Galea, 2014)

Norris, Friedman, and Watson (2002), as well as North (2016), also note that surviving a disaster 

caused intentionally by one or more people (an incident of mass violence or a terrorist attack) may 

place people at greater risk than surviving other types of disasters.

While risk factors are fairly consistent across mental illnesses after disaster, for post-disaster SUD, 

male gender is a risk factor, as is a preexisting SUD (North, 2016; Goldmann & Galea, 2014).

2 Some research finds that while people with disabilities and their families are more likely to experience more 

severe exposure to disaster and less support in disaster recovery, there have not been corresponding increased 

behavioral health impacts among people with disabilities or access and functional needs (Mann et al., 2021; 

Chakraborty, Grineski, & Collins, 2019).
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PROTECTIVE FACTORS FOR BEHAVIORAL HEALTH IMPACTS 

Researchers have also found factors that may be associated with greater resilience or lower likelihood 

of experiencing behavioral health impacts of a disaster. These factors include the following:

• Age, with older adults less likely to experience several disaster behavioral health impacts, 

including PTSD, depression, and substance use (Goldmann & Galea, 2014)

• Social support, with perceived social support in some cases more protective than actual social 

support (Goldmann & Galea, 2014; Norris, Friedman, Watson, Byrne, et al., 2002; Lowe et al., 

2019)

• Social embeddedness, which Norris, Friedman, Watson, Byrne, et al. define as “the structural 

component of social support describing the size, activeness, and closeness of the network” 

(2002, p. 239)

• Gratitude (Lowe et al., 2019)

• Religiosity (Lowe et al., 2019)

• Belief in your ability to cope, which has been defined as including optimism, self-esteem, coping 

self-efficacy, and hope (Norris, Friedman, Watson, Byrne, et al., 2002)

APPROACHES TO SUPPORTING BEHAVIORAL HEALTH IN DISASTER-AFFECTED 

COMMUNITIES 

Many approaches exist for supporting behavioral health in communities during and after disaster. 

These include specific interventions, the focus of a recent Supplemental Research Bulletin, as well 

as frameworks and programs. In this Supplemental Research Bulletin, we focus on the Federal 

Emergency Management Agency (FEMA) Crisis Counseling Assistance and Training Program (CCP), a 

federal grant program implemented by FEMA and administered and overseen by the SAMHSA Center 

for Mental Health Services (CMHS) (Uekawa et al., 2016). SAMHSA CMHS also provides training 

and technical assistance to CCP grantees (Uekawa et al., 2016). Because the SAMHSA Disaster 

Technical Assistance Center (DTAC), which produces the Supplemental Research Bulletin, is part of 

SAMHSA CMHS, we have access to anonymized, aggregated data across grant programs, and so 

we can provide more information about how the program works, whom it serves, and its outcomes. 

Because of the close relationship of services provided under CCP grants to Psychological First Aid 

(PFA), a widely adopted framework for supporting disaster-affected communities, we will also explore 

PFA in this section, including its history and background, evidence, and value as a way to equip whole 

communities to increase resilience following a disaster. 

Psychological First Aid 

The history of PFA has been traced as far back as a 1954 publication by the American Psychiatric 

Association, Psychological First Aid in Community Disasters, which proposed development of a mental 

health intervention disaster responders could use to help survivors cope effectively (Despeaux et al., 

2019). PFA was elaborated further in a 2006 field operations guide by the National Child Traumatic 
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Stress Network (NCTSN) and the National Center for PTSD, part of the U.S. Department of Veterans 

Affairs (West et al., 2021). The NCTSN and National Center for PTSD articulated eight core actions 

of PFA: 

• Contact and engagement

• Safety and comfort

• Stabilization

• Information gathering

• Practical assistance

• Connection with social supports

• Information on coping

• Linkage with collaborative services (West et al., 2021)

Another milestone in development of PFA was the 2007 publication of an article in which disaster 

behavioral health experts identified five elements or principles of intervention in the immediate and 

short-term aftermath of collective trauma: promoting a sense of safety, calming, self-efficacy and 

community efficacy, connectedness, and hope (Hobfoll et al., 2007, 2021; Ursano, 2021; West et al., 

2021). 

