Disaster Mental Health Guidelines

Disaster Mental Health

Guidelines

March 2012

Department of Adult Mental Health, （独）国立精神・神経医療研究センター National Institute of Mental Health, 精神保健研究所成人精神保健研究部 National Center of Neurology and Psychiatry, Japan

2

Introduction

large-scale disaster not only causes physical damage to, for example, residential buildings, but also

significantly impacts the human mind. During the early stages of disaster, those affected need care

and support that provide a sense of security and peace of mind. While for some people emotional

reactions triggered by a disaster subside with time, others may take a long time to recover or may even

experience certain difficulties in everyday life. Therefore, providing “kokorono kea”, or, mental health and

psychosocial support (MHPSS) in the early stages of disaster is essential particularly to follow up individuals

who would likely develop long-term mental problems.

Japan published pioneering disaster mental health care guidelines in 2003 and it has since become

customary in Japan to provide “kokorono kea” services after crimes or disasters. However, different support

methods are used by different organizations, and only a few of these methodologies have proven appropriate

based on “scientific evidence”. Moreover, because many of the approaches were developed and confirmed to

be effective in the United States and Europe after the Japanese guidelines were published, it is timely to revise

the guidelines. The revised guidelines should also account for the social structure and cultural aspects of Japan

before incorporating the policies and programs of other countries into a revised version of the Japanese

guidelines. In addition, in order to provide effective “kokorono kea”, it is necessary not only to improve the

skills of care providers, but also to establish a disaster mental health system for these support personnel

themselves. To date, however, no guidelines or policies have been established for the way to provide support

from outside as well as stress-coping techniques used by support personnel.

To address these issues, we embarked on revising the current Japanese guidelines by reviewing the

research on disaster mental health care reported previously in Japan and overseas, setting up a focus group of

experts in disaster mental health care, and conducting a national online survey to systematically gather

experience-based opinions. In the survey, we used the Delphi approach to promote consensus building by

asking disaster responders that included experts outside the mental health field to evaluate the appropriateness

of the policy for, and the issues associated with, disaster mental health care activities. Based on the results of

this research, this document presents the revised version of Japan’s Disaster Mental Health Guidelines.

Disasters are like a series of practical exercises; it is almost impossible to apply past experience to solve the

current situation. However, we hope that our experiences accumulated through past disaster responses will

help you through these guidelines to provide care that is tailored to different disaster situations.

Yuriko Suzuki, Satomi Nakajima, Yoshiharu Kim

Department of Adult Mental Health,

National Institute of Mental Health,

National Center of Neurology and Psychiatry

A


3

Definition of terms

1) “Kokorono kea” in a narrow sense (mental health and welfare service)

This definition includes the following mental health services that are provided in conjunction with

mental and community health services provided by medical, health, and welfare professionals: Early

detection and intervention of individuals with poor mental health, establishment of community mental

health promotion programs (mental health services), and provision of psychiatric, mental health, and

welfare services to individuals with mental disorder.

2) “Kokorono kea” in a broad sense (psychosocial support)

This definition includes the following services that are provided by individuals who are not mental

health professionals and should be differentiated from the services mentioned under 1): Provision of

specific livelihood assistance and emotional support in the disaster areas.

3) Initial response

The term “initial” in “initial response” used in the guidelines define a period of approximately one

month following a disaster, during which supplementary services to the regular medical care are often

provided to the residents at the community and evacuation centers.

The term “initial response” in the section of “III. The principle of kokorono kea” does not define

special treatment or preventive measures for mental issues or disorders. The “initial response”

means basic preparedness before interacting with disaster victims and an introductory service with a

referral, if necessary, to a mental health professional.

4) Mental health professionals

A multilayered support system is required in the event of a disaster, which includes self-help and

mutual help within a family and the community, services provided by community health, medical, and

welfare professionals, and care provided by mental health professions [3]. Mental health professions

here include psychiatrists, psychiatric nurses, psychiatric social workers, public health nurses

specialized in mental health, and psychologists.


4

Disaster mental health guidelines: Table of contents

Introduction __________________________________________________________________ 2 Definition of terms ____________________________________________________________ 3 Disaster mental health guidelines: Table of contents _____________________________ 4 I. Framework of disaster mental health service __________________________________ 5

1) Advanced planning and preparation for disasters _________________________________ 5

2) Mental health task force _______________________________________________________ 7

3) Disaster mental health plans ___________________________________________________ 8

4) Media relations ______________________________________________________________ 8

5) Training _____________________________________________________________________ 9

II. The principle of mental health teams_______________________________________ 10 1) Preparedness of disaster areas to accept outside aid ______________________________ 10

2) Dispatching mental health teams ______________________________________________ 10

3) The principle of other services _________________________________________________ 14

III. The principle of disaster mental health services ____________________________ 14 1) Basic preparedness (policy) ___________________________________________________ 14

2) Specific support methods _____________________________________________________ 16

3) Psychoeducation _____________________________________________________________ 19

4) Persons requiring special assistance in the event of disasters ______________________ 19

5) Roles of mental health professionals in the initial response phase __________________ 21

6) Screening ___________________________________________________________________ 22

7) Hotlines ____________________________________________________________________ 22

IV. Care provided to support personnel ________________________________________ 23 1) Advanced planning __________________________________________________________ 23

2) Care provided to support personnel in disaster areas _____________________________ 24

3) Care provided to support personnel dispatched to disaster areas ___________________ 24


5

I. Framework of disaster mental health service

1) Advanced planning and preparation for disasters In the event of a disaster, it is almost impossible to perform tasks that have never been performed under

normal circumstances. It is therefore important to develop a disaster response protocol in advance and

establish the systems of chain-of-command and communications and the emergency attendance and early

crisis intervention strategies within and between organizations. After a disaster, however, actual conditions are

often quite different from what are anticipated, thus such protocol needs to be disregarded and actions taken

flexibly. This may discourage organizations from spending busy business hours planning a disaster response

strategy; however, such planning requires the review of the regular business operations and the clarification of

employees’ roles in the organization, possibly improving the quality of care.

