SAMHSA's National Mental Health Information Center

Online Publications

Order Publications

National Library of Medicine

National Academies Press

Publications Homepage

printer friendly page

e-mail this page

bookmark this page

shopping cart

current or new account

Mental Health Response to Mass Violence and Terrorism

CHAPTER IV: Organizational Preparation and Response to Mass Violence and Terrorism and the Mental Health Role

Following a mass casualty criminal incident, emergency response priorities involve saving lives, protecting the safety of first responders, securing the crime scene, and initiating investigation activities. The mental health response must not interfere with these priorities. Mental health providers often are unfamiliar with the unique demands associated with responding to criminal mass victimization.

In particular, mental health responders must be oriented to three critical aspects of emergency operations: (1) the incident command structure and the position and function of mental health in that structure; (2) first responder immediate response priorities following a mass casualty incident; and (3) the role and boundaries of the mental health response in an ongoing criminal investigation. Preplanning, training on response protocols, and preestablishing relationships and channels of communication are essential for effective integration of mental health services into the overall emergency response.

States vary in their levels of emergency mental health preparedness. States are working toward clearly defined and practiced plans that involve coordination between the Department of Emergency Management (DEM), the Department of Mental Health (DMH), law enforcement agencies, and the crime victim assistance and compensation agency at the State level. They also are coordinating with the necessary county and local mental health response plans and cadres of trained providers. This degree of planning and preparedness requires a high level of commitment, funding, a State mandate, and repeated training and drills. This process helps ensure that appropriately trained mental health providers are available to respond and provide mutual aid of mental health services following community crises.

The community's emergency response must be carried out in a protocol-driven and efficient manner. This saves lives. Mental health responders must understand that they are part of the larger organizational structure. During the emergency response phase, mental health workers have a support role and operate in settings and circumstances controlled by other entities.

Emergency Operations

The scope, complexity, and nature of an incident determine the level of emergency response. The local jurisdiction responds initially, but large-scale mass casualty incidents often require a multicounty response, a State response, or a Federal response. Many communities use the Incident Command System (ICS) structure or a locally determined variation to organize and manage the emergency response. The ICS is a standardized approach for commanding, controlling, and coordinating the response to all types and sizes of emergency incidents.

An effective ICS structure includes common terminology, integrated communication, a top-down organizational structure, and comprehensive resource management. This standardization helps expand the incident response when the demands of the emergency situation exceed available resources. Figure 3, the first organizational chart, illustrates the ICS. Figure 4 shows the ICS with a Unified Command (UC) with police, fire, and Emergency Medical Services (EMS) in charge. A mass casualty incident would necessitate this type of structure (Federal Emergency Management Agency, 1998).

The Incident Commander, the first senior emergency responder to arrive at the scene, is responsible for protecting life and property and implementing the response plan. The Incident Commander is accountable for both first responder and public safety. Command can be transferred as an incident becomes more complex and as the responsible agency jurisdiction changes. Authority may shift as the cause of the incident becomes clearer. For example, the local fire chief may respond to an explosion and be the Incident Commander.

At the local level, the Police and Sheriff's departments, Emergency Medical Services (EMS), Urban Search and Rescue, the Fire Department, the Medical Examiner's Office, the Department of Emergency Management, and the American Red Cross may have high-profile roles (Federal Emergency Management Agency, 1998). If an incident is human-caused, jurisdiction may shift or expand to include State law enforcement. If it is determined to be an act of terrorism, authority shifts to the Federal Bureau of Investigation (FBI) (United States Government, 2001). The FBI has a law enforcement function and oversees technical activities such as forensics, intelligence, negotiations, and the investigation.

Figure 3: Incident Command System (ICS) Organizational Components

Interagency Domestic Terrorism Concept of Operations Plan

Figure 4: ICS Unified Command

Interagency Domestic Terrorism Concept of Operations Plan

As shown in Figures 3 and 4, four functional components support incident management: planning, operations, logistics, and finance/administration. These components are the foundation upon which the ICS is built and apply to routine emergencies as well as to mass casualty incidents. The ICS operates at an Incident Command Post located near the site of the incident. The Operations Section Chief or logistics Section Chief may request mental health services, and chaplaincy services for emergency responders at the staging area, a respite area, or as they end shifts. Mental health services may be requested for families and loved ones gathering near the disaster impact zone, which is also a crime scene. Initially, when crisis mental health response plans are not in place, these services usually are provided by mental health professionals, or chaplains affiliated with the local Fire and Police Departments. In States prepared with an integrated crisis mental health plan, providers from the local mental health agency may respond to the scene. In the future, "crisis mental health" or "victim services" may become a recognized and established component within the Operations Section of the ICS for incidents involving criminal mass victimization (B. Hammond, personal communication, 7/30/01).

