Historical changes in the care of people with mental illness and homeless persons living in the community have resulted in at-risk populations needing special help after a disaster. Although the number of such individuals housed in shelters or in damaged dwellings may be small in comparison to the total population, each case may need skillful handling and different approaches. Most disaster survivors who have existing mental problems will need additional help beyond crisis intervention.
Individuals suffering from a diverse variety of mental illnesses will exhibit differing reactions to the many stressors following a disaster. In a post-disaster situation, these individuals will fall into three major categories:
Individuals living in hospitals in the damaged areas: For these individuals, problems in their daily living arrangements will have been disrupted by interference with the availability of electricity, water, food, medical care, and nursing staff.
Individuals living in group homes: These individuals may be affected by loss of their homes, alteration of their surroundings, or limited access to medication. The loss of a familiar setting may increase the acuteness of their emotional reactions, which may, in turn, be manifested as symptomatology.
Individuals living with their own or foster families: These individuals also may have increased symptoms due to factors similar to those for individuals living in group homes.
If individuals are accompanied by a familiar adult helper, it may not be difficult to ascertain the diagnosis and the medication needed. This is not the case if the individual is discovered alone; in such cases, the signs of disturbance in cognition, disorientation, and severe difficulty in explaining who he/she is will make it clear that this is an individual who needs special attention. Individuals who cannot follow simple, life-preserving instructions will need individual monitoring. However, during a disaster, it is always necessary to rule out any undiagnosed head injuries that might cause similar symptoms.
Individuals who manifest behavior that appears inappropriate for the situation should be given a rapid assessment. The crisis worker should ask for consultation to differentiate between individuals suffering from acute stress and those with mental illness according to whether they exhibit the following conditions:
Stress reactions Changes in cognition-orientation, memory, thinking, and difficulty in decision-making; changes in emotions, lability, blunting, flatness; no break with reality awareness or loss of self-identify; behaves within social conventions and relates in a passive way.
Acute psychotic reactions Expressions of anxiety, affective, and thinking behaviors; subdued response to emergency; ranges from apathetic, depressed, expressing bizarre thinking or difficulty in understanding to hyperactive, manic, unrealistic, and difficult-to-control behavior.
Effect of head injuries Signs can mimic the characteristics of many psychiatric disorders; a neurological exam may show signs of trauma.
A number of individuals with mental illness are dependent on medication, and obtaining information about their regimen should be a priority. This should be followed by an attempt to structure their schedules and remove the patients from intense stimuli situations whenever possible. Using other survivors to assist in basic daily living activities may also be beneficial.
Disaster survivors are suddenly and painfully thrown together into a desperate and unfamiliar setting. The behaviors that emerge as they try to cope and adapt could be defined as "antisocial" if they break rules, do not accept schedules, refuse to take their turn dealing with helpers, or are identified as "trouble-makers" who may also steal and lie. Diagnosing these behaviors and sorting out which are motivated by anxiety and which by character disorders can challenge the skills of disaster workers. Because diagnosis must be rapid during the emergency phase, it may be difficult to ascertain the motivating emotions driving antisocial behavior. The best approach is to increasingly set limits on disruptive actions.
Survivors who act out due to anxiety will experience relief if structure and support are provided. They will express mortification or guilt, and will verbalize some of their fears. In the case of aggressive, self-centered, and nonempathetic individuals, crisis workers need to use stronger measures, including segregation from the group, until more individual measures are available.
Except for those with severe cases, most individuals with mental retardation will not need special measures other than instructions on how to manage in the shelter or obtain resources offered by agencies. Some careful explanation of what has happened and what plans have been made for the next few months may be of great relief to them. In cases where mental retardation is severe and accompanied by physical handicaps, it may be necessary to ask another survivor to assist in daily hygiene, feeding, and sleeping activities.