(1) Integration into regional disaster management plan

It is desired that mental health professionals are involved in the development of prefectural and municipal

disaster management plans, and that, from the public health and clinical perspectives, disaster mental health

services are incorporated into the regional disaster management plan.

Mental health professionals need to understand that regional disaster management plans are a generalized

crisis management plan and that mental health services need to be incorporated into a management plan

without disturbing its main objective. Because the positions and views towards disaster mental health activities

are unlikely to be shared by individual mental health professionals, it is recommended that care policy or

objectives be decided in advance and shared by mental health professionals.

(2) Business continuity and role identification during disasters and understanding the legal basis

Mental health professionals and community health personnel need to understand their roles in the event of

disasters and the legal basis of the service. It is necessary for the government agents and medical institutions to

establish an emergency attendance system and business continuity plan in advance.

Making a disaster management plan, however, is not enough; it is necessary to practice and execute the plan.

If an organization has a regular disaster drill, the drill can include training associated with mental health. If

one thinks that disaster management is all about dealing with unexpected circumstances, then understanding

the plan and the legal basis is not enough, but it is necessary to have alternative management strategies and

role identification plans.

(3) Policy for the initial response

In recent years, the “do-no-harm” first aid response, as represented by Psychological First Aid (PFA) [4, 5],

but not limited to psychological cases, is recommended as an initial disaster response [3]. However, some


6

mental health professionals recommend, in addition to such first-aid response, more proactive therapy that

includes treatment for acute stress disorder and post-traumatic stress disorder (ASD/PTSD). Because

differences in initial response policies between mental health professionals may result in confusion at the

disaster areas, local authorities should have a discussion about initial response policies when creating a

disaster mental health manual and reach the consensus.

(4) Collection and management of information

・Collection of information

At the time of disaster, each prefecture should take a leading role in collecting and marshaling

disaster-related information from different organizations and in continually offering the information back to

the disaster areas.

Centralized information dissemination is the key to disaster management. Accurate and timely information

dissemination will reduce the anxiety of the residents. Because the main body of information will be decided

by various factors including the degree and the place of disaster, there may be cases where the prefectural

government is not able to collect necessary information because of damage to the information system or the

physical distance between the affected prefecture and the severely affected areas in the prefecture. Such

problems may result in public distrust in the administration and the production of false rumors. Under certain

circumstances, the fire department, the police department, the Japan Red Cross, and the media may have more

disaster-related information. Each prefecture needs to establish the methods of collecting and disseminating

information that are functional in the event of a disaster because communication is fundamental to MHPSS.

・Information dissemination

To disseminate accurate information in the event of a disaster, it is necessary to maintain a working

relationship with the media and obtain their clear understanding of MHPSS activities. By the same token,

MHPSS providers need to understand the role of the media during disasters by holding a joint conference with

the media and appointing a public relations spokesperson at the MHPSS task force headquarters.

(5) Activity in conjunction with community health service

It is necessary to have a clear division of roles and collaborative relationships with public health nurses and other related agents in the community. As the phrase “things that cannot be done under normal circumstances will not be done in emergency situations” clearly indicates, it is important to establish solid collaborative relationships with people who work closely in day-to-day operations. In addition, it may be a good idea to take advantages of the following community networks, including those on public health, that are already routinely functioning.


7

(6) Training

・Training courses offered to care providers involved in all-kinds of disaster response activities

Care providers involved not only in medical, health, and welfare-related fields, but also in other disaster

response activities should take a disaster mental health training course. It would be best if courses about

general disaster response and mental health are regularly offered, but in any event, the introduction to MHPSS

should be mandatory to care providers who will take leadership roles. However, even if such training courses

are taken under normal circumstances, acquired knowledge and skills will likely fade with time. It is therefore

necessary to prepare a simple reminder course that can be completed within a couple of hours in the event of a

disaster. It can also serve as an orientation course to care providers from outside disaster areas.

・Training courses offered to mental health service providers and community health personnel

It is advisable that regular training courses and continual supervision are provided to mental health service

providers and community health staff who are in charge of providing continuous supports to disaster affected

people. It is desirable that these training courses offer, in addition to knowledge and information, other

features such as support for care providers and study sessions. With regard to supervising care providers,

although it would be ideal to have continuous consultation and advice and opportunities to review cases with

experts, at present there is a shortage of skilled human resources. In addition, supervisors unfamiliar with the

disaster area will not be helpful. Thus, it is advisable to offer training and study sessions regularly and,

through these programs, improve skills of continuous mental health service.