Crisis Mental Health Response

The Incident Commander is responsible for the on-scene response. When there are multiple sites of impact or a need for a more communitywide response, an Emergency Operations Center (EOC) typically is set up by the local or State Department of Emergency Management (DEM). The EOC is where department heads, government officials, and volunteer agencies gather to coordinate the larger community response. The Incident Commander establishes and maintains liaisons with primary responding agencies and organizations, including the EOC. At the EOC, the public health or human services functions have jurisdiction over mental health services for the public. The DMH may be requested to manage the delivery of mental health services at particular sites. Depending on the State's level of preparedness, the DMH may or may not be able to respond to the request.

Voluntary agencies such as the American Red Cross (ARC) are often represented at the EOC. The ARC usually has responsibility for mass care, including feeding and sheltering victims. The ARC disaster mental health function is activated following mass casualty incidents. ARC disaster mental health services (DMHS) personnel quickly arrive onscene to provide mental health support for victims and family members and to provide stress management services for other ARC staff and volunteers. Local mental health providers initially may volunteer through ARC or provide services under other auspices. Coordination between ARC disaster mental health services providers, the State's mental health workers, and responding crime victim assistance providers is essential.

COORDINATION BETWEEN ARC DISASTER MENTAL HEALTH SERVICES PROVIDERS, THE STATE'S MENTAL HEALTH WORKERS, AND RESPONDING CRIME VICTIM ASSISTANCE PROVIDERS IS ESSENTIAL.

An excerpt from the Federal Emergency Management Agency (FEMA) After Action Report from the Oklahoma City bombing demonstrates this collaboration and partnering:

The American Red Cross (ARC), which is responsible for immediate protective measures for disaster victims, worked in concert with local clergy and other support groups to establish the Family Notification Center, also known as the Compassion Center. For two weeks, 250 mental health professionals volunteered their expertise in support of the shocked and griefstricken community. The center provided victim information, crisis counseling, and resource information at one location to better assist victims' families and friends.

(Federal Emergency Management Agency, 1995)

Similarly, in New York City following the September 11 terrorist attacks, the Mayor's Office established the Family Assistance Center for families of victims, survivors, and others affected by the attacks. Numerous Federal, State, and city agencies; insurance companies; legal assistance resources; World Trade Center companies; and voluntary agencies were represented.

Mental health, crime victims services, therapeutic child care, translation services, spiritual care, and disaster psychiatry services were available. Hundreds of providers worked under the auspices of the State Office of Mental Health, ARC, the State Crime Victims Compensation Board, local crime victim assistance programs, and Disaster Psychiatry Outreach. All providers had special identification (ID) for access to the Family Assistance Center.

Managing the outpouring of volunteers wanting to provide mental health support has become a challenge following recent mass casualty incidents (Center for Mental Health Services, 2000b). When local planning and preparatory mental health training have not taken place, the genuine need for mental health services will remain unmet until these mental health volunteers are screened, oriented, and integrated into the emergency response. Systems must quickly be established to: track mental health provider contact information, availability, relevant professional experience, and areas of specialization; check credentials; schedule; and provide ID badges. No individual should be allowed to provide mental health services without proper identification, authorization, and orientation. To avoid the need to develop and implement systems under emergency conditions, communities are advised to develop systems before a disaster occurs.

In many parts of the country, the immediate mental health response often occurs in a crisis-driven manner, drawing from resources that happen to be available or from invited "experts" who are flown in for several days or weeks. The ARC may bring in hundreds of trained disaster mental health volunteers over a period of weeks or months, but eventually the local mental health system assumes responsibility for mental health services.

