becomes essential either as an adjunct to general health care treatment or as a primary intervention for major behavioral health conditions (including substance abuse and addictive disorders).

Nobody who experiences a crisis (e.g., one described by scenarios provided) is unaffected by its psychosocial impact. The individual and collective impact will introduce considerable variability in people’s ability to function. Behavioral health sequelae will impact the function of leaders, providers, and victims on both individual and collective levels. Understanding, anticipating, and specifically planning for these impacts is central to protection and promotion of the public’s health and successful event and recovery management.

Discussions within local communities that include the widest array of stakeholders with the goal of planning alternatives to conventional care and preparing for the eventuality of providing only crisis care can mitigate the premature and/or inappropriate movement to this level of care through a proactive planning and resource allocation process. The recognition and inclusion of behavioral health stakeholders and factors in these complex decisions is an essential component of sound preparedness, response, and recovery.

Roles and Responsibilities

In the broadest sense, nearly every organization and system and every governmental level has a stake in ensuring efficacious response to behavioral health factors in large-scale emergencies and disasters. Addressing adverse impacts of stress, suggesting actions, and implementing strategies that promote resilience, and ensuring efforts that provide appropriate care of those with behavioral health disorders, is in everybody’s best interest. Additional discussion about behavioral health in planning for and implementing crisis standards of care (CSC) is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.

Special Circumstances

All extreme events require understanding of, and adaptation to, new and complex challenges. All of these challenges have behavioral health (as defined earlier in this chapter) elements. While all extreme events are stressful and demanding, some are especially difficult and complex. In these types of events, it is especially important that planners and incident leaders/managers understand the special psychosocial sequelae involved and ensure that behavioral health content experts are fully integrated into both decision making and response implementation. These include

Situations where a transition must be made in the fair and just allocation of resources and care when circumstances will not allow for the optimal level of care for all: These are among the most difficult challenges that health care professionals can face. These are extraordinarily complex and difficult decisions that not only involve ethical and legal factors but also have major psychological impact on those involved in these actions and choices. Planners are strongly encouraged to involve behavioral health professionals in preparing for and implementing these difficult transitions. Integrating behavioral health consultation and services into this process will enhance the probability that adverse psychological consequences for those involved can be reduced.

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