・Training courses offered to interpersonal support personnel outside the field of mental health

Mental health training sessions should be provided to MHPSS providers in a broader sense (such as

caregivers, case workers, and volunteers). It is desirable to address mental health in general, the basic

information about emotional responses to disasters, and listening and interpersonal service skills in the training

sessions to the social workers who are not specialized in mental health. Because such knowledge and skills are

useful during normal activities, training sessions should be held regularly to improve the knowledge and skills

about mental health.

2) Mental health task force ・Organizing a mental health task force in the event of a disaster

During the initial stages of disaster, prefectural and municipal administration need to play a leading role in

organizing a mental health task force by gathering together local mental health providers. It is best that

prefectural administration or the public health center take the role because municipalities are expected to be


8

disorganized immediately after a disaster. Mental health services should be provided under the provision of the

mental health task force which incorporates mental health into general disaster response services in

conjunction with other activities provided in particular by local mental health welfare center and other

medical- and health-related resources. In addition, the mental health task force is expected to give advice to

the disaster recovery headquarters about the strategy to support disaster affected people from the standpoint of

mental health and welfare. To launch a task force smoothly, it is a good idea to obtain advice from experienced

professionals.

・Evaluation of disaster mental health program provided by mental health task force

Although there is no need to conduct a strict effectiveness evaluation study on disaster mental health

activities, it is necessary to evaluate the program as a project to validate the activities. Because it is not easy to

conduct the evaluation of programs on a regional basis, the mental health task force should conduct such an

evaluation study, establish clear definitions of program contents and outcomes, and provide technical support

by collecting and analyzing data. However, care must be provided so that burden to support personnel and

residents would not increase because of too much time and effort spent on such evaluation.

3) Disaster mental health plans To plan disaster mental health system and support activities for the initial stages of disasters, it is necessary

to obtain advice from disaster mental health professions and individuals with experience in disaster response.

Although disasters come in many forms, advice and support from individuals who have experienced similar

disasters are always helpful.

Disaster first response recommended in recent years is “first-do-no-harm” type response, as represented by

Psychological First Aid (PFA) (4,5) without limitation to clinical cases (3).

Outside supporters who enter disaster areas as disaster mental health experts should prepare to use the

conventional knowledge and past experience in disaster mental health to provide services tailored to individual

regional circumstances. By the same token, the person in charge of the affected area should take advice from

these professionals and provide support in line with the needs of the disaster area.

4) Media relations ・Set up media relations by the prefecture and centralize news coverage

Although it is important to centralize the source of information, whether the prefecture or the affected

municipality establishes media relations depends on the scale of the particular disaster. There are concerns

about the integrity and authenticity of news released by media relations of the prefecture which is away from

the affected area. Therefore, it may be necessary to provide press releases on a regular basis in collaboration

with related organizations.


9

・Protection of disaster affected people from unnecessary media exposure

Because of the unprepared state immediately after disasters, disaster affected people are vulnerable to media

exposure, and thus, the government should protect them from unnecessary interviews and coverage. Methods

of media coverage need to be cautioned to protect affected people’ privacy and prevent repeat victimization,

and to do that, it may be necessary to place a notice at the entrance of an evacuation center asking the media

not to enter the building without permission of the residents. Furthermore, under certain circumstances, it may

be necessary to ask the media to refrain from releasing the information or obtain the cooperation of the police.

However, in reality, it is not easy to limit media coverage, because of the freedom of the press. Possible

solutions to this may be to establish certain rules that ask for consideration and understanding regarding news

coverage, inform disaster affected people about their right to privacy and no obligation to conduct news

interviews, and organize study sessions involving media organizations.

Practical examples：

Request for voluntary agreement to the media

A site-specific zoning for the media at the evacuation center and affected areas (permit to enter off-limit

areas)

Promotion of autonomous control by the residents at evacuation centers (banning the media that violates the

agreement)

Regular press conference

5) Training For more information, please read (6) Training under 1) Advance planning and preparation for disasters.

・Training directed at supporting personnel involved in all aspects of disaster response

Support personnel, not only those in medical, health, and welfare fields, but also in all disaster response

activities need to take training related to disaster mental health. For example, it may be a good idea to ask the

media to take a short mental health course as an orientation program.

・Training directed at mental health and community health workers

Regular training sessions and continuous supervision should be provided to support personnel in the area of

mental health and community health. The contents of training should include support for support personnel

and case conferences, in addition to providing knowledge and information.


10

・Training human aid workers outside the field of mental health service

Support personnel involved in the broad definition of mental health care (including caregivers, care workers,

and volunteers) are expected to take MHPSS-related training that includes the basic information about mental

health and psychological responses following disasters as well as skills about listening and providing

interpersonal services.

II. The principle of mental health teams

1) Preparedness of disaster areas to accept outside aid ・Decision to accept external support

Immediately after a disaster, if the disaster is confined in a local area, a first response team organized by the

prefecture and consisting of locals familiar with the area should gather information and determine the needs of

the disaster area. However, in the case of a large-scale disaster, response team members are also disaster

affected people, making it difficult to set up a local team. In such cases, local response members who are

familiar with the area should work with external response teams. If the information service and

chain-of-command systems have been put in place well by local teams, then it is possible for external disaster

response teams to enter the area without internal help.