Key Considerations For Mental Health Providers Responding to Criminal Mass Violence

Mental health providers must be knowledgeable about the issues unique to responding to a mass criminal event. Emergency responders face unfamiliar circumstances, uncertainty about what might happen next, and lack of precedence on how best to respond. Operational decisions with far-reaching consequences must be made rapidly and often with partial information. Mental health workers need to recognize the larger context and conscientiously follow guidelines set forth by the mental health response manager and the Incident Commander. The following parameters provide further guidance for mental health responders:

The Incident Commander is in charge and directs when and where mental health services are provided. The mental health response is subordinate to the emergency response, the goals of law enforcement, and the criminal investigation process. Mental health responders provide emotional support, stabilization, and assistance as directed by the Incident Commander. In most instances, victims and witnesses initially are interviewed by investigators before they can speak with mental health providers. Frequently, mental health providers are first assigned to work with worried and frantic loved ones at the crime scene;
Securing and protecting the crime scene are law enforcement priorities. The scene of the incident automatically becomes a crime scene and the focus of a criminal investigation. Anything contained within this "crime scene" area may be evidence. Evidence must not be disturbed before it has been documented and collected, thus necessitating tight security and control by law enforcement officials (e.g., the FBI, National Guard, local police officers). Unauthorized passage through a secured area could jeopardize the safety of emergency workers and mental health workers. Mental health responders and victims' loved ones do not have access to the crime scene and are frequently directed to a nearby site. This may cause distress for family members who want to help locate and rescue their loved ones. Mental health responders may be asked to help distraught family members at a gathering site or hospital. Mental health workers must remain within the geographic boundaries of their assignments and have appropriate identification and legitimate assignments for access to protected areas;
Information regarding the status of victims is released by designated government officials through sanctioned channels. Through the course of coordinating with emergency responders, law enforcement, or the Incident Commander, mental health providers may learn the status of individual victims. whether they were killed, injured, or missing. Families are desperate for this information. However, it is outside of the mental health responder's role to deliver this information to families, the media, or anyone else before it has been officially verified and formally provided. This can be a challenging and stressful position for mental health providers (R. Benedetto, D.P.A., personal communication, 7/31/01). In fact, mental health providers may choose to avoid seeking this information before official family notification or only receive it as a part of briefing for their immediate support role with a particular family;
Mental health providers must work within established protocols for dealing with the media to protect survivors and families. Catastrophic mass casualty disasters attract considerable media attention. Typically, reporters seek interviews with victims and those most seriously affected. They may approach mental health providers to gain access to victims. Mental health responders should not act as agents for the media, and recruit or coach victims. Also, mental health providers should avoid describing how first responders, victims, and family members are reacting when giving media interviews, which can give the appearance of a violation of confidentiality and might undermine the credibility of mental health efforts. The mental health response manager coordinates with the Incident Commander to clarify protocols and to ensure that adequate security and protection from the media is provided for survivors and bereaved family members. In addition, the mental health response manager works with the ICS Public Information Officer to ensure appropriate mental health information is provided to the public. Using the media to disseminate helpful mental health information is a valuable way to reach large numbers of people. Under no circumstances should mental health responders provide information to the media without prior authorization sanctioned by the agency or organization of which they are a part; and
Conflicts may arise between law enforcement's search for information relevant to the criminal investigation and the prosecutorial process and mental health's protection of client confidentiality. Pre-incident planning, coordination, communication, and cross-training between law enforcement and mental health providers can alleviate turf battles regarding roles and boundaries (B. Hammond, personal communication, 7/30/01). Teamwork and cooperation are fostered through a respectful understanding of each group's responsibilities and obligations. Mental health providers are not trained to be detectives or to know what information is relevant to the investigation process, yet they may counsel witnesses or suspects. They have a legal and ethical duty to protect the privacy of those with whom they speak. Mental health goals are to stabilize survivors' emotional reactivity and to facilitate appropriate coping, which also may enable survivors and family members to participate more helpfully in the investigative process.

Mental health providers should consult first with their clinical supervisor or the mental health response manager with questions regarding whether information gained through a counseling contact has relevance to the criminal investigation (R. Benedetto, D.P.A., personal communication, 7/31/01). A determination may be made for the worker to maintain confidentiality and to trust that the criminal investigative process will uncover the information, or the mental health response manager may consult with the agency's legal counsel or the State's attorney. Ideally, the mental health response manager and the Incident Commander have a cooperative alliance for sorting out these inevitable challenging dilemmas.