The 2007 article and its five elements laid the foundation for an adaptation of the framework by the 

Australian Psychological Society and Australian Red Cross, who have developed a version of PFA that 

encompasses the five principles and action steps of look, listen, and link (West et al., 2021). The World 

Health Organization, American Red Cross, and the International Federation of the Red Cross have also 

developed their own versions of PFA (West et al., 2021).

BENEFITS AND RISKS OF PSYCHOLOGICAL FIRST AID 

An important benefit of PFA is that it can be taught easily to people who are likely to be interacting with 

disaster survivors, such as first responders and others who are not behavioral health professionals 

(West et al., 2021). As such, it broadens the population of people within a community who can be 

equipped to provide meaningful support to others experiencing impacts of a disaster. Because it is a 

principle-based, high-level program, it is amenable to adaptation for cultural appropriateness around 

the world.

PFA, when implemented well, can reduce distress symptoms and increase self-efficacy among 

survivors. If implemented poorly, PFA can undermine credibility (downplaying appropriate responses, 

making promises that cannot be kept), undermine survivors’ self-efficacy, or miss opportunities to 

connect someone to mental health services when needed. A scoping review by Wang and colleagues 

(2021) found wide implementation but scant documentation of the content of PFA trainings, including 

length/duration of training (which could range from 90 minutes to 6 days). To avoid potential harms of 

poorly implemented PFA, Wang and colleagues recommend that any training include opportunities to 

rehearse and practice, post-training supervision, and increased clarity on role boundaries (particularly 

when to refer to mental health services).
| Page 13

EVIDENCE INFORMING AND IN SUPPORT OF PFA 

In general, researchers have noted it has been difficult to build evidence for PFA—sometimes because 

of aspects of PFA that might be considered strengths. In a recent commentary in a journal issue looking 

back on the 2007 “five elements” article and considering its ongoing applications, West and colleagues 

observe that the flexibility of PFA makes it difficult to build evidence for it as an approach (2021). They 

go on to highlight some of the challenges of conducting research on post-disaster interventions and 

approaches to supporting individual and community healing: 

Incidence of trauma-related disorders can be measured, but data have been mixed on whether 

application of PFA prevents major depressive disorder and post-traumatic stress disorder following 

traumatic exposure. . . . While diagnosed illness following disaster may be more reliably measured, 

it is confounded by an array of pre- and post-disaster factors as well as the duration and intensity of 

trauma exposure by individual survivors. In this context, it has proven difficult to measure the impact 

of PFA interventions. (West et al., 2021, p. 374)

In a randomized controlled trial specifically of the Johns Hopkins RAPID model of PFA (rapport 

building via reflective listening, assessment of needs, prioritizing attending to mild versus severe 

reactions, intervention, and disposition), with the adverse event in the experiment being viewing a 

distressing video, researchers found that after the intervention, participants in the RAPID-PFA group 

had significantly lower state anxiety scores, both immediately after the intervention and 30 minutes 

later. RAPID-PFA also significantly increased positive affect scores 30 minutes after the intervention 

(Despeaux et al., 2019).

In a systematic review of research on PFA from 1990 to 2010, researchers concluded that PFA as 

delivered by non-mental health professionals could be considered evidence-informed, though lacking 

in adequate scientific evidence to support its implementation as, or as part of, a treatment standard or 

guideline (Fox et al., 2012). In a review of research on the impact of PFA on mental health and wellbeing, researchers found that while findings from the studies included in their review indicated positive 

impacts of PFA, including reductions in symptoms of anxiety, depression, posttraumatic stress, and 

distress, problems with the body of research (e.g., inconsistent intervention components, inadequate 

evaluation methodologies) made it difficult to determine overall efficacy of PFA (Hermosilla et al., 2022).

One of the challenges, as observed by Figueroa and colleagues (2022), may be the short-term benefits 

of PFA for distress but not necessarily inoculative benefits against PTSD or later depression symptoms. 