It is preferable to gather the information and determine the needs of the affected area before establishing a

system to control internal and external teams. However, depending on the scale and characteristics of disasters,

it is impossible or only partially possible to determine whether external support is needed. In many cases, it is

necessary to regulate external support while the assessment of the affected area is still in progress because

such assessment cannot be completed in a short period of time. Because external support begins to come in

immediately after disaster, it is necessary to have a coordination system for the very early stage of a disaster.

In addition, it is recommended to start working with external support teams, particularly disaster mental health

professionals who can supervise, while still assessing the needs of the community. This will make it easier to

coordinate external teams and plan more appropriate support activities.

2) Dispatching mental health teams *A “Mental health team” is a professional team dispatched to a disaster area to provide mental health

services to the residents through professional psychiatric treatment and public awareness programs (a narrow

sense of “kokorono kea”).


11

(1) The organization

・The composition

A mental health team should consist of a psychiatric physician, a nurse, a public health nurse, a psychiatric

social worker, and office staff who handle logistics. Clinical psychologists may be included. Although public

health or general nurses have higher priority over clinical psychologists, in certain cases it is better to include a

clinical psychologist specialized in child psychology.

Although the above composition is ideal, it is not always possible to organize a team with all the

professionals, and thus it can be flexible as long as team members can provide mental health care.

・Dispatching period

In the event of a massive disaster, to be able to provide adequate clinical services in the disaster area, one

team (with the same members) needs to stay in the area for at least one week, including the first day for

taking-over and the last day for handing-over, although the length of their stay can vary slightly depending on

the support activity, the scale of the disaster, the availability of human resources in the disaster area, and

geographical factors. One week is regarded too short by some, but the length is reasonable considering the

stress from the disaster response work and the length of time being away from their regular job. On the other

hand, if the length of stay is shorter than one week, it will result in frequent transitions and orientations for the

local personnel to handle, thus imposing more burden on the disaster area.

(2) Work-related precaution

・Attending medical and health meetings

* “Medical and health meetings” are gatherings held multiple times a day in a disaster area by all disaster

response teams involved in medical and health activities (such as Disaster Medical Assistance Team (DMAT),

the Japan Red Cross, the Health Center in the disaster area, municipal public health nurses, and the medial

association) to exchange information and report activities.

Regular participation in medical and health meetings and exchange of information are necessary. It is also

necessary to obtain understanding of mental health service provision policy from other parties who are in the

fields of medicine or public health because such understanding is the basis for a collaborative work and for

mental health of the response team member themselves. Furthermore, it is almost impossible for disaster

affected people to take advantage of mental health services if these services are not supported by other disaster

response teams.


12

・Records of disaster response activities and supports

Clinical and activity records are needed to smoothly hand-over operations at the time of transition for

continuous care in the affected areas. This is especially true when operations are handed over from external

teams to local ones. Because disaster response activities are usually analyzed later, it is preferable that the

format of the recording form used in a particular disaster is uniform among all the response teams. Because

local personnel are very busy, it is advisable to have someone outside to analyze the records.

In disaster response cases where the support activities cannot be completed, it is necessary to document

clinical cases and disaster-related activities in the routine work record as these activities are being taken over

by the regular public health activities, so that the cases will be readily referred later. However, if a time

constraint is the issue, only high risk individuals or those requiring special assistance (the elderly living alone,

individuals with an intractable disease or a specified disease) may be recorded in a way that the record is not

duplicated or can be referred to as one file.

・Cautions on unnecessary medications

Caution needs to be exercised when administering a drug because disaster affected people may be

prescribed from multiple sources. In particular, it is necessary to take notice of duplicate sleeping aid

prescriptions by the medical and mental health teams and potential drug addicts and buyers.

・Mental health care provided to local disaster response personnel

External support teams are to provide mental health services to not only the residents, but also local

administrative staff and public health nurses. External support teams can often observe things objectively as a

third party and point out things that local teams often overlook. Even so, it is necessary to bear in mind that

external teams will rotate every few days, thus making it difficult for them to provide continuous support.

(3) Operation policy and the principle

・Entering the disaster area with a clear understanding of the situation

It is not always easy to obtain the latest information about the disaster stricken area because the local

information system may be down or the actual situation keeps changing faster than the system can report. This

means that, even though information needs be gathered as much as possible in advance, it is necessary to

prepare for any kinds of situations before entering the disaster area because the up-to-date information may

only be available inside the area. It is also necessary to obtain the information about the geographic area even

if most up-to-date disaster information is not available. External support teams should not operate with their

own judgment and understanding, but be coordinated by local support teams.


13

・Arrange accommodations, such as housing and food, and supply your own equipment

During support activities, no burden should be given to the local staff. Utilizing local hotels and restaurants

open for business can be a contribution to the regional economy.

・Always obtain the permission of the local health administration office in the disaster area and provide services in conjunction with local mental health and medical resources

The local health administration office may not be functioning following a large-scale disaster, and it may be

necessary to “do whatever it takes”. However, as a rule, you need to obtain the permission from the local

health administrative office before entering the area.

In addition, agents that send external support teams into disaster areas should take the responsibility of not

dispatching individuals who cannot operate in collaboration with other organizations under the permission of

the local health administrative office, who insist that others follow their orders, or who ask the disaster area to

accommodate their stay.

・External support teams provide services where the local mental health staff cannot cover, such as offering psychoeducation to the affected people at evacuation centers

Regardless of the services, external support teams should work closely with the local teams, by providing

services under the direction and request of the local teams, by obtaining permission from the local mental

health personnel who are in charge of operation, and by reporting the timeline and nature of their activities and

intervention.

