development of an emergency preparedness assessment tool

Development of an Emergency Preparedness Assessment Tool for Handling Disaster Victims Who Have Serious Mental Illness

Justin McConnell

Clemson University


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Abstract Anecdotal evidence from recent disasters across the United States highlight the need for

emergency preparedness professionals to include the distinct needs of people who suffer from

Serious Mental Illness (SMI) in emergency operations plans. Considering the needs of this

population is an ethical and legal requirement set forth by several legislative measures. The

specific population suffering from SMI and their needs during a disaster may need to be

considered, not as an annex, but within an intentional framework of local, state and federal

emergency operations plan. This demonstrable need has prompted the development of an

assessment tool for emergency planners to use to ensure that the needs of this population are not

neglected. This tool addresses ways for emergency planners to preserve the autonomy of people

with SMI during an emergency; including communication, medical needs, independence,

supervision, and transportation (CMIST). This tool can be used as a self-assessment, or by a

second party, to assess the readiness of a jurisdiction to handle people with SMI during a

disaster. This tool was piloted using a survey instrument to all county level emergency

preparedness offices in the state of South Carolina. The results of this survey illustrate that the

current state of planning to accommodate the functional needs of those with SMI is inadequate in

South Carolina. Using this tool to pilot this research provides an early foundation for further

study and evaluation of this important issue. The hope is that this research jumpstarts

conversations and research to help plan for these vulnerable populations in times of disaster.


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Acknowledgments

It is with the unending patience and valuable guidance of my Capstone Committee that I

was able to conduct this research. I would like to thank all of you for having faith in me and this

project. Each of you have had a positive impact on me throughout my time in this program and I

hope to take the information and direction that you have given and use it in a way that allows me

to have that same impact on someone in the future.

I would also like to thank Dr. Chris Martin for always answering the phone when I had a

question or needed some after hour guidance. Without his help I would not have been able to

produce this quality of work. Your guidance and friendship have been invaluable to me through

this process.

None of this project would have been possible without the unending support from my

family. My kids Hailey, Samantha, Reese and Harper have been very understanding when I was

unable to be there for them because I was working on this. They all helped make this possible by

being amazing children and going the extra mile to pick up my slack. My wife Christan has been

amazing through this process as well. She was there to encourage me when I was struggling,

celebrate with me when I got a win, and give me the push I needed when I wanted to quit. She

has been my rock and my inspiration.


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Table of Contents Acknowledgments 3

List of Tables Table 1: Participant responses to the question about the importance of planning and preparing for disaster victims who live with SMI and whether their organization prepares for this? Table 2: Tally of participant responses to survey questions about communicating to those with SMI before, during, and after a disaster. Table 3: Tally of participant responses to survey questions about addressing medical needs of those with SMI before, during, and after a disaster. Table 4: Tally of Participant responses to survey questions about helping people with SMI maintain their independence during and after a disaster Table 5: Tally of Participant responses to survey questions about helping people with SMI, who need supervision, are accommodated during and after a disaster. Table 6: Tally of Participant responses to survey questions about helping people with SMI with transportation issues during and after a disaster.

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Introduction 5

Review of Literature 12

Research Objectives and Methodology 20

Results 24

Discussion 36

Future Research 40

Conclusion 42

Appendix A (PATSMI Survey) 44

Works Cited 46


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Introduction

In emergency management planning and preparation, the laws and recommendations to

date have been relatively broad and general in relation to the populations they are considering. In

the field, the term special needs appears to be used to characterize all individuals that are not

completely self-sufficient, and as it is used today would embody 50% or more of the US

population. (Kailes & Enders, 2007). As a profession, it can be argued that we may fail the

people who trust us to plan for their needs when we make a broad generalization like this and

neglect the intricacies of varying functional needs across different groups. These generalization

leave a wide berth to conduct research on the needs of this vulnerable part of our population and

to determine more effective ways to serve them in their time of greatest need.

There has been an extensive amount of research performed and information published

about disaster preparedness, response, and recovery (Alexander, 2015; Blackman, Nakanishi, &

Benson, 2017; Hernantes, Labaka, Turoff, Hiltz, & Bañuls, 2017) . There is specific research

focused on preparation for, response to, and recovery from natural events (Tierney, Lindell, &

Perry, 2001), articles published on how emergency managers should plan for, respond to, and

affect the recovery from terroristic activities (Perry & Lindell, 2003), and some research has

focused on the effective use of social media to aid emergency preparedness, response and

recovery (Houston et al., 2015). While focusing on specific groups has not been the primary

focus of this field, there is some research on the disproportionate effects of natural disasters on

those who live in poverty (Fothergill & Peek, 2004). Governments around the world have

invested a considerable amount of time and money into disaster preparedness (Perry & Lindell,

2003). However, there is an area within this broader field that seems to have been neglected; how

to prepare for the needs of patients with Serious Mental Illness (SMI) throughout all phases of a


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disaster. Published research primarily focuses on the acute stress reactions of victims and those

who respond to disasters, but very little is focused on how disasters affect people who have

chronic mental illness. Within the field of emergency management and disaster preparedness

there needs to be a greater focus placed on this issue. The issue of improper, inadequate, or non-

existent care of these victims is one that has been gravely overlooked by the professionals in this

field.

The patient with chronic significant mental illness, like a patient with cancer, or a patient

who is diabetic, requires continuous care and will deteriorate rapidly if normal care is

interrupted. A disruption in care can be caused by many logistical, legal, or financial reasons

following a natural or man-made disaster. Preparedness for these issues can make it possible to

work through and around obstacles and can ensure that quality of life is preserved for these

patients. The planning and preparing for these events with these types of issues in our line of

sight can greatly decrease the impact realized by target populations, like those that are mentally

ill.

To fully understand the difficulties faced by these patients during a disaster there needs to

be an agreed upon definition of serious mental illness. The American Psychiatric Association

defines a person with SMI as someone who has a diagnosis of one of several conditions such as

schizophrenia or related psychotic disorder, bipolar affective disorder, autism, major depression,

obsessive-compulsive disorder, or panic disorder, and that the diagnosed mental illness causes a

marked interference in the patient’s daily living processes (American Psychiatric Association,

2000). Patients suffering from SMI exist in all communities, age ranges, and demographics.

There are recent estimates that suggest 8.26 million United States citizens suffer from SMI

(Pearson & Fuller, 2007)


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Patients with SMI may exhibit any number of reactions in emergency situations. The

physical effects of emotional and mental issues can cause a person to need a wide range of

assistance measures during a disaster. A person facing a major depressive disorder may not

respond quickly to instructions and may have a decreased appetite (Hall, 2010). The former issue

is concerning because in emergent situations a quick response to instruction is imperative to

survival. As well, a decreased appetite, along with other physical symptoms, can have serious

implications on a person’s health making them more vulnerable to a weakened immune system

and other health consequences (Hall, 2010).