A study of severely distressed emergency room patients in Chile found that a form of PFA (PFAABCDE or active listening, breathing retraining, categorization of needs, referral to ancillary services, 

and psycho-education) reduced immediate distress and short-term PTSD symptoms when compared 

to general psycho-education alone (step “E” of ABCDE). Participants who received PFA-ABCDE 

reported greater distress relief. Fewer PTSD symptoms were reported 1 month after the intervention 

in the PFA-ABCDE group, but the intervention did not have an effect on depressive symptoms at 

1-month follow-up or in PTSD symptoms at 6 months. However, if the large majority of disaster-affected 

individuals experience symptoms following a disaster and improve with time (as in Lowe et al., 2020), 

then this short-term distress relief has a benefit for a large number of disaster survivors (even if a small 

percentage will experience ongoing symptoms).
| Page 14

Crisis Counseling Assistance and Training Program 

As noted earlier in this bulletin, the CCP is a federal grant program implemented by FEMA and 

administered and overseen by SAMHSA CMHS (Uekawa et al., 2016). Perhaps the most central and 

integral of its services is crisis counseling, which is based on PFA as articulated in Hobfoll et al.’s 2007 

article—i.e., it is aimed at promoting in disaster survivors a sense of safety, calming, self-efficacy and 

community efficacy, connectedness, and hope (Hobfoll et al., 2007; Bellamy et al., 2019). 

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

93-288, as amended by Public Law 100-707), the FEMA CCP provides grantees—states, territories, 

and federally recognized tribal governments—with supplemental funding and assistance to meet their 

residents’ behavioral health needs associated with natural disasters, technological disasters, incidents 

of mass violence, and terrorist attacks (Uekawa et al., 2016; Bellamy et al., 2019). The CCP comprises 

two grant programs: the Immediate Services Program (ISP), which runs for 60 days, and the Regular 

Services Program (RSP), which is designed to support recovery after conclusion of the ISP over 9 

months, up to the 1-year anniversary of the disaster (Bellamy et al., 2019). Through an ISP or RSP 

grant, a state, territory, or tribe can hire crisis counseling staff directly, or they can subcontract with 

local provider organizations, who in turn hire crisis counseling staff and deliver services in communities 

(Norris, Hamblen, & Rosen, 2009). 

CCP SERVICES 

In federal regulation, crisis counseling is defined as “the application of individual and group treatment 

procedures which are designed to ameliorate the mental and emotional crises and their subsequent 

psychological and behavioral conditions resulting from a major disaster or its aftermath” (Crisis 

Counseling Assistance and Training, 1989, p. 369). Through the CCP, grantees provide a range of 

services, including individual and family crisis counseling; brief educational and supportive contact; 

group crisis counseling; public education; assessment, referral, and resource linkage; and community 

networking and support (FEMA & SAMHSA, 2021). Within the CCP model, crisis counseling services 

are provided by people who are often from the communities they serve and who may therefore have 

earned the trust of members of the community prior to the disaster (FEMA & SAMHSA, 2021). As with 

PFA, within the CCP services can be provided by people who have been trained in service provision 

but who are not licensed mental health professionals (NCTSN & National Center for PTSD, 2006; 

FEMA & SAMHSA, 2021). However, CCP training and guidance documents encourage programs 

to have licensed mental health and SUD treatment professionals to whom they can refer disaster 

survivors in need of clinical treatment, including immediate or emergency treatment (FEMA & SAMHSA, 

2021; SAMHSA & FEMA, 2022). Grantees also provide secondary services including development 

and distribution of psycho-educational materials, as well as media and public service announcements 

(FEMA & SAMHSA, 2021). 

As noted, one of the most central and commonly provided services under the CCP is crisis 

counseling—and specifically, individual and family crisis counseling, in which counselors meet with 

disaster survivors, discuss reactions to the disaster, make survivors aware of the reactions that are 

common after disasters, and offer tips and resources for coping. Crisis counseling often involves 

assessment and referral, which counselors are trained and encouraged to perform after multiple visits 
| Page 15

to a single survivor or anytime they sense that a survivor may be having trouble coping with reactions 

to the disaster (SAMHSA DTAC, 2022).

FLEXIBILITY OF THE CCP TO FOCUS ON DISASTER-SPECIFIC SPECIAL POPULATIONS 

An important element of the CCP model is its focus on special populations. As discussed earlier in 

this bulletin, specific populations may be at heightened risk of poor behavioral health outcomes after 

a disaster due to shared risk factors such as gender, socioeconomic status, and preexisting mental 

illness. In addition, some disasters have distinctive special populations—e.g., frontline healthcare 

workers during the COVID-19 pandemic (Bender et al., 2020; Hennein & Lowe, 2020). As explained in 

a U.S. Government Accountability Office (GAO) report, 

Its [the CCP’s] funding recipients conduct a needs assessment that identifies the most vulnerable 

populations that would benefit from receiving crisis counseling services. FEMA notes that in most 

disaster situations, children, adolescents, older adults, underserved populations, individuals with 

disabilities, and individuals with access or functional needs may benefit from program services, but 

the needs assessment may reveal additional groups who are vulnerable to disaster effects or who 

have been particularly affected by the disaster. (GAO, 2021, p. 41) 