・Meet the needs of the affected area

External support teams should bear in mind that their past experience may not be useful to the present

situation and thus operate accordingly. While it is important to take advantage of past experiences, attempting

to superimpose a past experience onto the current situation may be intrusive to the local personnel or may

even disempower them. In addition, external support teams should enter the disaster area with an

understanding that the needs for mental health service may not be there. They also should not start services

that the subsequent teams or the local support personnel are not able to take over.

・Because the service provided by external support teams is temporary, they should refer patients to the local mental health service providers without treating them all by themselves

When it can be done properly in a short time, external support teams should complete the treatment of

patients without handing them over as unfinished clinical cases, because it would overwhelm local teams. This

is especially true when the involvement of an external support team is very limited. External support teams


14

should remember that they are there on a temporary basis and thus operate in the way they would like external

support teams to operate if they were a local team.

3) The principle of other services ・Professional volunteers

Volunteers specialized in medicine, nursing, welfare, and clinical psychology should be dispatched through

an organization if possible, and they should refrain themselves from entering the disaster area by themselves.

To local support personnel and disaster affected people, repeated personal offers of assistance are a nuisance to

say the least and often an exhausting task to handle. Even if entering disaster areas privately, medical and

psychotherapy services should be provided through an organization.

This is mostly for proper handling and sharing of personal information and smooth operation as a team. In

general, professionals with a broad experience with disaster medical dispatch are capable of entering a disaster

area on their own. Even so, they should not see patients privately, but work with the local disaster response

headquarters under the direction of the local administrative office. This is because, even if residents who

received disaster response services make inquiries about the service later, the local administrative office can

only respond to inquiries about services provided under their direction. In addition, when a problem arises, it

is not clear where the responsibility lies, making it difficult to take appropriate action.

Even if it is possible to accept individual supporters because the systems to accept and coordinate individual

supporters are in place, the qualification of supports, such as licenses, experience, education, and competence,

should be carefully checked.

III. The principle of disaster mental health services

1) Basic preparedness (policy) ・The initial response should promote a sense of safety

In the early stages of disaster, “practical and solid services” offer a feeling of security, and this can be

achieved by providing ① information (about safety confirmation services; accommodations; contact

information regarding general inquiry, counseling, supports, and short-term outlook), ② handling of actual

problems (disaster prevention system; compensation for clothing, food, and housing; life support, and physical

issues), and ③ empathy of support personnel (closeness, listening). The needs and readiness of disaster

affected people to accept these services need to be confirmed before providing these services. Because an

unfounded sense of security will only create more problems, it is necessary to gather accurate information and


15

collaborate with other departments. Mental health should not be forced upon disaster affected people even in

the chaotic early stage of a disaster.

・The initial response should promote calming

Although support teams always try to help disaster affected people regain their composure, this is often

difficult to accomplish in a place with an unsettling atmosphere, like an evacuation center and a school

gymnasium. In addition, it may be too early for some affected people to receive such intervention. Despite

these issues, there are a number of “specific services that help affected people regain their composure”:

・ Avoid creating confusion among affected people and try to make their everyday life more comfortable

・ Understand and try to meet the needs of them

・ Provide realistic support, such as securing life and living, guaranteeing clothing, food, and housing, and

ensuring the minimum standard of living

・ Provide an opportunity to express concerns

・ Listen to disaster affected people as needed

・ Protect them from excess media coverage

・ Teach affected people to embrace themselves because “it is natural to have unusual feelings”

・ Make sure to avoid situations that cause them to suppress their real feelings and look calm on the

outside

・ The initial response requires practical, pragmatic support provided in an empathic manner


16

・ During the initial response phase, provide concrete support to the affected people with empathy

It is important to interact with the affected people with an attitude of empathy; yet, support teams should

understand their limitations because “there are limits as to how deep one can empathize”. Training may be

needed to learn empathetic gestures because all-too-easy empathy is not recommended by some people.

“Practical services” include providing clothes, food, housing, a space for relaxation, support that meet the

affected people’ s needs, medical services, and a place that offers peace of mind. To provide such practical

support, it is necessary to crease a close connection with the local government and medical institutions and to

eliminate the gap between shelters. However, one needs to understand that it is not always possible to provide

specific support or meet the needs of the affected people.

・When helping affected people, show sincerity and willingness to address various issues with an open mind

When interacting with the affected people, it is important to come out of one’s narrow area of expertise and

open-mindedly address issues that are important to them. This “willingness to address various issues with an

open mind” defines a flexible attitude with which one provides supports that specifically meet the needs of

individual affected persons. This does not at all mean that one needs to solve all problems; unresolved

problems should be referred to appropriate support organizations.

・Provide services to maintain community communication networks during the initial disaster response

Following a disaster, maintaining communication networks within the community reduces the levels of

various stresses associated with changes in living environment. It also strengthens the sense of community

solidarity, which is an important framework in post-disaster reconstruction. To maintain community networks,

people from the same community need to be housed closely in evacuation centers and temporary housing sites,

and support should be provided in line with individual community networks. It is also important to share

information about damage and aid and establish an information network system and a tool to distribute

information. Information about the community should be gathered as much as possible without invading

privacy.

