Emergency Mental Health and
Traumatic Stress

Case Management and Advocacy within Crisis Counseling Programs

Note: This is the fourth in a series of program guidance documents developed to ensure consistency in addressing key program issues in the Crisis Counseling Training and Assistance Program (CCP). The Crisis Counseling Training and Assistance Program is funded by the Federal Emergency Management Agency (FEMA) under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act. On behalf of FEMA, the Center for Mental Health Services (CMHS), Emergency Services and Disaster Relief Branch (ESDRB) provides technical assistance, program guidance and oversight.

Purpose
This program guidance discusses advocacy and case management and clarifies the types of activities that are appropriate and inappropriate for implementation in the Crisis Counseling Assistance and Training Program (CCP). This guidance may be particularly helpful for Crisis Counselors who have prior experience as case managers within the public health system because some commonly-practiced advocacy and case management activities are not within the scope of the CCP.

Case Management and Advocacy within the Public Mental Health System
Case management, in some form, is practiced in most public mental health agencies. While definitions and models vary greatly, case management typically involves coordination of client services to assure continuity of care and accountability for service provision. Within the public mental health system, advocacy is generally considered to be an important element of case management. Advocacy involves representation of the needs and interests of people with serious mental illnesses in order to obtain services, assure fair and reasonable accomodations for special needs, and promote opportunities for maximum independence in the community. Advocacy may include interpretation of client needs to providers, consultation and technical assistance in reducing and eliminating barriers, and assertive efforts to assure adaptations and accommodations. In some instances, advocacy can be an adversarial process directed toward forcing a system, resource or provider to serve the client.

Case Management and the Crisis Counseling Program

The Crisis Counseling Program is funded by FEMA and administered by the Emergency Services and Disaster Relief Branch (ESDRB) of the Center for Mental Health Services (CMHS). Crisis counseling often includes assisting survivors in understanding the availability of other FEMA human services programs and the mechanisms for obtaining information regarding the status of their applications for assistance.

In many respects, the activities of crisis counselors may be similar to those of case managers in the public mental health system, especially to the extent that many cases in the mental health system involve clients who require support from several community-based and governmental services. In addition, many crisis counselors have previous case management experience and are familiar and comfortable with that role. However, it is important to note that there are key differences between the disaster crisis counseling program and case management services. Not respecting these differences can lead to confusion and difficulties. Key differences between traditional case management activities and the services offered through the CCP are listed in the table below.

Case Managers	Crisis Counselors
Provide services to individuals who may have a serious and/or persistent mental illness or other disability of indefinite duration.	Provide services to disaster survivors who are assumed to have a high level of functioning.
Responsible and accountable for client or patient service provision.	Services provided do not require continuity of care.
Have the power to influence the provision of services for their client.	Empower the disaster victim to advocate for services needed.
Have long term relationship with clients.	Have short term relationships with disaster victims.

Crisis counselors may encounter disaster survivors who are seriously impaired. This impairment may result from a wide variety of sources including acute and chronic mental or physical illness, substance abuse, addiction, or a developmental disability. The magnitude of need and the compelling nature of a disaster victim's problems may incline the crisis counselor to assume a more central and expanded role than is appropriate. Crisis counselors should consult with their immediate supervisors before assuming any additional responsibilities for disaster survivors. It is entirely appropriate for crisis counselors to participate in activities designed to assure coordinated and comprehensive services to these individuals, but it is not appropriate for crisis counselors to assume the central role in the establishment or coordination of those services.

Whenever possible, the crisis counselor should determine if the survivor already has a designated case manager within the public mental health system and ensure that relationship is re-established. It is important to recognize that the CCP was not intended to establish or replace other needed mental health or social services in a community. Accomplishments gained through the crisis counseling program can be compromised by creating dependence on crisis counseling staff and service programs that will not continue to exist following the end of the Crisis Counseling Program.

Advocacy and the Crisis Counseling Program
Advocacy has emerged to varying degrees in many crisis counseling programs. In its most controversial form, it has evoked the perception that some crisis counselors have represented or advocated for disaster survivors in their conflicts with other FEMA human services disaster programs. The focus of FEMA supported human services programs, including the CCP, is to assist survivors in organizing and accessing the disaster related resources that will help them achieve pre-disaster levels of functioning and equilibrium. In order to serve the wide variety of needs of disaster victims in the most efficient and cost-effective manner possible, each program addresses a different disaster recovery need. Learning to navigate the array of organizations and agencies offering disaster assistance becomes a central recovery task for disaster survivors. This experience can be overwhelming and frustrating for the survivor and can create additional trauma and stress. Survivor expectations often exceed the magnitude and speed of assistance FEMA is authorized to provide, and in turn they may view the process as cumbersome, slow and insufficient. Consequently, survivors may become angry and may even feel that FEMA (and the FEMA staff with whom they come in contact) is unable to, or not interested in, assisting them. As a result, identifying the source of the disaster related stress and choosing the appropriate intervention may be complicated.

The purpose of the crisis counseling program is to help disaster victims recognize that, in most cases, their emotional reactions are normal and to develop coping skills that will allow them to resume their pre-disaster level of functioning and equilibrium. Allowing survivors to grieve their losses, enhancing coping mechanisms and developing skills are desired long term outcomes of the CCP. Crisis counselors need to be knowledgeable enough about other resources to guide and direct the survivor to the appropriate sources for obtaining assistance or resolving problems. It is not appropriate or expected for the crisis counselor to become expert in the intricacies of other programs or to serve as an advocate for the survivor in obtaining services or resolving disputes. It is important to remember that the crisis counseling program is based upon assumed competence of disaster survivors. A key tenet of the program is the assumption that the vast majority of disaster survivors, given support and adequate information, are capable of appropriately representing themselves and resolving their own difficulties. Listed below are appropriate and inappropriate activities for crisis counselors.

Appropriate Activities for Crisis Counselors

Normalizing the disaster recovery experience by identifying and acknowledging that dealing with new and complex organizations is difficult and often stressful;
Assisting survivors in organizing and prioritizing recovery tasks and external demands to reduce stress;
Identifying normal reactions such as frustration and confusion, as well as defense mechanisms such as displaced anger;
Establishing and maintaining current information about a wide variety of recovery resources in order to make efficient referrals;
Assisting survivors in obtaining or maximizing skills such as communication, problem solving, conflict resolution, time management and stress management, to better enable them to work more effectively with recovery organizations;
Representing the mental health perspective on "unmet needs" committees.

Inappropriate Activities for Crisis Counselors

Assuming responsibility for representing a survivor to any organization;
Advocating in an adversarial manner on behalf of a survivor;
Becoming an expert on disaster relief and recovery programs outside the CCP;
Becoming involved in the development of community resources for disaster relief;
Creating or implementing emergency preparedness activities;
Engaging in disaster relief fund raising activities for victims;
Completing applications and appeal forms for disaster victims;
Providing child care services or transportation for disaster victims.

For More Information
This program guidance was developed to ensure that the context, boundaries and strategies of the Crisis Counseling Program are consistently implemented throughout the United States. If program managers have questions regarding this guidance, they should contact their State disaster mental health program director for clarification. If the State program director needs additional guidance, he or she should contact their CMHS Project Officer.

Center for Mental Health Services
Emergency Services and Disaster Relief Branch
5600 Fishers Lane, Room 17C-20
Rockville, MD 20857
(301) 443-4735
(301) 443-8040 FAX

11/2000

Emergency Mental Health and Traumatic Stress

Case Management and Advocacy within Crisis Counseling Programs

Emergency Mental Health and
Traumatic Stress