EVIDENCE INFORMING AND IN SUPPORT OF THE CCP SERVICE MODEL 

The CCP service model is designed to meet a spectrum of common behavioral health needs following 

a disaster:

• Crisis counseling to support many people in coping with stressors and reactions

• Assessment and referral to help people who need clinical behavioral health services to access 

those services

• Group services and community linkages to foster resilience through connections, networking, and 

support

• Broader educational efforts through social and mainstream media to make people aware of 

common disaster reactions and availability of behavioral health support

As such, the program’s services are responsive to the preponderance of evidence regarding how 

communities typically experience and react to disaster. 

In the summary of their landmark research review, Norris, Friedman, and Watson conclude that 

“altogether, the research demands we think ecologically and design and test societal- and communitylevel interventions for the population at large and conserve scarce clinical resources for those most 

in need” (2002, p. 240). As noted earlier in this bulletin, this is essentially the CCP’s approach: many 

of the workers under each grant program are community members as opposed to clinical behavioral 

health professionals, but the CCP’s frontline workers are trained to assess survivors and refer them to 

clinical resources if needed (FEMA & SAMHSA, 2021).

North cites research indicating “support, education, and reassurance”—cornerstones of services 

provided by CCP crisis counselors—for “subdiagnostic distress”—i.e., the type and level of distress that 
| Page 16

the majority of disaster survivors will experience (2016, p. 139). Goldmann and Galea (2014) discuss 

the importance both of helping disaster survivors meet their social needs and also of referring people 

with urgent psychiatric needs to services—and both activities are foci of the CCP.

EVIDENCE IN SUPPORT OF THE CCP 

In addition to evidence informing CCP services, some evidence seems to indicate that the programs 

themselves are beneficial, and that aspects of the program help states, territories, and federally 

recognized tribal organizations to support their communities in disaster response and recovery. 

For example, evidence from CCP data aggregated and analyzed by SAMHSA DTAC suggests that 

programs may help people cope effectively with post-disaster challenges. CCP crisis counselors and 

outreach workers collect data on individual and family crisis counseling encounters, indicating event 

reactions survivors are experiencing or absence of event reactions, indicated on the data collection 

forms as “coping well.” As shown in Exhibit 1, in an analysis of data from 2018 and 2019 natural 

disaster-related CCP grants, increasing proportions of people receiving CCP individual and family crisis 

counseling services have been identified as “coping well” over time.

Exhibit 1. Percentage of Survivors “Coping Well” After 2018 and 2019 Natural Disaster CCP Grants

Note: The analysis was limited to natural disasters because their impacts are discrete, unlike a public health emergency such as the 

COVID-19 pandemic or technological disasters, where impacts may occur over longer periods of time.

There is evidence suggesting the reach of CCP services is in good proportion to level of community 

need. In an article reviewing service use in Project Liberty, a CCP established in New York State to 

support response to disaster behavioral health needs linked to the September 11, 2001, terrorist attacks, 

the researchers note that overall service use matched prior estimates of service need, and individuals 

served reflected the demographics of the targeted service areas (Donahue et al., 2006). In a review of 

19 CCPs across multiple states over 16 months to help support survivors and evacuees after Hurricane 
| Page 17

Katrina, Norris and Bellamy (2009) found evidence of reach in the general alignment of numbers of FEMA 

registrations for assistance and numbers of CCP encounters. 

Donahue et al. (2006) also note that in some areas, the proportions of African Americans and Hispanics 

accessing Project Liberty services exceeded what would be expected based on census data and 

estimates of lifetime diagnoses of PTSD, mood disorders, and anxiety disorders. In addition, gender did 

not seem to affect how survivors accessed services. The researchers conclude that “these findings must 

be interpreted cautiously, but they appear to suggest that provision of free crisis counseling services in 

community settings may have reduced stigma and improved access, particularly for individuals from racial 

and ethnic minority groups and for men” (Donahue et al., 2006, pp. 1265–1266). 