2) Specific support methods ・Confirm information so that false information will not be provided to the affected people

A variety of information, including false information, often flies around in disaster areas. Due to fear,

disaster affected people are vulnerable to erroneous information and rumors, and thus, dissemination of

accurate information is needed. In addition, special consideration must be given to individuals with visual or


17

hearing impairment and foreign nationals who understand little or no Japanese. Before providing information,

the following steps should be followed to collect, confirm, and distribute information:

① Confirmation of information that needs to be distributed

・ Confirm information with the Disaster Response Headquarters and an individual in charge in the

disaster area, such as the mayor

・ Gather adequate information about the areas before entering

・ Confirm the credibility of existing information in a meeting before starting support activity, especially

when external support teams are around

・ Research anticipated questions in advance and confirm the content with collaborating organizations

・ Before entering a disaster area, make a consensus among team members regarding the extent to which

questions are answered without causing any problems

② Methods of information distribution

・ Distribute information on the assumption that regular communication methods would not work (for

example, information may not be provided because the affected people are gone while acquiring

information)

・ Provide the date that information is acquired

・ Inform the affected people that it always takes time to confirm information

・ Provide information that does not include lies without delay

・ Inform the affected people if there is a possibility that information is not necessarily accurate

・ Start asking people about their immediate concerns and physical conditions

When meeting with disaster affected people, it is better to start asking about their physical condition and

disaster situations, instead of immediately asking about their mental status. This is because immediate

concerns and the health condition of the people are often associated with their mental issues.

・If an affected person is overwhelmed by anxiety and fear or stunned by recent developments, then simply stay very close to the person without a word

If an affected person show intense disaster stress responses, they should not be forced to talk and express

their feelings, instead, it is necessary to create an environment that offers peace of mind and simply stay with


18

them because this will deliver empathy and a sense of security. If necessary, however, medication can be

provided.

Examples of treatments that offer a sense of security are as follows:

・ Use kind words (using a dialect may be necessary)

・ With respect, convey that “now and here” they are safe

・ Focus on actual problems including immediate concerns

・ Listen when the affected person is talking

・ Take in the reality expressed in words and convert it into a sense of security

・ Stay with the affected person overwhelmed by emotions (for example, support personnel can offer

words of understanding of the overwhelming feelings of the person, staying close and patting his/her

back, and holding his/her hand.) * Care must be taken, or obtain consent in advance, when making

physical contact (such as patting the victim’s back and holding the hand), because some person may be

surprised at or feel uncomfortable with such physical contact.

・The affected person should not be forced to talk about disaster-related experience in detail

Psychological debriefing that normally helps the affected person talk about their disaster experience and

release emotions should not be conducted immediately after disasters because of the risk of making them

relive the experience. Some people even get hurt after talking about work that they should have done, but

could not. Thus, it has been pointed out that a conversation held without adequate preparation can worsen the

mental state of the affected persons.

The affected people are not to be forced to talk; they should be waited until they are ready to talk. Listen

when the persons are willing to talk about their experience in detail and create an opportunity and environment

(such as health consultation) that encourage such conversations.

・During the initial stages following disasters, emotional responses are regarded as normal responses

In general, it is acceptable to consider initial emotional responses following a disaster as “common

responses to extraordinary situation”. However, professional evaluation and follow-ups are needed for the

affected people with a history of mental illness and those with symptoms such as anxiety that are lasting for a

while or worsening. It is also necessary to differentiate general explanation of emotional reactions given to a

group of people from clinical evaluation of an individual affected person.


19

3) Psychoeducation ・Offer the information regarding mental health to disaster affected people

Information regarding mental health consultation and support services, lectures, common psychological

responses following disasters, and the prevention of alcohol abuse should be provided using a pamphlet

prepared for promoting public awareness so that the pamphlet can be read later as a reminder or is used to pass

the information on to others.

However, because a variety of pamphlets and posters are posted at evacuation centers, posting a pamphlet

may not be enough to convey the importance of mental health. Therefore, it may be necessary to change the

contents or delivery methods of the pamphlet depending on the needs of individual affected person or by

combining with a training or relaxation session. Furthermore, it is often the case that mental health issues are

not recognized as one’s own problems, and therefore, it is sometimes more effective if the information is

introduced as one made specifically for “friends and family members” of the affected persons.

・Provide information about initial emotional responses following disasters and proactively explain that such reactions are normal responses

Emotional responses that occur over a period of approximately one week post-disaster needs to be defined

as “common response to extraordinary situation”.

Yet, when proving a professional service to a disaster affected person in a clinical setting, the use of the

phrase “common response to extraordinary situation” is not recommended. It is necessary to recognize the

needs of each person and provide information about clinical care including follow-up observation and

consultation.

Such psychoeducation is needed not only for acute cases, but also for medium- to long-term ones. In

addition, it is helpful to provide psychoeducation to supervisors in cases where disaster affected people are

returning to work as well as for the mental health of supporters.

