This is a preliminary report on the reflective analysis of the disaster mental health management response in San Francisco following the 1989 Loma Prieta Earthquake. It was conducted in preparation for the development of a joint research project comparing the mental health management response in Hanshin and San Francisco earthquakes respectively and based on interviews with key mental health administrators.
II. The Impact of the Earthquake:
The earthquake casualties in the San Francisco Bay Area included 253 deaths, 421 hospitalized and 1016 non-hospitalized injuries. The property damage was estimated at nearly $2 billion and included 378 buildings destroyed, 667 buildings severely damaged and 1,775 buildings damaged. The Bay Bridge, a major route in and out of the City, was damaged disrupting commuters and City businesses. Looting and assaults were reported during the night of the quake.
III. Phase Specific Response of the Mental Health Community:
In San Francisco, the responsibility to respond and organize mental health disaster assistance was delegated to the director of the Community Mental Health and Substance Abuse Services and her managers, who begun the organizing effort on the day after an evening of destruction and confusion. They coordinated their effort with the Public Health Department medical services, as well as other City departments, e. g. Police, Fire Department, and private disaster assistance organizations such as American Red Cross, Salvation Arm.
1. First 10 Hours: The earthquake hit at 5:04 p.m., when most of the staff were leaving their offices and heading home. During the first 10 hours, there was much chaos and confusion about the extent of damages. Prior to the disaster, the department did not have a well defined disaster action plan nor was it clear what actions were required of the mental health managers and staff. With limited information available about the extent of the damage, they went home and concentrated on assessing their own personal damages, and to rest for the night. They did not begin to mobilize until the following morning, 15 hours after the quake. However, the Cityfs general hospital, with its 24 hour psychiatric emergency services, and other hospitals were in full operation throughout the evening. During the first 10 to 15 hours, there were a few psychiatric emergencies.
2. 100 Hours Post Disaster: The director of mental health/substance abuse services reported to the Department of Public Health (DPH) Command Center the following morning to consult and coordinate the mental health response with the DPH hospital and medical services activities. While awaiting for directions from DPH, the mental health managers first begun to assess the extent of damages among the nearly 200 programs within the system and the status of their clients to the extent they were able. Although there were some structural damages as well as broken office equipment and furniture, the damages were not serious and all programs could reopen for services within a few days. However, many of the more seriously ill clients, who did not live with families, but lived alone in structurally vulnerable, cheap buildings, lost their housing when their buildings were seriously damaged.
Working through the second night, the mental health managers made the quick decision to concentrate their effort on outposting their staff at Disaster Assistance Centers(DACs) and to mental health shelters to provide crisis intervention and outreach services. The director of mental health and her 10 managers took turns to work through the nights to direct the assistance effort. They kept some of the clinics in more seriously impacted areas closed and kept other programs partially open, so that the staff could be deployed to the facilities where high risk victims were concentrated. They also called for other county mental health authority to send mutual aid teams and professional organizations for assistance in staffing the 24 hour operation. Although the managers involved with DACs were familiar about the role of mental health professionals and welcomed them, the Red Cross managers, who were in charge of the shelter operation, were unfamiliar with mental health involvement and were initially quite reluctant to allow them on the premise. However, when the mental health staff were able to quickly intervene in potentially explosive situations, involving acutely mentally ill or drug/alcohol addicted individuals, they became much more supportive. At a later time, when the emergency situation subsided and they begun planning for future disaster preparedness, Red Cross and San Francisco mental health system created a memorandum of understanding (MOU), a first of its kind in U. S., to assure timely future cooperation.
During this time, the managers also made arrangements with local hospitals to respond to emergency hospitalization needs and set up a crisis hot line through the local suicide prevention center.
Second Phase : During the second phase of organizing, which lasted approximately 90 days, until mid-January, the initial chaotic and hectic pace has subsided significantly, allowing the managers to begin to organize the assistance activities in a more orderly manner. Within 14 days of the Presidential declaration of the disaster, the managers developed a federal grant proposal, FEMA Immediate Service Grant, to obtain funding to meet the emergency expanded staffing needs. The managers believe that the state and federal consultants provided them with invaluable assistance greatly facilitated the process (Myers, 1994). The grant made it possible to reimburse the volunteers for their expenses and to assure continued retention of temporary staff and consultants. It was also possible to pay for emergency crisis lines, obtain disaster assistance publications, and to conduct media campaign. The services developed included the following:
1. Services at Shelters: As the chaos and the level of distress gradually begun to subside, the around the clock mental health staffing was gradually reduced over a 4 week period to a partial day coverage. The Red Cross closed the shelters on December 1, 1989, and transferred one of the shelters to the City as a homeless shelter. The mental health shelter staffing was also terminated at that time with the expectation that the services, if needed, could be provided at nearby outpatient and day treatment programs.