The CCP reaches individuals within populations that may be at heightened risk of post-disaster behavioral 

health impacts. For example, analysis of CCP data from COVID-19 grants indicates that more than half of 

individual or family crisis counseling encounters included women (59 percent), two-thirds included people 

from historically marginalized racial or ethnic groups (67 percent), and nearly 1 in 4 (18 percent) included 

people with a mental health and/or substance use need (Exhibit 2).

Some states had successful outreach to vulnerable populations, particularly from historically marginalized 

racial and ethnic groups. For example, more than half (55 percent) of the individual or family crisis 

counseling encounters in Rhode Island were with Hispanic individuals, nearly half of the encounters in 

Utah (44 percent) were with American Indians/Alaska Natives, and almost one-third of the encounters in 

South Dakota (31 percent) were with individuals with a physical limitation (other state-specific rates are 

provided in Appendix A).

Exhibit 2. Percentage of CCP COVID-19 Grant Individual/Family Crisis Counseling Encounters by Select Characteristics

Characteristic

Percentage of CCP COVID-19 Grant Individual/

Family Crisis Counseling Encounters Including 

Individuals With the Following Characteristics

Female 63.1%

Children (0–17 years) 7.6%

Adult (18–64 years) 83.7%

American Indian/Alaska Native 1.6%

Asian 6.7%

Black or African American 32.2%

Native Hawaiian or Other Pacific Islander 0.8%

Hispanic 32.6%

Had Physical Need 11.4%

Had Cognitive Need 3.4%

Had Mental Health or Substance Use Need 17.9%

Evidence also shows that the structure of the CCP and the services and activities it supports are 

effective in helping disaster survivors and attaining program goals. For example, in an article reflecting 

on Project Liberty, the authors note that the ability to engage specific provider organizations—in the case 

of their program, local nongovernmental organizations—was helpful, as it allowed the program to reach 
| Page 18

populations it might not have reached otherwise (Sederer et al., 2011). In the same article, the authors 

report that media and public education activities were effective in helping lower stigma about seeking 

behavioral health support and in enhancing awareness of common disaster reactions and program 

services available; by the 1-year anniversary of the disaster, they note, half of New Yorkers surveyed 

reported knowing about Project Liberty, and one-third had called or were considering calling the project’s 

toll-free mental health hotline publicized through the CCP (Sederer et al., 2011). 

Some research has zeroed in on CCP services, and even on specific aspects of these services. For 

example, in a cross-site study of several CCPs established after the 2005 hurricane season, which 

included Hurricane Katrina, researchers found that aggregate ratings of participants’ perceived benefits 

from program services improved with increases in service intensity (longer visits or more repeat visits), 

service intimacy (services provided in homes versus in public places), and frequency of psychological 

referrals, and with decreases in provider job stress (Norris, Hamblen, & Rosen, 2009).

As part of the CCP, survivors who receive CCP services are asked to complete a feedback survey. When 

asked about specific CCP services, the majority of disaster survivors have indicated that they found the 

services helpful, though they have identified some services more frequently as helpful than others. More 

than half of respondents reported finding all types of core CCP services identified in the survey helpful. 

Survey respondents were most likely to report handouts, materials, and one-to-one interactions as helpful 

(98 percent of respondents). Exhibit 3 presents the reported helpfulness for each type of service.

Exhibit 3. Percentage of Survivors Who Indicated Various CCP Materials Were Helpful

In the study of CCPs established after the 2005 hurricane season, researchers also found that 

participants in services were generally quite satisfied (with an average score of 87 on a 100-point 

scale) (Norris, Hamblen, & Rosen, 2009). 
| Page 19

In the survey of CCP recipients of program services, respondents generally have positive feedback. 

Ninety-four percent of respondents have reported that the CCP was “very useful” or “extremely useful.” 

When asked about specific program goals, more than 90 percent of respondents indicated that the CCP 

did a “good” or “excellent” job in various aspects of the program, including helping understand feelings 

and helping with self-care (see Exhibit 4).