Anxiety disorders can cause a patient to have difficulty functioning properly as well, but

for different reasons. The increased stress of the emergency can precipitate acute anxiety or

panic attacks (Hall, 2010). This condition, while generally not life threatening on its own, can

have grave consequences in an emergent situation. The panic attack itself can cause rapid

breathing, palpitations, and dizziness, all of which can cause muscle cramping. It is also possible

that these situations may result in a patient not being able to comprehend or be capable of

following instructions. Disorders on the spectrum of psychosis can evoke feelings of paranoia

and reclusiveness. These people may not be able to attend to their own hygiene and the disaster

situation can exacerbate paranoia (Hall, 2010). Another area of concern is the media’s repeated

portrayal of images displaying damage, death, and destruction. This type of exposure can cause a

paranoid schizophrenic patient to have delusions of terrorists attacking that person directly

(Nathanson, 2010).

While not within the scope of this research, there are other groups that may face

challenges in a disaster situation. For example, those with Autism spectrum disorder and post-

traumatic stress disorder are groups of individuals who may need critical attention during a


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disaster situation. Those with SMI, and others, would benefit from targeted research covering

best practices for mitigating the effects of a disaster and ensuring continuity and continuation of

the care they are receiving before a disaster happens.

There is an endless array of disaster scenarios for which one could plan. Everything from

a terrorist attack, to a plane crash, or a massive natural disaster could affect any town in any part

of the world at any time. These disaster situations have the potential to disrupt a jurisdiction in

many ways, one of which is their ability to attend to the functional needs of its citizens. No

matter the cause, disruptions in care for those with SMI is an area of concern as communities

plan for potential events. For example, loss of infrastructure and damage to facilities will be a

barrier for receiving medications, as well as seeing counselors. It would likely be nearly

impossible to gain access to mental health services during, and directly after the incident

(Rutkow, Vernick, Wissow, Kaufmann, & Hodge, 2011). These disruptions are likely to reach as

far as the patient’s primary care provider’s office or the pharmacy where the patient’s

prescriptions are filled. These two areas are essential for mental health care and after a disaster

they may be non-existent. According to Arietta et.al (2007), this infrastructure is essential for the

continuous provision of care to all patients with chronic disease.

While there is little research available which specifically targets disaster preparedness for

those with SMI, there has been at least one analysis performed examining the personal

preparedness of those with SMI when compared to those who do not suffer from this disability.

This research found that a person with SMI is 1.81 times more likely to be unprepared for a

disaster than a person without mental illness (Smith & Notaro, 2015). This illustrates not only a

disparity in the preparedness between these two groups but also a need for emergency


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preparedness leaders to pay more attention to how they intend to respond to this population in a

disaster setting.

One of the challenges with SMI populations is their needs are not always clear unless

there is robust planning and coordination. For example, individuals who live with

communication disabilities such as deafness or blindness have a functional need which is

relatively easily combated with alternative communication sources already available to the

public. These include visual alert systems for people who are deaf or hard of hearing and

vibration alerts for those who have difficulty seeing. There is, however also a need to plan for

those who interpret information differently. Many people with SMI have difficulty responding to

emergency information and often do not have the capability to respond in the predicted manner.

Their difference in reaction to information may also require them to have trained friends or

family who help facilitate their responding appropriately to an event (Center for Mental Health

Services, 1996).

These individual level challenges, combined with a gap in planning by emergency

management organizations, has the potential to have detrimental effects on an already vulnerable

population. This has played out in recent disasters across the world and more specifically in the

US. Hurricane Katrina, which struck the Gulf Coast of the US in 2005 illustrated the many

complications faced by those with SMI in a disaster setting. The difficulties were felt during the

evacuation due in part to the inability of some with SMI to comprehend evacuation messages and

to follow instructions during the process. This led to them being treated harshly and unfairly

(National Council on Disability, 2006) A number of these issues replayed themselves in August

of 2017 when Hurricane Harvey made landfall. A report published by CBS News which

indicated that a number of homeless people were turned away from shelters during Hurricane


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Irma because the operators were afraid that those requesting shelter were either mentally ill or

sex offenders (Assosciated Press, 2017).

The maltreatment of those with psychiatric disabilities continued inside of the shelters, as

many facilities were ill prepared to house people with such needs. It has been widely reported by

patrons of general shelters, advocates, those with psychiatric disabilities and first responders that

people with SMI face challenges difficulties with general shelters. These problems included the

loud, chaotic, and crowded atmosphere of shelters, as well as violent acts that occurred within

the shelters (National Council on Disability, 2006). These situations can make it difficult for

someone with SMI to cope during a disaster. In the cases above, many people with SMI who

smoked were not be allowed to return to the shelter after smoking and had no choice but to live

on the periphery of the shelters. This caused many with SMI to be refused service because the

shelters would only serve those inside. There were a few “special needs” shelters set up but they

were mainly in place to serve those with physical and medical needs not those with SMI

(National Council on Disability, 2006). The disparity was also evident in the fact that, in general,

many people with psychiatric disabilities in emergency shelters were segregated from the

general shelter population with physical barriers and did not have contact with the rest of the

population (National Council on Disability, 2006).

There have also been complaints by some homeless people that, during Hurricane Irma,

in at least one shelter they were given wrist bands that were yellow to identify them as homeless

and that they were to stay in an area with others who had yellow wristbands. The reason for this

was because of their potential to be either mentally ill or have a criminal history. Once they were

separated they were then denied other needs such as food, cots and medical care (Assosciated

Press, 2017). The discrimination went even further; when a shelter did not have the resources or


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ability to serve a difficult patron they would send them to jails, emergency departments, or

mental institutions. During the Hurricane Katrina evacuation, many shelters in Texas, where

evacuees were being taken from other states, attempted to place those with SMI into in-patient

psychiatric beds, as representatives felt that those with psychiatric disabilities “didn’t blend well”

with the general population(National Council on Disability, 2006). This lack of planning can

easily be interpreted as discrimination and did not uphold the ethical requirement of the entities,

whose mission should be to protect all vulnerable populations.

Unfortunately, this discrimination did not stop once the disaster was over. There were

also many issues faced by those with SMI in the recovery and relief phase of Katrina. One

example is the difficulty that some with SMI had in navigating the FEMA bureaucracy alone and

the denial, by some shelters to allow relief advocates into the shelter to help this population with

understanding the paperwork. At least one person was wrongfully denied housing by FEMA

because they were concerned about her mental health status. The result of this denial was a

functional person with SMI spending months in a psychiatric institution despite the opinion of

mental health professionals that she was perfectly capable of living in FEMA housing (National

Council on Disability, 2006). Another way that people with SMI were excluded from service is

that many were denied government funding for crisis counseling based on the fact that they had a

pre-existing mental health diagnosis (National Council on Disability, 2006). Hurricane Katrina is

one example of how unprepared emergency managers are to appropriately handle those with

SMI before, during and after a disaster.

The disparities illustrated above are not isolated to this disaster and there are many more

examples that illustrate this challenge. A population that has a disability which leaves them more

vulnerable, less able to prepare, and more likely to need assistance needs to be at the forefront of


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our planning. They need to not only be part of the plan but involved in making the plan (National

Council on Disability, 2006). The difficulties faced by people with SMI are many and there

needs to be a plan in place to make the navigation of a disaster as efficient and effective as

possible for them.