Crisis Mental Health Response: Future Directions

Every community should have a Crisis Mental Health Plan as part of its overall Emergency Operations Plan. Local mental health providers are pretrained and their job descriptions include responding to the psychological needs of first responders and community members during and after community crises. Crisis mental health responders may be drawn from community mental health centers, crime victim assistance programs, faith-based counseling agencies, and social service agencies that serve special populations. While involving mental health professionals as volunteer responders adds depth to human resources, the community's crisis mental health plan should not rely on volunteers only. Management and supervision positions, in particular, should be filled by individuals whose job descriptions include these responsibilities. In addition, responders should be prepared to step into the community's ICS and EOC structures and have prior relationships with the key players.

EVERY COMMUNITY SHOULD HAVE A CRISIS MENTAL HEALTH PLAN AS PART OF ITS OVERALL EMERGENCY OPERATIONS PLAN.

The crisis mental health plan fits more effectively into the overall emergency response when the ICS management structure is used. An On-Site Commander functions as the mental health response manager and stays at the Incident Command Post or the EOC, coordinates with other responding entities, receives information from the field, and manages and directs the mental health response and resources. A Personnel Coordinator must be activated quickly to facilitate callout and deployment of mental health personnel. Depending on the magnitude of the incident and the degree of mental health preparedness of the community, the response structure may range from paralleling the ICS to providing limited mental health support at designated sites. At a minimum, each site should have a Coordinator, and every five mental health responders should have a Lead. The City of Austin Mental Health Crisis and Disaster Plan provides an example of a plan that utilizes the ICS structure and is integrated into the local emergency response and the crime victim services agency (see Recommended Reading at end of this chapter). While specific descriptions of comprehensive crisis mental health plans are beyond the scope of this manual, the following components generally are addressed:

Training and guidelines for crisis mental health interventions;
Descriptions of assignment settings and mental health roles;
Callout, deployment, human resource management;
Certification and badging for responders;
ICS and EOC structure, responsibilities, and the role of mental health;
Mental health response management, supervision, and line-staff roles and responsibilities defined;
Services to special populations, use of interpreters, guidelines, and resources;
Communications, transportation, supplies, and logistics;
Public information and dealing with the media;
Mutual aid agreements; and
Mental health staff stress management.

Every State Mental Health Authority (SMHA) should have a federally funded full-time position for disaster mental health planning and response and a State disaster mental health plan (Center for Mental Health Services, 2000b; American Psychological Association Task Force, 1997). The State disaster mental health coordinators' responsibilities typically include: (1) ensuring that all counties have plans and participate in drills; (2) providing repeat training on disaster mental health for all counties; (3) maintaining a resource bank of post-disaster psycho-educational materials; (4) maintaining cooperative relationships with State, Federal, and voluntary agencies involved in emergency and disaster response; and (5) helping counties obtain Federal grants for post-disaster mental health services.

Long-Term Mental Health And Crime Victim Assistance Services

The Office for Victims of Crime (OVC) has authority to provide assistance to victims of acts of terrorism or mass violence. Since victims of terrorism and mass violence experience a range of physical, financial, emotional, and legal needs that may persist over an extended period of time (Office for Victims of Crime, 2000), Federal funding that supplements existing State resources is available. OVC assistance includes funding for counseling, community needs assessment, crime victim services, and technical assistance and training. State crime victim compensation programs reimburse crime victims or their families for out-of-pocket expenses such as medical expenses, mental health counseling, funeral and burial costs, and lost wages related to their victimization. State and local victim service agencies provide assistance to victims of Federal and State crimes such as criminal justice advocacy, temporary shelter, and crisis counseling (U.S. Department of Justice, 2001). Eligibility and benefits vary from State to State, and may change with the particular terrorist or mass violence event, so mental health providers and others working with victims should learn about Federal and State eligibility requirements. OVC coordinates with local and State programs to maximize services for victims. For information about OVC grant programs, see the OVC Resource Center Web site at www.ncjrs.org or call 1-800-851-3420.