Exhibit 4. Percentages of Survivors Who Indicated That Various Aspects of the CCP 

Did a “Good” or “Excellent” Job or That Overall the CCP Is “Very Useful” or “Extremely Useful”

CCPs also collect data on satisfaction of service provider staff members with their experience of the 

program. In a study of survey responses from CCP employees from November 2012 through March 

2016, researchers found that a majority of respondents reported fairly low levels of job stress, and, 

for a majority of job satisfaction-related questions, high mean levels of job satisfaction (Bellamy et al., 

2019). In data analyzed across CCP grants, SAMHSA DTAC staff have found that, of service providers 

completing the Service Provider Feedback Form, another data collection tool used by CCPs, 85 percent 

indicated that the services provided were “good” or “excellent” matches to the needs of the community, 

92 percent indicated that there was a “good” or “excellent” likelihood of their referring someone with a 

need to the CCP, and 91 percent reported “good” or “excellent” quality of services provided by the CCP 

(see Exhibit 5).
| Page 20

Exhibit 5: CCP Providers’ Rankings of Services and the Program Overall 

A goal of the CCP is to provide needed referrals to survivors, and counselors receive training on 

how and when to refer a survivor throughout the grant period. Sixty-six percent of respondents to the 

survey of recipients of program services reported they used at least one referral. Across all referrals 

used, CCP service referrals (42 percent of referrals used), community service referrals (34 percent), 

and mental health service referrals (15 percent) were the most common types used. Disability-related 

resources (4 percent), other referrals (3 percent), and substance use referrals (2 percent) were not 

commonly used (see Exhibit 6).

Exhibit 6: Percentages of CCP Referrals Used by Type
| Page 21

EVIDENCE SUGGESTING CHANGES TO THE CCP MAY BE ADVISABLE

In their summation of 20 years of disaster behavioral health research, Norris, Friedman, and Watson 

(2002) write that “disasters that engender severe, lasting, and pervasive psychological effects are rare, 

but they do happen” (p. 246) and specify that, according to their review of sample populations from 

various research studies, 

it appeared that sample- (and presumably population) level effects were greatest when at least two 

of the following event-level factors were present: (1) The disaster caused extreme and widespread 

damage to property, (2) the disaster engendered serious and ongoing financial problems for the 

community, (3) the disaster was caused by human intent, and (4) the impact was associated with a 

high prevalence of trauma in the form of injuries, threat to life, and loss of life. (p. 246) 

They go on to write that even in disasters where at least two of these factors are present, they do not 

expect a majority of survivors to experience clinically significant behavioral health problems, but that 

in these disasters, additional professional clinical behavioral health support may be needed (Norris, 

Friedman, & Watson, 2002). Arguably the World Trade Center terrorist attacks of September 11, 

2001, involved two or more of the four factors specified by Norris and colleagues, so it is perhaps not 

surprising that Sederer et al. (2011) identified exclusion of coverage for treatments, limited duration 

of clinical programs, and follow-up on long-term conditions as issues for their CCP. They attribute 

these issues to program design based on the inaccurate view that “individuals needing additional 

services would be served by the public (or perhaps private) systems of mental health care” (p. 1088). 

While acknowledging the insufficiency of systems to meet the mental health needs of segments of 

the disaster-affected population, Sederer et al. note the importance of assessment and referral to 

community-based mental health services, even if these services are overburdened. In another article 

on the same disaster and the CCP, Donahue et al. (2006) observe that “spikes in help seeking occurred 

five to eight months after the attacks, and service use remained high for nearly two years afterward ... 

These findings point to the need for long-term service availability” (p. 1265). 

Norris, Hamblen, and Rosen (2009) also discuss the issue of CCP grant length, observing that

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. (p. 183) 

Recommendations aimed at ensuring CCP crisis counselors are equipped to refer survivors appear 

both in the research literature (Bellamy et al., 2019) and also in CCP guidance (FEMA & SAMHSA, 

2021; SAMHSA DTAC, 2023). 

Over time, flexibilities in the CCP model related to timing have allowed for longer grant periods. For 

example, of the 51 RSP CCP grants established to support communities in coping during the COVID-19 

pandemic, 44 (86 percent) had an extension of the typical RSP period. These lasted anywhere from 60 

days to 18 months. This aspect of flexibility of the CCP was historically valuable during the COVID-19 

pandemic, with its protracted period of impact and spikes in collective adversity and fear.
| Page 22

CCP grants in response to the COVID-19 pandemic differed in many ways from “typical” disaster 

response programs, but they both highlight the flexibility of the CCP model and hold potential lessons 

learned for what long-term CCPs may look like. As noted above, these programs began in 2020 and 

continued through several extensions, many running through the end of 2022. With the pandemic 

and its impacts lasting longer than other disasters, many grantees described pivoting as community 

needs changed and public health restrictions ebbed or returned. In the face of restrictions that limited 

in-person services due to infection risk, grantees leaned into tools that could deliver remote, 24/7 

services such as helplines and text lines. Websites and social media accounts were also more widely 

used as a way to disseminate educational information to survivors and promote synchronous services. 