I will set the stage for my research with a thorough review of the pertinent literature

about serious mental illness and disasters. Next, the methodology and survey instrument will be

examined. Following this examination there will be a discussion of the results and what they

reveal about the current state of planning for people with SMI in a disaster. Finally, I will

identify topics that should be considered for research in the future.

Review of Literature

Providing public health and medical services presents complications through all phases of

emergency management and the complexity only increases as the incident progresses from the

Response phase to post event Recovery. As well, the length of the crisis may further complicate

the needs of different populations. One area of response and recovery that is often neglected is

the inclusion of populations with functional and special needs in the planning efforts across all

disaster stages. The social and community aspect of this area of disaster management is one that

presents some unique challenges and is often left out when conducting planning sessions. Of

special interest are the functional needs of populations with pre-existing serious mental illness,

who also become victims of disaster. This problem is not well researched and presents a

significant challenge in all phases of disaster management.

Disaster victims who already suffer from mental disease are more vulnerable than the

general population for a couple of key reasons. First, many people with serious mental illness


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live in poverty. According to the World Health Organization (WHO) those suffering from SMI

are twice as likely as the general population to live in poverty (World Health Organization,

2007). This disparity makes it difficult to plan for this group of citizens because they are often

not as self-sufficient as those living without SMI. The second part of this problem is that people

with SMI may not react to stress in the same manner as a person who does not suffer from

mental illness. People with SMI may have little or no need for assistance in a stable environment

but can suffer from significant changes in functional ability when a stressor is applied to their

circumstances. Those who suffer from conditions of a psychiatric nature may become disoriented

or incapable of functioning in an unfamiliar environment (Kailes & Enders, 2007).

Disaster planning places a substantial amount of effort on the continuation of care for

people with medical illness and disability, but there is little consideration for those who have

serious mental illness. One issue with SMI patients is that due to their decreased socioeconomic

status they lack many of the resources available to people who are not impoverished. Medication,

transportation, and a place to evacuate are major life needs to which the poor may not have easy

access. Many of these patients are Medicare or Medicaid recipients and because Medicaid is a

state administered, federally funded program each state can impose its own requirements and

restrictions. One restriction is how long a relocated person can use Medicaid in a different state

from the state of origin. This can lead to some difficulties especially for displaced people who

are unaware of these regulations and who fail to let the appropriate agency know of their new

address (Centers for Medicare & Medicaid Services, n.d.). Some of those evacuated during

Katrina ran into this exact issue. Due to the lack of accountability of who was evacuated where,

letters of service cancellation were sent and never received (National Council on Disability,

2006)


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By reviewing how disasters can affect pharmaceutical dispersion during a disaster, it

becomes clear that a closer investigation of this issue for SMI patients is warranted. Many

medications prescribed to treat mental illness must be taken in regular doses to maintain a

therapeutic level and failure to adhere to medication regimens can have serious negative effects

(Bellack, A. S., Bowden, C. L., Bowie, C. R., Byerly, M. J., Carpenter, W. T., Copeland, L. A.,

Zeber, 2009). These reasons make it very important for SMI patients to have immediate access to

personnel who can write prescriptions (Rutkow et al., 2011). Many of the medications taken by

people with SMI are also controlled substances and can only be prescribed by specific

professionals and may also be restricted by how many can be received within a specified time

frame (Rutkow et al., 2011). Complications also may arise with some medications that are not

controlled by law but are controlled by insurance companies. Medicare, Medicaid and many

private insurance companies set regulations against stockpiling more than a one month supply of

specific substances (Arrieta, Foreman, Crook, & Icenogle, 2009). This reveals the potential for

difficulty getting a new prescription if medication is lost during evacuation.

The Food and Drug Administration (FDA) and the Drug Enforcement Agency (DEA)

regulate the scheduling of controlled substances. Many medications used to treat mental

disorders and psychiatric conditions are Schedule II, Schedule III or Schedule IV. In most

situations only, the individual to whom a prescription is written can have controlled medication

dispensed to them. This can be a significant problem if a person has physical or financial

limitations which prevent them from reaching an alternate location to receive their medications.

Further they may have to rely on a friend or family member to ensure medications are available

(Hodge Jr., Rutkow, & Corcoran, 2014). The medication problem that will be the most difficult

to overcome is that of the patient who does not have proof of his or her medication prescription.


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This issue is a significantly more difficult hurdle because the patient will now have to be seen for

another prescription to be written and the most likely place for a medically disparate individual

to seek care is the Emergency Department at the nearest hospital.

While the planning process is critical, the emphasis on caring for this special needs

population must occur throughout all phases of disaster response, to include mitigation,

preparedness, response, and recovery (Hoffman, 2009; Kailes & Enders, 2007; Parsons &

Fulmer, 2007; South Carolina Department of Health and Environmental Control, 2016).

Emergency managers and other disaster professionals have an ethical responsibility to plan and

care for all citizens, including those with specific mental health needs. Aside from the ethical

aspect, there is also a legal obligation. According to sections 308 and 309 of the Robert T.

Stafford Disaster Relief Act of 1988 (Stafford Act), emergency planning is governed by the same

civil rights as other government entities and discrimination is strictly prohibited. Even if it is for

this reason alone, more of a concerted effort must be made to accommodate people with SMI

functional needs in times of disasters. If appropriate provisions are not made then a case can be

made for discrimination where an emergency management planning agency, and potentially

others, could be held liable.

To begin planning for the needs of those with SMI, the emergency planner must realize

that there is a range of functional needs which need to be accounted for and that no single plan

can effectively treat all individual’s functional needs. Planners should reach out to local entities

who provide functional needs services and plans to those with SMI. Emergency management

professionals should consult with relevant professionals regularly and collaborate with these

local stakeholders as these plans develop and are implemented. These entities bring knowledge

and skill sets that can assist in the formulation of emergency plans (Parsons & Fulmer, 2007).


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Gathering information about the functional needs of populations in each jurisdiction can be

difficult and time consuming. The use of many community and organizational sources that know

these populations can assist in trying to develop a complete picture of the SMI population of any

community. There are many functional needs advocacy groups, healthcare organizations, social

service agencies, and special housing developments among others who could assist with data and

add depth to the planning process. Where possible it is also important to include the

stakeholders themselves, those with SMI, into the planning process (Parsons & Fulmer, 2007).

The goal of the emergency management profession is classically utilitarian; to do the

most good for the largest number of citizens possible (Hoffman, 2009). This should include

ensuring that a population is not neglected because the profession did not consider their needs.

In their current state, plans for vulnerable populations attempt to be all encompassing and fail to

address specific needs of those people (Chen, Wilkinson, Richardson, & Waruszynski,

2009).This broad planning translates into failures in response to disasters because the plans lack

specificity for identified groups.

A framework developed to ensure that this population is adequately considered is one

where functional needs are directly targeted and specifically addressed. Research underscores

the importance of five critical needs most often associated with special needs populations. The

assistance most frequently needed by people with SMI in disaster situations are communication,

medical needs, independence, supervision, and transportation also known as C-MIST (Kailes &

Enders, 2007). Citizens with these functional needs require planning above and beyond that of

the general population and if these needs are not met in a timely manner following a disaster

there could be negative outcomes for these individuals. As noted earlier, the failure to care for


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these people and their functional needs may result in exacerbation of their conditions and relapse

for those who were adequately treated prior to the disaster (Wissow et al., 2012).