2. Crisis Hot Line: Additional lines were created to respond to the pressing demands for help. For many of the callers, who were experiencing the normal level of post traumatic stress reaction, it was sufficient to talk with hot line counselors to be reassured about their anxieties and to feel supported. Others who needed emergency interventions or formal counseling were referred to appropriate agencies.
3. Outreach and Crisis Counseling: With the increased staffing, outreach and crisis counseling to high risk groups such as the elderly, children, homeless and those who may have been exposed to traumas in the past, e. g. combat veterans, Southeast Asian and Central American refugees. Multilingual workers educated the public about normal stress reactions and resources in the community.
4. Community Education and Support: In order to prevent flooding of our acute services by less urgent needs, we relied heavily on the media to educate the general public about various symptoms indicative of post traumatic stress reactions, how to cope with them, and when to seek help. Parents were warned that many children would exhibit symptoms such as separation anxiety, multiple fears, sleep disturbances, school phobias and behavior problems, and were given suggestions about how to reduce them fears.
5. Assistance to Disaster Workers: Debriefing and Other Activities: Based on the wide-spread understanding of the need to relieve the highly stressed disaster workers (Marmar, Mitchell, , they provided debriefing sessions to the participating mental health professionals, emergency team staff, Red Cross, police and fire department workers.
Third Phase: Based on their experience during the second phase, the managers developed and received a 9 month service grant from FEMA beginning on January 17, 1990. Although there was significant reduction in the level of anxiety and distress in the community by this time, there was still demand for continuing the services initiated in the Second Phase, i. e. continuation of hot lines; outpatient counseling services; public education and media campaign concerning disaster mental health issues; and debriefing and counseling assistance to rescue workers. It was also possible to mount an aggressive staff training programs to prepare them to deal with future disasters. Through these training, the mental health staff gained greater confidence about their ability to deal with disasters and were able to provide valuable assistance to other communities when disasters struck in subsequent years, including the disaster in Northridge in 1994.
Termination Phase: Although the grant was to terminate in October, 1990, the managers were concerned about the triggering of anxiety and crisis during the anniversary period in October and managed to extend the activities through June 30, 1991, the end of the fiscal year 1990-91. They used this phase to assist clients to terminate the outpatient counseling services. They also used this period to evaluate their assistance effort during the disaster and to take actions to be better prepared in future disasters.
IV. Summary and Conclusions
Although mental health managers and professionals in San Francisco were unfamiliar with the disaster assistance work, they were able to respond quickly in a chaotic and disastrous situation. In conducting retrospective analysis and in preparation for future disasters, they believe the following issues should be recognized:
1. In order to avoid the initial confusion immediately after a disaster, a clearly defined action plan should be developed, indicating responsibilities and actions needed for managers and individual staff.
2. Availability of emergency federal and state technical support and funding for rapidly expanding the mental health service capacity.
3. Screening and establishment of volunteer professional registry, .
4. Existence of mutual-aid agreement and mechanism with other local mental health authorities and professional organizations.
5. Providing sufficient relief and support to the mental health staff involved in the disaster assistance activities.
Marmar, C. R., Foy, D., Kagan, B. , & Pynoos, R. S. (1993). An integrated approach for treating post-traumatic stress. In J. M. Oldham, M. B. Riba, & A. Tasman. (Eds.) American Psychiatric Press Review of Psychiatry. 12.
Mitchell, J. & Everly, G. (1995). Critical incident stress debriefing: An operations manual. Ellicott City. MD: Chevron Publishing.
Myers, D. (1994). Disaster response and recovery: A handbook for mental health professionals. Rockville, MD: Center for Mental Health Services, U. S. DHHS. Publication No. (SMA) 94-3010.
Tatsuki, S. (1997). A life-modelled social work practice with earthquake victimes: Phase specific responses during crisis and post-crisis periods. A paper presented at the 5th US/Japan Workshop on Urban Earthquake Hazard Reduction.