Other tools, such as cloud storage automated text translators and free videoconferencing, also 

helped grantees quickly disseminate information in ways that were fast to implement and accessible 

from anywhere. In addition, these kinds of tools and ways of working offer potential solutions to the 

challenges of a CCP—finding those in need, quickly and easily disseminating resources and referrals, 

and keeping track of program activities to ensure the most vulnerable are being included in program 

services.

CONCLUSION

Disasters impose stressors on individuals and communities. Many survivors show signs of stress and 

distress that last for relatively short periods and often resolve on their own. Some develop short- and 

long-term mental health problems linked to the disaster and post-disaster adversity; conditions linked 

to disaster, typically in a subset of the impacted population, include acute stress disorder, PTSD, 

depression, anxiety, and increased alcohol and substance use. Survivors seem not to develop new 

alcohol or substance use disorders after disasters very frequently. While in the past research has not 

found increases in suicide after disaster, and while there seem not to have been increases in suicides 

in association with the COVID-19 pandemic, research published in the next few years may provide 

a clearer picture of how the pandemic impacted collective risk of suicide. Disaster survivors may 

experience psychological distress, problematic anger, health problems, and loss of resources including 

optimism, self-efficacy, social support, and perceived control. Resilience is more common after disaster 

than ongoing distress or psychopathology. People show most distress and behavioral health problems 

in the first year after a disaster, though symptoms and issues can persist for years. Risk factors for 

poorer behavioral health outcomes after disaster include female gender, middle age, youth, lower 

socioeconomic status, and being of a historically marginalized race or ethnicity, as well as pre-disaster 

trauma and adversity, greater disaster exposure, and greater resource loss in and after the disaster. 

Protective factors include older age, social support and connectedness, self-efficacy, and hope. 

While many approaches are available for supporting community behavioral health after a disaster, in 

this bulletin we focus on the FEMA CCP, which provides a range of services to help disaster survivors 

cope with stressors, understand their disaster reactions, and access their natural resilience. A core 

service of the CCP is crisis counseling, which is based on PFA, a widely adopted and adapted 

approach to supporting communities in the immediate and mid-term aftermath of disaster. Many forms 

of PFA have been developed and implemented, but one of the most influential was articulated in a 

2007 paper, in which five elements or principles were highlighted: promoting a sense of safety, calming, 
| Page 23

self-efficacy and community efficacy, connectedness, and hope (Hobfoll et al., 2007). PFA and crisis 

counseling in the CCP are beneficial in that they can be taught to and delivered by people without 

professional clinical behavioral health backgrounds, and in that they are amenable to adaptation 

for appropriateness for various local cultures and communities. In part because of its flexibility and 

diversity in forms, PFA is difficult to research, and it is largely understood as an evidence-informed 

approach. With roots in PFA and other practices and bodies of evidence, the CCP is a federal grant 

program to help states, territories, and federally recognized tribes to supplement their resources 

to meet the behavioral health needs of their residents after disaster. The CCP can be initiated 

immediately after a disaster declaration, and services can continue through the 1-year anniversary 

of the disaster, or longer, if needed. In particular in response to the COVID-19 pandemic, many CCP 

RSP grants were extended. CCP grantees can hire provider organizations that are well-positioned 

to reach specific communities and populations within their service area. CCPs provide a spectrum of 

services, including individual and family crisis counseling; brief educational and supportive contact; 

group crisis counseling; public education; assessment, referral, and resource linkage; and community 

networking and support; as well as development and distribution of educational materials and media 

and public service announcements (FEMA & SAMHSA, 2021). The CCP is in alignment with what 

researchers have predicted community disaster behavioral health needs are likely to be. Research 

has also elucidated benefits of the program, including customization options and ability to reach target 

populations, and high satisfaction levels among service providers and recipients. One area of potential 

improvement that has been highlighted by research is the need for coverage for clinical care, although 

some have pointed out that the CCP is designed to foster referral for clinical services and as such 

should not cover these services, but instead make sure that local provider organizations are trained at 

assessment and equipped at referring people to clinical care as needed.