Communication is a key component of the planning necessary to account for the

functional needs of people with SMI during times of disaster. People who have a disability that

interferes with their ability to receive information and properly respond to it need to be provided

access to the same information as other populations, but in different formats (Kailes & Enders,

2007). This may require additional effort on the part of the planners, as well as the agency

responsible for disseminating emergency information. Information support such as publishing

information in multiple languages and American Sign Language, as well as ensuring that the

information presented will be understood by those with learning disabilities is absolutely critical

(Parsons & Fulmer, 2007). This provision can also include posting information in specified

public locations and assigning a time when the latest information will be presented in alternate

formats (Kailes & Enders, 2007). The goal is to ensure that the widest proportion of a

community’s population is reached given the different information mediums.

To reduce burden on the responding agencies it is important to remember that a person

may have a visible ailment or physical disability and not require any functional needs assistance.

Medical needs can be defined as those which require ongoing medical care, such as those which

would be necessary for treating patients already admitted to a hospital or in a Skilled Nursing

Facility (Kailes & Enders, 2007). These people are patients who require ongoing medical

interventions such as continuous oxygen or patients receiving regular dialysis treatments. In the

context of SMI medical needs largely applies to those treatments required to ensure stabilization

of a patient’s mental health status. The acquisition of required medications and ongoing therapy

is essential to the well-being of this population and it is important that these services be restored


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quickly (Kailes & Enders, 2007). It is also important to note that without these treatments, those

with SMI may experience negative physical outcomes due to their medical instability. This

makes restoring services increasingly important and with ongoing and minimally interrupted

intervention many people with mental disorders can continue to function normally.

The maintenance of independence for people with SMI is also essential for their

continued recovery and level of functioning. (Adair et al., 2005). By facilitating the

independence of these citizens, with the continuation of treatments and other care, in times of an

emergency many of these individuals can be housed in shelters with the general population

during the crisis. Traditional shelters may have little to no assistance for individuals beyond

food, basic health care and other basic needs assistance. A traditional disaster shelter is designed

to be a place for room and board, but they offer very little, if any medical assistance. A “special-

needs shelter on the other hand is set up to provide an established set of medical and personal

needs throughout the disaster. The ability to house those whose mental illness is stable in a

general population shelter can be valuable to the incident response teams because it frees up

space in special care shelters. The value for the individuals with SMI is ongoing independence

and preventing medical commitment or legal detention. An added benefit to responders and the

public is that independent individuals do not tie up emergency services and allows emergency

responders to handle other critical issues (Kailes & Enders, 2007).

When individuals are not capable of being independent, they require supervisory

services. The reasons that individuals do not function well on their own are many. This can be

due to an exacerbation of illness or decompensating due to trauma of the event. There are those

whose illness is such that they cannot function without help in the best of circumstances (Kailes

& Enders, 2007). These conditions can include any number of disorders that cause a person to be


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unable to respond appropriately to environmental stimuli; illnesses such as severe depression,

intense anxiety, bipolar disorder, schizophrenia and others may fall into this category. (Kailes &

Enders, 2007). From an emergency services perspective those who require supervisory care

demands additional planning and coordination with a range of public and private service

agencies to ensure that these individuals will be accommodated in times of crisis.

Transportation is also a significant problem for many SMI patients and may be a factor

limiting their ability to evacuate during a disaster. In 2015 The U.S Census Bureau reported that

9.1% of people in the United States lived in a zero-vehicle household. This equates to over 10

million citizens who are unable to evacuate without dependence on public transit or other

assistance )(U.S. Census Bureau, 2015). There are a variety of reasons individuals may not have

access to a means of transportation; along with reliance on public transportation and ridesharing,

poverty and mental illness are specific indicators that a person will not own a vehicle. Recent

data has shown that as many as 60% of those who live without personal vehicle also live below

the poverty line (Tomer, 2010) . Whether, urban or rural the transportation needs of those with

special needs will be paramount in any community emergency management plan.

The redefining of special needs and addressing the relevant issues in the context of

functional needs across different sub-populations of a community will help to better frame the

role of emergency planners in ensuring that all populations are properly cared for when disasters

strike. Assessing the functional needs of people in a specific jurisdiction is a complex yet

necessary task which must be coordinated community approach. SMI is a prevalent set of

disorders which run the gamut of functional abilities, and if not attended to, can have lasting and

devastating effects on personal, community, and regional recovery from a disaster. Ensuring that

the most basic functional needs of communication, medical needs, independence, supervision,


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and transportation are met will allow most of the patrons needing services to remain mostly

functional and will buffer the effects of the disaster on this already fragile population. It is with

this in mind that this research examines what Emergency managers are currently doing in the

state with regard to planning and preparation for the SMI population. The next section explores

the key research question in more detail and outlines the methodology of this research.

Research Objectives and Methodology

Given the critical needs of people with SMI it is argued that local emergency managers

need a tool, which allows for an effective assessment of the ability to respond to mental health

needs during a disaster affecting their jurisdiction. The aim of this study, as discussed previously

in the introduction and abstract, is to begin to develop such a tool and to use it to assess the

readiness of each county level emergency management office in South Carolina to respond to

this population should a disaster happen in their jurisdiction.

The idea behind the “Preparedness Assessment Tool for Serious Mental Illness"

(PATSMI) was based on the five functional needs discussed by Kailes and Enders (2007) who

identify these needs as universal for all populations with special needs. They also concluded that

accounting for the functional needs of certain populations is essential to making a jurisdiction

more prepared to care for all people. There was also a significant amount of influence and insight

from the research of Parsons and Fulmer (2007) when they determined that the term “special

needs” is too ambiguous and has been used inconsistently to describe many different

populations. They went on to explain that the term functional needs “…fosters the development

of an operational set of predictable supports.” (Parsons & Fulmer, 2007 p. 4).


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To develop the PATSMI, an evaluation protocol was developed to test the potential of

this type of tool for the emergency management community. The evaluation tool covers all five

areas of functional needs that have been discussed; communication, medical needs,

independence, supervision, and transportation. These were shown to be the primary needs for

disaster victims who require functional assistance. While each person needing assistance may

prioritize these needs differently, from an emergency planning perspective, all needs must be

addressed for the individual. PATSMI was framed to allow each emergency manager to answer

questions about how their emergency plan incorporates functional needs assistance for those who

suffer from SMI. The survey was validated by a content expert to ensure that the questions were

unbiased and offered a valid representation of the subject matter.

The tool was distributed, based on a sample of convenience, to all 46 South Carolina

county emergency management offices. PATSMI was sent by an email invitation through Survey

Monkey (“Survey Monkey,” n.d.). The email was addressed to the director of each agency with

instructions on how to access the questionnaire and record answers. There was a total of 36

questions, with the majority being Likert scale responses. Questions were framed to examine

respondent’s support of more robust planning efforts, whether they currently planned for

individuals with SMI and if their organization supported more targeted planning efforts for

individuals with SMI conditions. There were also demographic questions and space available

under each response for participants to provide further information, ideas, or experiences.