4) Persons requiring special assistance in the event of disasters ・Persons requiring special assistance in the event of a disaster include the elderly, children,

mothers with an infant, foreign nationals, individuals with disability, and individuals with a history of mental or physical disorder

In the Manual for Evacuating Persons Requiring Special Assistance in the Event of a Disaster [7], the

elderly, individuals with impairment, foreign nationals, infants, and pregnant women are specified as persons


20

requiring special assistance in the event of a disaster. This manual also states that, regardless of specific

subpopulations, it may be necessary to increase response capabilities to cover a wider population that includes

“persons requiring help to perform a series of disaster response actions, such as quickly and accurately

identifying necessary information and evacuating to a safer place to protect themselves from disaster”. Such a

group may include (1) young women, individuals excluded from family and community networks, (2) disaster

relief workers, local administrative staff, (3) financially challenged individuals, and (4) individuals with

difficulty in collecting necessary information and/or taking quick actions by themselves.

Due to handling of personal information, in reality it is difficult to identify persons requiring special

assistance in the event of a disaster, casting doubt on the ability to conduct immediate disaster response.

Service providers need to collect necessary information in advance and maintain the list to be used in the event

of disasters.

・Persons requiring assistance need special care and intervention that meet individual needs from the early stages

For example, special care and intervention required by the elderly are preventive health care and the

countermeasures against disuse syndrome and cognitive impairment. Infants and thus mothers need a place for

peaceful nursing. Hot water for taking a bath and psychoeducation may be needed for children. In reality, there

is not much room for such special assistance in the event of a disaster, and accordingly they are often

overlooked. To avoid that, it is necessary to make a list of disaster response activities required by different

subpopulations.

Although it is ideal for different subpopulations to have individualized disaster response plans, these plans

should be incorporated into the general response strategy and conducted in conjunction with other plans.

Because, in some cases, the resumption of pre-disaster life is more effective therapy than the provision of

special care, it may be better to decide on special treatment on a case-by-case basis after resuming pre-disaster

life.

・Special assistance for school-age children

To provide MHPSS to school-age children, it is necessary to collaborate with their regular mental health

personnel in charge at school (including school counselors) and the child guidance center. MHPSS at school

needs to be managed by the board of education and operated by the personnel who are in charge in normal

time. In the case of children, “kokorono kea” may sound more familiar. However, the services only cover

“psychological care”, and it is currently extremely difficult to connect these services with health and medical

care, making it necessary to build collaborative network among the corresponding administrative departments.


21

In addition, child psychiatrists need to be involved because the care cannot be provided by any psychiatrist,

and if the number of child psychiatrists is not enough in some areas, outside support may be needed.

・Support for small children

To provide MHPSS to small children, it is necessary to respond to the concern of their parents first so that

the parents can confidently interact with their children. This is basically done by providing psychoeducation

and living and childcare support to parents. In some families, however, parents cannot be stabilized,

necessitating professional observation, assessment, and intervention.

There are many cases where families were previously under consideration for careful watch, but surfaced as

a concrete child welfare case only after disaster. In such cases, it is a good opportunity to provide intervention

using the previous experience with and assessment about the family.

・Supports for infants

Similarly, parents are targeted when proving support to infants, and such support includes providing

information about child psychology and handling and offering counseling at evacuation centers, kindergartens,

and childcare centers. Leaflets can be used to provide the information at different locations depending on the

content of information and the situation of parents.

5) Roles of mental health professionals in the initial response phase ・Collaboration with acute care medical professionals and administrative staff

During the first 1-2 weeks following a disaster, it is desirable that mental health professionals treat

psychological problems of the disaster affected people and support personnel in collaboration with acute care

medical professionals. The general public often hesitate about obtaining mental health services at an

evacuation center where protection of personal information is generally not sufficient. Accordingly, it may be

desirable to offer mental health-related services in conjunction with regular medical and health activities while

the residents are still at these centers. Because some disaster affected people need other services beside

medical care, it is necessary to collaborate with the local administrative staff, public health nurses, and other

consulting agencies.

・Advice to acute care medical professionals and administrative staff

In the early response phases, it is important that mental health professionals play the role of a consultant and

give advice to acute care medical professionals, public health nurses, and administrative staff. Having a

system backed up by mental health professionals will give a sense of security to acute care medical staff

especially when dealing with a difficult case.


22

Because acute care medical professionals, public health nurses, and administrative staff are not always

aware of the importance of mental health and may be too busy to seek advice, mental health professionals may

want to first ask whether any advice is needed, instead of giving top-down advice. To do that, for example,

mental health professionals can back up cases labeled as a “difficult case” by acute care medical professionals,

public health nurses, and administrative staff.

It is desirable to build a system that can accommodate a wide range of needs because volunteers, nursery

staff, and teachers may also need advice from mental health professionals. Because such a system is useful not

only during the initial phases, but also on the medium- to long-term basis, the system should be operated in

conjunction with different fields.

・Providing professional assessment of individuals with prolonged mental health problems

Individuals with a history of mental health problem will likely develop issues related to mental health after

disasters and thus may require continuous support even after normalcy returns. In particular, professional

assessment should be provided to individuals at risk of suicide.

“Individuals with a continued mental health problem” need professional assessment to clarify whether they are in

a prolonged state of stress response to the disaster or have recurring mental illness, and based on the assessment,

they should be treated differently.

6) Screening ・Mental health screening should be conducted to identify high-risk individuals, but not to

conduct a research

Screenings are needed to identify and assist high-risk individuals. Although research aimed simply to assess

the present situation is necessary sometimes, it would often cause harm to the general public, such as

re-exposure. Therefore, the balance between the two factors should be taken into consideration before

conducting mental health screening. When conducting such screening, the agency in charge of the screening

should evaluate the ethical side of the screening and clearly state the advantages and disadvantages of such

screening to individuals and to the public.