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. 
| Page 24

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https://doi.org/10.3390/ijerph20043346
APPENDIX A. INDIVIDUAL/FAMILY CRISIS COUNSELING ENCOUNTERS DURING CCP COVID-19 SELECT CHARACTERISTICS

State % Female % Child (0–17)

% American Indian/ Alaska Native

% Asian

% Black or African American

% Native Hawaiian/ Other Pacific Islander

% Hispanic % Physical Need % Cog

Nee

U.S. 63% 8% 2% 7% 32% 1% 33% 11% 3% 

AL 78% 8% 0% 1% 64% 0% 34% 8% 1% 

AR 73% 11% 0% 1% 40% 0% 55% 8% 2% 

AZ 79% 5% 3% 1% 15% 1% 53% 26% 7% 

CA 69% 10% 1% 26% 14% 3% 21% 16% 5% 

CO 73% 24% 12% 3% 8% 0% 39% 12% 6% 

CT 56% 3% 0% 1% 42% 0% 31% 15% 5% 

DC 73% 9% 0% 5% 74% 0% 12% 17% 13% 

DE 77% 1% 0% 0% 26% 0% 72% 5% 2% 

FL 82% 60% 2% 3% 34% 2% 40% 30% 12% 

GA 70% 5% 4% 1% 42% 0% 48% 19% 4% 

HI 61% 10% 1% 21% 3% 33% 36% 11% 9% 

IA 65% 7% 1% 1% 4% 0% 89% 19% 8% 

ID 74% 3% 5% 1% 0% 0% 86% 16% 4% 

IL 62% 16% 0% 3% 28% 1% 35% 7% 2% 

IN 63% 1% 0% 1% 23% 0% 74% 21% 3% 

KS 60% 4% 1% 2% 13% 1% 75% 22% 5% 

LA 65% 3% 0% 1% 64% 0% 33% 10% 3% 

MA 69% 5% 1% 6% 12% 1% 63% 11% 4% 

MD 85% 0% 0% 2% 26% 0% 71% 4% 0% 

ME 60% 9% 1% 1% 23% 0% 70% 13% 6% 

MI 60% 2% 1% 1% 19% 0% 76% 12% 3% 

MN 63% 8% 14% 2% 59% 0% 8% 3% 1% 

MO 65% 5% 2% 1% 20% 1% 73% 18% 5% 
State % Female % Child (0–17)

% American Indian/ Alaska Native

% Asian

% Black or African American

% Native Hawaiian/ Other Pacific Islander

% Hispanic % Physical Need % Cog

Nee

MT 70% 6% 23% 1% 0% 0% 72% 14% 2% 

NC 65% 5% 2% 2% 23% 0% 67% 18% 7% 

ND 48% 3% 20% 1% 6% 2% 71% 7% 6% 

NE 71% 3% 3% 1% 3% 0% 87% 10% 2% 

NH 68% 0% 0% 0% 0% 0% 100% 4% 0% 

NJ 64% 13% 0% 3% 21% 0% 52% 18% 3% 

NM 47% 11% 29% 0% 6% 1% 31% 15% 4% 

NV 65% 10% 1% 3% 12% 1% 52% 9% 3% 

NY 61% 6% 1% 6% 42% 0% 20% 9% 2% 

OH 56% 20% 0% 1% 43% 0% 41% 17% 9% 

OK 70% 18% 12% 1% 28% 1% 53% 26% 4% 

OR 68% 11% 6% 2% 14% 1% 60% 20% 7% 

PA 56% 1% 0% 1% 5% 0% 92% 21% 14% 

RI 80% 9% 2% 1% 8% 0% 35% 10% 2% 

SC 58% 3% 0% 0% 41% 0% 46% 0% 0% 

SD 75% 13% 5% 30% 19% 0% 44% 32% 4% 

TN 49% 5% 0% 0% 11% 0% 87% 10% 4% 

TX 70% 7% 0% 2% 32% 0% 42% 4% 2% 

UT 72% 11% 44% 0% 2% 1% 32% 8% 1% 

VA 68% 2% 1% 6% 29% 0% 47% 10% 1% 

VT 74% 1% 1% 2% 4% 0% 81% 10% 2% 

WA 55% 1% 5% 1% 3% 1% 86% 18% 3% 

WI 61% 4% 1% 1% 48% 0% 37% 6% 3% 

WV 51% 3% 0% 1% 4% 0% 94% 13% 8%