Respondents could opt out of any question, any section, or the entire questionnaire.

Survey research often encounters limitations and this research is not exempt. Sample bias

is one of the ongoing challenges with this type of work. This bias is a concern because the

individuals who received the survey had absolute discretion over whether to respond to or refrain


22

from participating in the collection of data. An individual’s pre-conceived beliefs about the need

to specifically include people with SMI in emergency planning was a deciding factor in whether

they completed the questionnaire or refrained. A person who feels more strongly, positively or

negatively, about a subject is more likely to participate in a survey about that subject (Dooley,

2001). Sample bias is this case may be further complicated by personal issues and knowledge of

or experiences with individuals with SMI. However, this effort was meant to serve as a baseline

instrument and part of this baseline needed to include emergency management professionals

even with potential bias.

Future researchers should consider extending this research to mitigate this bias. One idea

would be to obtain the emergency operations plans from each jurisdiction and have them

assigned randomly to a group who would use the tool to evaluate them. Additionally, diverse

focus groups and interviews that delved more deeply into these questions and potential issues of

bias would also be of value. These are important that were not practical for the time and budget

restrictions of this study.

Response bias is significant in other ways. This challenge occurs when individuals who

refrained from responding to the survey would have different answers to the extent that it would

substantially change the aggregate results (Creswell, 2009). This is problematic because those

who don’t answer could have responses that would significantly change the research outcomes.

A separate and equally problematic bias that is possible during survey research is

observation bias. When having people respond to a survey it is imperative that the questions do

not lead the participants to an answer in a pre-determine way. This would skew or bias the data

(Dooley, 2001). To reduce this potential bias, researchers utilized subject matter experts to

review the questions and provide feedback for revision. Additionally, to reduce survey fatigue


23

and data collection error, researchers emphasized that participants could refrain from answering

any question that was perceived as sensitive and could stop taking the survey at any time. While

this has the potential to reduce sample size for those questions it also helps to reduce the risk of

inaccurate data being collected.

Another limit of survey research is the length of the questionnaire. While it is generally

accepted that a longer questionnaire is more reliable it is also understood that length may also

affect participation. The level to which the person being questioned is interested in the topic can

influence the length of a survey that that person will answer. A person highly interested in a topic

will likely answer more questions about that topic than someone who feels this topic is not

important (Dooley, 2001). To balance the need to collect as much data as possible and produce a

tool that wasn’t too cumbersome to be useful the researcher asked subject matter experts to

provide an assessment of both content and length.

Finally, the order in which questions are asked can also have a significant impact on the

data produced by a survey. These are described as order effects and highlight the importance of

not leading participants to answer questions in a certain manner because of placement. It is

equally important to ensure that the order of the questions does not confuse the participant

(Dooley, 2001). To reduce any potential order effects bias, this study groups questions by the

five functional needs areas already describe (Kelley, Clark, Brown, & Sitzia, 2003). This allowed

for the participant to move smoothly through the tool and focus on one functional needs area at a

time.

This tool was sent to forty-six people and realized a total of five responses. The large

number of non-respondents limits the analysis of the data in its ability to be generalized for the

entire state of South Carolina. With the data received it is only possible to understand the


24

readiness level of the individual responding (Dooley, 2001). Non-observation error is a limitation

of this study and a solution was not feasible within the time constraints of the project, therefore

the researchers took this into account for interpretation of the results. The next section describes

the results, followed by a discussion and future research.

Results

This survey was developed to ascertain to what degree county emergency management

agencies in the state of South Carolina are prepared to respond to the need of people with SMI

during a disaster. As far as the researcher knows a survey like this has not been developed or

used to investigate how prepared an agency is to respond to this population and offers a novel

approach to assessment of readiness in the emergency preparedness setting. Research in the

realm of functional needs has historically focused on those with physical and medical disabilities

and omitted the population who suffer from SMI.

There were five respondents to this survey and of those, four answered the survey in its

entirety. The one respondent who failed to complete the survey answered the first nineteen items

except for question number two and did not respond to the remaining seventeen. This equates to

a response rate of 10.8% of the target audience. They evaluation tool is attached in Appendix A.

Emergency Operations and SMI

The first two questions are an attempt to get a general idea of how important the

respondent thinks this research is to emergency management and to assess whether they may

have considered some of these ideas in the past.


25

• 80% of respondents indicated that SMI was not specifically covered in the emergency operations plans for their jurisdiction, with one emergency manager indicating that SMI was specifically included in their emergency operations plans.

• Relative to whether there was a need to incorporate serious mental illness into Emergency Operations planning, 80%of those who responded believed that it is not important to incorporate this population into their community emergency operations plan.

Communication

Questions three through eight focused on communicating with people living with SMI.

The questions address how well communication needs of this population are covered in each

respondent’s emergency operations plan. They include needs in all phases of disaster;

preparation, response and recovery. Results from these questions are as follows:

• 80% of respondents revealed there was no information in their plan regarding how to effectively communicate warnings to the population suffering from SMI that alters the way that they interpret information. The other respondent indicated their community had “very little” information about this topic in their plans.

• Similarly, 80% of the respondents indicated there was no information in their plan regarding about how to effectively communicate ongoing information to the population suffering from SMI that alters the way that they interpret information. When asked about how much information EOPs include around planning suggestions for those with mental illness, two of five respondents answered they had no information on this subject in their emergency operations plan, two

Table 1: Participant responses to the question about the importance of planning and preparing for disaster victims who live with SMI and whether their organization prepares for this?

Survey Question Yes No Does your Emergency Operations Plan specifically cover individuals with a serious mental illness?

1 4

Do you see a need to incorporate serious mental illness into your Emergency Operations Plan as a specific area?

1 3


26

answered there was “very little” information in the plan and one indicated there was “some” some information incorporated into their plan.

• 60% of the responses to a question pertaining to the amount of information included in their EOP about educating people with SMI on ways to prepare for disasters indicated that there was no information on this topic and the remaining two replied that there was “very little” information in their EOP.

• Regarding the inclusion of communication with people suffering from SMI in

training and drills four of five respondents answered that communication with people suffering from SMI was “never” incorporated into their disaster drills or training exercises. The remaining response revealed that they occasionally included this into their training and drills.

• With regard to the use of subject matter experts in disaster planning and the SMI

population, all five respondents answered differently from none to a substantial amount.


27

Medical Needs

The next six questions addressed the medical needs of people with SMI during a disaster.

They examine ways to continue medical treatment for people with SMI in all phases of a

disaster.

• 60% of respondents answered that their emergency operations plan was absent of planning to bring mental health providers in from unaffected areas to assist with

Table 2: Tally of participant responses to survey questions about communicating to those with SMI before, during, and after a disaster. Question None

or Never

Very Little or Rarely

Some or Occasionally

Quite a Bit or Often

A Substantial Amount or Always

How much information does your Emergency Operations Plan contain about getting warning communication to people whose serious mental illness alters the way that they interpret information?

4 1 0 0 0

How much information does your Emergency Operations Plan contain about getting ongoing communications to people whose serious mental illness alters the way that they interpret information?