7) Hotlines ・Establishment of mental health phone consultation service (hotline) in the early stage

following a disaster

Phone consultation service (hotline) can be quickly established following a disaster, offering peace of mind

to the residents. Such service is however not always in huge demand and the staff in charge may question its

usefulness. They need to keep in mind that phone consultation services are limited to offering information and

simply listening.


23

IV. Care provided to support personnel

1) Advanced planning ・Certain measures should be taken to establish an emergency attendance and contact

procedures

It is not practical to develop detailed emergency procedures because disasters come in different forms and

the disaster scenarios are different. However, certain measures should be taken in advance so that it would be

easier to adapt to different circumstances in the event of a disaster. It is also a good idea to develop emergency

contact information and the procedure and report format.

・Establishing inquiry and consultation services about the safety of support personnel and the information distribution procedure for family members

It is not necessary to take special action when the communication system is functioning normally. However,

depending on the scale of disasters and the accessibility to the communication system after a disaster, support

personnel may need to operate without getting in touch with their family members. When this happens, an

organization needs to contact the families of support personnel about their well-being.

・Establish the guidelines for medical professionals to treat injured individuals and those requiring assistance on the way to work

It is necessary to establish minimum standards to deter support personnel from making personal judgments

on each medical case; however, such guidelines should be flexible enough to be used under unexpected events.

Some policies even need legal support. However, it will be problematic if support could not be provided

unless the guidelines were in place, and therefore, medical response guidelines need to be flexible.

・Providing training sessions and developing a manual for the entire organization about how to organize a work schedule for their support personnel, especially about the need for rest and relaxation

An excessive work schedule greatly affects the mental health of support personnel. Yet, it is almost

impossible to take sufficient rest in actual disaster scenarios. In particular, it is difficult for municipal

personnel, who live or work in the vicinity of a disaster area, to take a rest because they are worried about

others watching. Although it has been pointed out that an all-too-easy manual or training would cause an

opposite effect, as one measure to overcome situations like those mentioned above, supervisors need to fully

understand the need for staff to rest. It is also desirable that the local disaster prevention plan covers such

needs and rest period requirements.


24

・Training to enlighten and educate about self-care

It is necessary to provide training sessions about emotional support for disaster affected people, stress

management of support personnel, and anger management techniques.

2) Care provided to support personnel in disaster areas ・Organize care providers to rotate so that they can take a rest between shifts

It is difficult for support personnel to actually take shifts or rest because there are so many tasks to perform and

support personnel often do not feel fatigue because they are in the state of mental exaltation. In order to manage

stress among support personnel, from the viewpoint of labor management, managers and supervisors need to

know the situations of excessive work hours and overtime and request additional help if necessary. It is also

necessary to force personnel to take a rest if they do not do so by themselves. In case additional help is not readily

available because of license requirements, office workers can take care of support personnel’s paperwork to

reduce their work load. Making an opportunity to temporarily leave a disaster area or providing a place where the

staff can be separated from disaster affected people and take a rest is another option.

・Provide opportunities to take a rest between tasks

Even when it is not possible to take a rest, it is still important to proactively remind supervisors and workers

about the need for taking a rest. It is said that there is no need to organize benefit and reward programs for the

relaxation of personnel because it would lead to more stress. It is also important to “feel appreciated by others”,

not necessarily through something tangible.

・In the vicinity of the evacuation and disaster areas where they work, provide a rest area for the staff to relax and maintain some degree of privacy

Although it is necessary from the standpoint of labor management to set up a rest area for the staff to

maintain their privacy, this is not easy to accomplish because the priority goes to disaster affected people and

securing a space in a disaster area is difficult. In addition, support provided to disaster affected people and

services directed to providing care need to be balanced to avoid any misunderstanding that support personnel

are treated favorably.

3) Care provided to support personnel dispatched to disaster areas ・Provide opportunities for a dispatched team back from the disaster area to hold review

sessions, health screenings, and counseling

Having a post-dispatch meeting to share disaster response experience can bring certain degree of calmness

back to staff’s life. However, it is advisable not to force attendance.


25

・Provide a rest period to support personnel back from a disaster area

Complete mental and physical rest is needed after each dispatch; however, in reality, there is simply too

much work to take a break from support activity. Therefore, to provide sufficient rest to disaster response

workers and to prevent work from accumulating, organizations that dispatch workers to disaster areas should

establish a leave program for dispatched workers and a system to coordinate operations in advance. It is also

necessary for disaster response workers to realize that taking leave from work after completing a dispatch

mission is a part of their job.

・Organizations that send response teams to disaster areas should consider each operation as a team effort by not only the workers who were dispatched to disaster areas, but also by those stayed in the office to cover the work of dispatched workers

Because disaster experience is invaluable and can provide an opportunity for training, it is constructive to

have some kind of feedback to the workplace, and for that, the entire work place needs to understand the

purpose of dispatch operation. Although having an opportunity to share disaster response experience is one

example, because some are reluctant to do so, it is necessary for each organization to decide the feedback

process that is most suited to its policy and work conditions.

Date post:	24-Jul-2015
Category:	Documents
Upload:	psilocybe-inc
View:	196 times
Download:	3 times

Disaster Mental Health Guidelines

Documents