4 1 0 0 0

How much information does your communication plan include about providing planning suggestions to those with serious mental illness who struggle with changing routines?

2 2 1 0 0

How much information does your communication plan contain about educating those suffering from serious mental illness on pre-disaster preparations that they should consider?

3 2 0 0 0

How often do your disaster drills and training exercises incorporate a component to assess your communication with people suffering from serious mental illness?

4 0 1 0 0

During disaster planning, how much input do subject matter experts have in the area of effectively communicating information to the population who have serious mental illness?

1 1 1 1 1


28

caring for the population with SMI. The remaining responses indicated that one jurisdiction incorporates “some” of this information into their plan and the other one answered, “quite a bit”.

• 100% of respondents indicated that there were no concessions in the emergency operations plans of the respondents to ensure the distribution of essential psychiatric medications during a disaster. In fact, two respondents included in the comments section of this question that they did not believe this was information that should be included in an emergency operations plan.

• 80% of emergency managers who responded answered that their emergency

operations plan did not include any information about vetting mental health professionals in the event of a disaster. The remaining person indicated there is “quite a bit” of information in the emergency operations plan for their jurisdiction regarding mental health professionals from other states being allowed to practice in their area during disaster operations.

• In response to a question about the amount of information in their EOP regarding

the continuation of community mental health care services during response to and recovery from a disaster 40% of participants indicated that there was “very little” information, another 40% indicated that there was “some”, and the remaining respondent revealed that this topic was not covered in their EOP.

• 80% of respondents indicated that the emergency operations plan for their

jurisdiction included no information about appropriately treating people with SMI if the affected person has an acute or emergent episode during a disaster. The other respondent had “very little” information about this in their plans.

• 100% of the participants advised that there was no information about educating

responders to effectively recognize people with SMI in their emergency operations plans.


29

Table 3: Tally of participant responses to survey questions about addressing medical needs of those with SMI before, during, and after a disaster. Question None or

Never Very Little or Rarely




How much information does your plan include about bringing in mental health professionals from unaffected regions during a disaster to assist with treatment of victims who suffer from serious mental illness?

3 0 1 1 0

How much information does your plan include about the distribution of essential mental health medications such as Selective Serotonin Reuptake Inhibitors, Serotonin-norepinephrine Reuptake Inhibitors, and Anti-Psychotic Medications during a disaster?

5 0 0 0 0

How much information does your plan include about procedures for vetting mental health professional licensure across state lines in the event of a disaster?

4 0 0 1 0

How much information does your plan contain about the need for community mental health to continue operations throughout the disaster in order to ensure continuation of treatment for their current patients?

1 2 2 0 0

How much information is in your plan addressing the proper treatment of individuals suffering from serious mental illness in an acute or emergent setting?

4 1 0 0 0

How much information does your plan contain about educating responders to effectively recognize people with serious mental illness?

5 0 0 0 0


30

Independence

There are five questions in this section that pertain to people with SMI retaining their

level of independence. All these questions survey the abilities of a jurisdiction to help people

with SMI continue functioning independently during a disaster.

• 100% of respondents replied that there is no information in their emergency operations plan to ensure people with SMI retain their medications during a disaster.

• 100% of participants indicated there was no information in their planning

documents about properly housing those with SMI during a disaster to ensure these individuals are not unnecessarily incarcerated or institutionalized.

• All respondents indicated their emergency operations plan were absent of

information explaining how most individuals with serious mental illness can function normally with appropriate access to medications, counseling and assistive devices.

• With regard to the use of subject matter experts in the area when planning to

appropriately shelter people with SMI, two respondents indicated that these experts had “some” input into the plan, on answered “quite a bit”, one answered “a substantial amount”, and the remaining respondent indicated that there was no input by subject matter expert about sheltering people with SMI.


31

Table 4: Tally of Participant responses to survey questions about helping people with SMI maintain their independence during and after a disaster. Question None or





How much information does your plan include about ensuring that people with serious mental illness are not separated from needed medications during a disaster?

5 0 0 0 0

How much information does your plan include about people with serious mental illness not being institutionalized or detained for the sole purpose of sheltering during a disaster?

5 0 0 0 0

How much information does your plan include to ensure that people with serious mental illness are not institutionalized or detained for the sole purpose of sheltering?

5 0 0 0 0

How much information does your plan include to explain that most people with serious mental illness will be able to function normally as long as they are afforded their normal medications, assistive devices and counseling treatments?

5 0 0 0 0

During Disaster planning how much input have subject matter experts had concerning sheltering people with serious mental illness?

1 0 2 1 1


32

Supervision

The next six questions are centered on ensuring that those who need it are properly

supervised during a disaster. These questions cover all phases of the disaster planning, response,

and recovery. From question twenty onward there are only four respondents to each question.

• 100%of respondents indicated there was no information in the emergency

operations plan regarding assisting people with SMI with sheltering in place during a disaster.

• None of the respondents’ emergency operations plan had information included

about assisting those with SMI in a situation where evacuation is required.

• Similarly, 100% of responses indicated there is no planning around supervision for those with SMI when they must be housed in traditional shelters.

• With regard to planning for daily living activities during a disaster, 75% of the

respondent indicated there was no information in their emergency operations plans about this issue, while the other response advised that there is “some” information about this need.

• 100% of the respondents indicated that there is no planning around assisting those

with SMI when they have become separated from caregivers or other support individuals during a disaster.

• 100% of respondents revealed there is no information about pre-disaster

identification of people with SMI who may need assistance in a disaster setting.


33

Table 5: Tally of Participant responses to survey questions about helping people with SMI, who need supervision, are accommodated during and after a disaster.

Question None or Never

Very Little or Rarely


Quite a Bit or

Often

A Substantial Amount or

Always

How much information does your plan contain describing how to help

those with serious mental illness who need assistance sheltering in place throughout all phases of a disaster?

4 0 0 0 0

How much information does your plan contain describing how to help

those with serious mental illness who need assistance

evacuating throughout all phases of a disaster?

4 0 0 0 0

How much information does you plan include about ensuring that those with serious mental illness receive needed supervision in a

disaster shelter?

4 0 0 0 0

How much information is contained in your plan about attending to

people with serious mental illness who need assistance with daily living

activities during a disaster?

3 0 1 0 0

How much information is contained in your plan addressing people living with serious mental illness who are

normally supervised by a family member or other guardian and have

been separated from that support network?

4 0 0 0 0

How much information does your plan contain about identifying, before a disaster, those with serious mental illness who will need supervisory assistance in the event of a disaster?

4 0 0 0 0


34

Transportation

The next six questions were focused on people with SMI having access to adequate

transportation during evacuations and post-disaster when normal transportation routes are

inaccessible or not in operation. This is relevant as it is important to make sure this population is

able to get out of harm’s way, make it to recovery processing centers, and to and from

counseling appointments during disaster operations.

• 50% of respondents indicated that their EOPs identified some transportation options for those with SMI who cannot drive or do not own a vehicle. The other 50% responded t there was no information about this topic.

• In terms of movement of people with significant mental illness living in group homes or institutions, 75% of respondents said there was no information included in their jurisdictions’ emergency operation plans concerning this issue. The remaining response indicated that there was “some” information in the plan for that particular jurisdiction.

• 100% of respondents indicated there was no information in their EOPs about

transporting people with SMI to and from counseling appointments and medication distribution areas.

• A question about pre-disaster planning education reveals that none of these

jurisdictions incorporate pre-disaster education of people with SMI and their support systems about transportation during a disaster.

• 100% of participants indicated that there was no information in their EOP regarding pre-disaster identification of those with SMI who will need transportation.


35

Table 6: Tally of Participant responses to survey questions about helping people with SMI with transportation issues during and after a disaster. Question None or





How much information does your plan contain about identifying transportation options for people with serious mental illness who cannot drive or do not own a vehicle?

2 0 2 0 0

How much information does your plan include detailing movement of people with significant mental illness living in group homes or institutions?

3 0 1 0 0

How much information does your plan contain detailing transportation for people with serious mental illness, to and from counseling and medication distribution areas throughout the incident?

4 0 0 0 0

How much information does your plan contain detailing pre-disaster education of people with serious mental illness and those who care for them, on transportation procedures and options in the event of a disaster?

4 0 0 0 0

How much information does your plan contain detailing pre-disaster identification of the citizens with serious mental illness who will need access to transportation for evacuation?

3 1 0 0 0


36

Demographics

The remaining six questions inquired about the jurisdiction where the respondent is

involved in emergency management planning. All four of the respondents answered there were

between one and five people in their agency who are directly involved in disaster planning. Only

two respondents identified their annual budget for emergency management. One respondent

indicated their agency had a $45,000 budget and the other indicated their budget was $100,000

annually.

The estimated populations in these four jurisdictions ranged from 38,000 to 165,000.

Respondents experience in the field ranged from ranged between 3-15 years. None of the

departments had any professional with a mental health professional background and three of the

five respondents identified the SMI population as approximately 1-5% of their total community

population and one individual did not know.

Discussion

Overall results reveal that the vast majority of responses to specific questions and their

inclusion in the EOP were either “none” or “very little”. Of the responses, 83.7% of them

highlight that emergency management plans have either very little or no information regarding

taking care of the mentally ill during a disaster. This is of note as these professionals

acknowledge little, if any, formal emergency management planning for individuals with mental

illness. They only interview response section with fewer than 83% of responses falling into the

little or no information was Medical Needs. The highest rate of none or very little response was

in the section pertaining to maintenance of supervision for those with SMI who specifically need

this type of assistance. Of the twenty-four responses in this section, twenty-three (95.8%)


37

indicate that accommodation for this functional need was marginal if included at all. These

numbers indicate that people with SMI may be neglected in emergency operations plans and at

the very least illustrate the need for this type of study to be expanded to other counties and states.

Respondents who wrote comments in the provided spaces were very helpful in providing

the researcher with a deeper understanding of the issues related to planning for this population.

The large majority of these comments reveal that respondents believe that the emergency

operations plan should not include specific information about helping people with SMI during a

disaster. When asked if their EOP included information about ensuring psychiatric medications

are available in a disaster, one respondent answered “The EOP is not where this should be found.

This should be part of ESF8's SOP for dealing with needed medications. This is way too specific

for any plan.” This response is indicative of the attitude that this research was hoping to better

understand. The potential benefits of having an EOP that purposefully includes this type of

information is the assurance that this population is not marginalized during disasters. A second

respondent had a similar response to this question saying “I do not believe that information

should be part of an overall emergency operations plan.”

There are several instances where respondents identified that planning for this specific

population was not the responsibility of emergency management. In a few of these responses the

participant indicated a specific organization or emergency support function who should house

that information. When asked about how much information in their EOP addresses the proper

treatment of individuals suffering from serious mental illness in an acute or emergent setting,

two responses repeated this was not information that should be in the general emergency

operations plan. One of those two responses said “This item is not, nor does it need to be a part

of the Emergency Operations plan. This is part of the SOG the EMP/Paramedics develop.” While


38

EMS does develop protocols for the treatment of the mentally ill, the medical treatment of these

individuals is not the only concern. A person with SMI could have an acute exacerbation of

symptoms at any point during a significant event and evidence indicates that shelter workers may

need training to discern when help needs to be called for these people. Equally as important, law

enforcement officers, National Guardsman, State Guardsman, and many other organizations

involved in a disaster must have, at least, a basic understanding of how to treat people with SMI

who may be having an acute exacerbation of symptoms. By including this type of information in

a general EOP it will ensure that all involved in emergency planning, response, and recovery are

able to react appropriately to this situation and will allow for the handling of this population with

safety, respect and dignity.

Similarly, with regard to whether the EOP includes information to ensure that people

with serious mental illness are not separated from needed medications during a disaster, similar

responses were received. Two respondents expressed it was not necessary to include this

information in the general EOP. One of those responses said it is the responsibility of mental

health professionals to ensure this is part of their plan. It is important to understand that this type

of planning can be ineffective because very few, if any, mental health professionals would be

conducting evacuation activities or rescuing people after the effects of a disaster. If this

information was included as part of an EOP it would make it available to those who were

participating in evacuation and rescue activities. Additionally, mental health professionals

should be involved in emergency planning to help plan how to handle people with SMI who have

been separated from their medications. Mental health professionals could also help educate this

population to bring their medications when they evacuate, but by putting this type of

information solely in mental health professionals plans, there are likely to a large number of


39

people involved with those with SMI in a disaster who do not know how they can help this

population.

When asked about how much information the EOP contains related to educating

responders to effectively recognize people with serious mental illness, similar gaps in

information and planning for this population appear. Two respondents again said that this

information was not needed in the EOP. Neither indicated this was not important just that it

wasn’t the job of the EOP or emergency planners. One respondent said “This is not part of nor

should it be of the EOP. This is an education/training process and should be part of the training

activities of the different response agencies.” There is an expectation in this response that rather

than include this in the EOP of the county, each entity involved in disaster response should

provide training in this area. There is the concern that without formal inclusion in the EOP, the

functional needs of people with SMI will be properly accounted for or even worse that they may

be infringed upon.

Conclusions and Future Research

This research has highlighted gaps in county level EOP planning related to education and

planning for the SMI population in times of crisis. In addition, this works highlights the potential

conflict between different public and private sector agencies over who should be planning for

this population group. The issue of who has responsibility of this issue is of the utmost

importance for this group’s effective care in times of crisis. Future research should focus on

closing the gaps in our understanding of emergency management planning and individuals with

SMI. This study is just a beginning and can be expanded in multiple ways. A larger sample size

and higher response rate are imperative to making generalizations about the level of preparation


40

by emergency managers and EOP’s across South Carolina and the United States regarding the

functional needs of this population. A larger sample size will ensure a more representative

sample and an improved response rate would help reduce the effect of non-observation error in

the study.

With additional time, a thorough qualitative assessment of EOPs across the state would

be informative. Researchers could review each EOP and conduct the PATSMI survey with each

plan to gain specific information on planning gaps. It is possible that external researchers may

be more objective about these plans than conducting interviews with county level emergency

management professionals. This approach would also solve the problem of a low response rate

and small sample size. It would also be beneficial to have multiple surveyors conduct the

PATSMI on each EOP as another way to eliminate bias responses.

While this research focused on SMI it became apparent during this research that there are

other functional needs populations that would also benefit from research on whether and how

emergency management organizations plan and prepare for their needs during a disaster. An

emerging population, children with autism spectrum disorders (ASD), is one group of patients

who urgently need basic research to undercover the best practices for mitigating the effects of a

disaster and ensuring continuity and continuation of the care they are receiving before a disaster

strikes. Autism is a growing problem that is becoming more prevalent every day. It is estimated

by the CDC that 1 in 68 children will be diagnosed with an ASD by the time they are eight years

old (Centers for Disesase Control and Prevention, 2014). Autism Spectrum Disorders encompass

a wide range of functionality and symptoms which make planning for their care challenging.

They require special communication and do not respond well to changing environments. People

with ASD may react violently in response to anxiety and may have sensory perceptive disorders


41

which could cause adverse reactions to emergency lights and sirens (Autism Spectrum Disorder

Foundation, 2012). Beyond ASD, there is a broad spectrum of behavioral and cognitive

conditions that cause victims to need functional assistance in a disaster situation. These

populations could all benefit from the use of a PATSMI like tool to assess whether and how

these groups functional needs re being accounted for when a crisis occurs.

An additional gap highlighted from this research is that functional needs in general are

not well understood by emergency management professionals responding to this survey. It may

be that the specificity of this research is too premature. It may be that research needs to be

conducted on how to address functional needs in general before looking at specific population’s

disease processes. It is also possible that research on how to handle functional needs in general

will have an impact on many specific populations. For example, when looking into how to

effectively transport people with no ability to transport themselves, a solution for the blind or

elderly may also be a solution for those with SMI. However, understanding the nuances of

specific populations is critical as some functional needs will not overlap across disease processes

or conditions. For example two groups may have a functional need in the area of communication,

but the solutions to meet these needs may be unique.

Another area of interest to be investigated in the future is that of organizational

responsibilities. Several respondents indicated that specific solutions to the functional needs of

those with SMI where not the job of the EOP or the emergency management team. This “not our

job” mentality has the potential to exacerbate the difficulty in closing the planning gap for those

with functional needs. This field would benefit from more research on which stakeholders are

currently involved with these populations, which groups would or could be involved in a

disaster, and how to effectively assign responsibility of and for these groups in emergency


42

situations. In order to improve our understanding of these group’s needs, it is imperative that

organizational responsibilities are identified and directly addressed.

Due to the historically utilitarian ideology of the emergency management profession the

thought that “we can’t help everyone” is strongly imbedded into the profession. This research

highlights this idea for the way EOPs consider the SMI population. Because those with SMI are

a significant minority when compared to the general population, emergency planners focus most

of their efforts on helping the population at large. While some may argue that most of the effort

needs to be focused on those who will suffer the most damages, this research argues that a better

ideology fitting the responsibility of the EOP is one that supports doing our best for all people.

By having the mindset that we can’t save everyone we may search for a group to leave out, but

by doing our best to help all people, even if we are challenged to do so, no one is marginalized

intentionally.

There has been much talk in the United States about bias and a lack of understanding for

those with mental illness. This research highlights this possibility in the area of emergency

management. It could be that emergency management planners and professionals are not well

informed of the functional needs of this group which are different than the general population. It

is also possible that these professionals do not know that this group suffers disproportionately

from the general population during a disaster. What is clear is that it is imperative that

populations with functional needs and those who are trained to care for these populations are

brought to the table for robust engagement on how best to plan for these populations in times of

emergencies. Through this research it is our hope that the gap around emergency management

planning for specific groups like the SMI population has been highlighted. This is early research


43

but clearly an area that is deserving of additional exploration to better serve all population in

times of disaster.


44

Appendix A Preparedness Assessment Tool for Serious Mental Illness

Communication 1. Does your Emergency Operations Plan consider getting accurate information about

warnings to people whose serious mental illness alters the way that they interpret information?

2. Does your Emergency Operations Plan consider getting accurate ongoing information to people whose serious mental illness alters the way that they interpret information?

3. Does the communication plan have a strategy to make specific planning suggestions for those with serious mental illness who struggle with changing routines and have difficulty making plans?

4. Do your disaster drills and training scenarios have a component to assess your jurisdictions communication with people suffering from serious mental illness?

5. Does your plan employ subject matter experts in the area of effectively communicating information to the population who have serious mental illness?

6. Does your communication plan involve educating those suffering from serious mental illness on pre-disaster preparations that they should consider?

Medical Needs

1. Does your plan include bringing in mental health professionals from other areas to assist with treatment of disaster victims who suffer from serious mental illness?

2. Does your plan identify procedures for vetting mental health professional licensure across state lines?

3. Does your plan identify the need for community mental health to continue operations as normal throughout the disaster so that they can continue treatment of their current patients?

4. Does your plan have provisions in place that allow for distribution of essential mental health medications such as: Selective Serotonin Reuptake Inhibitors, Serotonin-norepinephrine Reuptake Inhibitors, Anti-Psychotic Medications?

5. Does your plan account for education of responders in recognition of serious mental illness?

6. Does your plan address the proper treatment of individuals suffering from serious mental illness in an acute or emergent setting?

Independence

1. Does your plan ensure that people with serious mental illness are not separated from needed medications?

2. Does your plan ensure that people with service animals and other assistive devices are not separated from them?

3. Does your plan ensure that people with serious mental illness are not institutionalized or detained for the sole purpose of sheltering?

4. Does the plan take into account that most people with serious mental illness will be able to function normally as long as they are afforded their normal medications and counseling treatments?


45

5. Does your plan include subject matter experts for matters concerning sheltering people with serious mental illness?

Supervision

1. Does your plan make provisions to ensure that people who need assistance sheltering in place or evacuating will receive assistance throughout all phases of the disaster?

2. Do you have a plan to attend to people with serious mental illness who need assistance with daily living activities throughout the disaster?

3. Is there a plan to address people living with serious mental illness who are normally supervised by a family member or other guardian and have been separated from that support network?

4. Is there a provision in your plan to ensure that those who function normally in their homes but are in need of assistance in a foreign environment receive assistance?

5. Does your plan have a way of identifying those with serious mental illness who will need supervisory assistance in the event of a disaster?

Transportation

1. Does your plan identify transportation options for people with serious mental illness who cannot drive or do not own a vehicle?

2. Does the transportation plan include movement of people with significant mental illness living in group homes or institutions?

3. Does the plan include transportation, for people with serious mental illness, to and from counseling and medication distribution areas throughout the incident?

4. Does your plan educate the people with serious mental illness and those who care for them, on transportation procedures and options in the event of a disaster?

5. Does your agency have a way to identify the citizens who will need access to transportation for evacuation?

Demographics

1. Number of employees in your emergency management division who are directly involved in planning?

2. Annual Budget? 3. Population of your jurisdiction? 4. Number of years that you have been involved in disaster planning? 5. Does your department have anyone with a professional mental health background on

staff? 6. Estimate the number of people in your jurisdiction who are diagnosed with serious

mental illness.


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