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Macro-Level Interventions in Disasters: Theoretical Foundations for Improving Mental Health Outcomes.

Major disasters in the United States, such as Hurricanes Katrina, Sandy, Maria, Harvey, and Michael, emphasize the need for a disaster response that takes into account mental health issues (Nahar et al., 2014). Analysis of these disasters shows that the psychosocial functioning of survivors is disrupted by major events (Carroll, Balogh, Morbey, & Araoz, 2010). This dysfunction includes an increase in mental health disorders (Norris & Elrod, 2006) and a decrease in functioning for affected communities (Gil-Revas & Kilmer, 2016; Norris et al., 2008; Wells et al., 2013; Zahran, Peek, Snodgrass, Weiler, & Hempel, 2011). Posttraumatic stress disorder (PTSD), depression, and anxiety are the most common mental health difficulties in disasters (Norris & Wind, 2009). Global climate change has already had a moderate effect on the severity of disasters (Morrissey & Reser, 2007), and the number of severe weather disasters is likely to increase (Intergovernmental Panel on Climate Change [IPCC], 2012).

The social work profession is a major responder in disasters, arriving soon after first responders such as police, fire, and emergency management (Zakour, 1996). Social workers provide most of the services after a disaster and help restore functioning at home, in neighborhoods, at school, at the workplace, and in the community as a whole. Social workers provide assistance in disasters at the micro, mezzo, and macro levels. They have long provided and managed volunteer services for emergency relief. Additionally, they have sought to improve access to disaster services for vulnerable populations. The traditional clients of social work are older persons, children, persons with disabilities, women, and persons with low incomes (Nahar et al., 2014). These same populations are highly vulnerable in disasters (Zakour, Mock, & Kadetz, 2018).

In accordance with the profession's goal of prevention, social workers have been engaged in disaster mitigation, and many approaches to disaster relief used by social workers are preventive. Social work seeks to coordinate services for people in a disaster, to ensure continuity of care, and to improve the effectiveness of the disaster services system. All of these goals of social work in disaster are part of the role of social workers as change agents from the individual to the organizational and policy levels (Zakour, 1996). The social work curriculum has been infused with content on trauma and crisis intervention, preparing social workers to reduce the distress of disaster survivors and workers (Newell & MacNeil, 2010).

Disaster Social Work and Mental Health Outcomes

Importance of Empowerment

Empowerment in this article, as well as in vulnerability and resilience theory, means increasing a population's access to resources and the ability to mobilize resources. The level of access to resources through empowerment is a central theme in applying vulnerability and resilience theories to improve mental health and psychosocial well-being (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008; Wisner, Blaikie, Cannon, & Davis, 2004). Populations and communities need to be empowered to gain and maintain access to high-quality resources as an issue of social justice. Without access to resources relevant to disaster preparedness, response, and recovery, populations are highly vulnerable. Access to resources through empowerment increases the likelihood of a resilient recovery.

Holistic Epistemology at the Generalist Level

Vulnerability and resilience theories include variables from the individual to the policy level and connections among levels (Hoffpauir & Woodruff, 2008). Although the focus in resilience research is often at the community level, resilience is observed also at the individual, small group, and other micro levels. Disaster vulnerability is multidimensional (Zakour & Gillespie, 2013) so that vulnerable communities are highly susceptible to disaster's effects on systems at all levels.

Ecological Framework

Vulnerability theories identify the causes of vulnerability and resilience not in the individual, but in the social and physical environment (McEntire, 2004). These theories emphasize liabilities and capabilities in the environment that promote both vulnerability and resilience in individuals, groups, populations, communities, and societies. The presence and levels of liability in the environment of communities can be thought of as risk factors leading to vulnerability. The presence and levels of capabilities in the social and physical environment reduce community disaster vulnerability and foster a resilient recovery (Norris et al., 2008; Wisner et al., 2004; Zakour & Gillespie, 2013).

Respect for Diversity

Although disadvantaged groups tend to be more vulnerable, social and demographic attributes of people are associated with but do not cause disaster vulnerability (Zakour & Gillespie, 2013). Rather, vulnerability is not evenly distributed among people or communities; this is the essence of vulnerability. Many of the traditional clients of social work are more vulnerable in disasters and are less likely to enjoy a resilient recovery because of the prevalence of liabilities in their social and physical environments. These populations are less likely to have access to high-quality resources that reduce their vulnerability and promote a resilient recovery (Zakour & Gillespie, 1998; Zakour & Harrell, 2003).

Problem Statement

This article is a literature review of theoretical foundations of macro interventions for improving disaster mental health. The category for this conceptual article is emerging practices. Vulnerability and resilience theories are the focus of this article because these theories are proactive and underlie interventions in both day-to-day and disaster contexts (Zakour & Gillespie, 2013). A theory that integrates vulnerability and resilience concepts and theory is vulnerability-plus (V+) theory. This theory is broader and more inclusive than vulnerability and resilience theories.

In this article, and in vulnerability and resilience theory, disasters include natural and technological hazards, as well as mass shootings and terrorism. Warfare is a different kind of emergency, and the interventions suggested by vulnerability and resilience theory may not apply well to that context (Norris et al., 2008).

Disaster vulnerability refers to both the likelihood that a community will be affected by a disaster and the degree of loss that is likely to occur (IPCC, 2012). A community with high levels of vulnerability is very likely to be affected by disaster and to experience substantial losses (Wisner et al., 2004). A resilient disaster recovery (Zakour & Gillespie, 2013; Zakour & Swager, 2018) is one that is rapid and complete and leads to a transformation in community systems that make the community less vulnerable to a future disaster. A highly resilient recovery (Laska, 2012) is one that leads to substantial adaptation and a new, if not higher, level of wellness. Wellness refers to a high level of functioning (Norris et al., 2008) and an absence of health and mental health problems. The level of functioning includes that at home, in the family of origin and extended family, in the neighborhood, at school or work, and in the community (Norris et al., 2008). A high level of wellness means that the individuals and populations of a community function well in a variety of contexts and have relatively low frequencies and levels of health and mental health problems (Norris et al., 2008).

In a disaster, mental health problems are reduced through direct interventions at both the individual and family levels and the macro levels of social work practice. Macro-level interventions to reduce community disaster vulnerability and foster resilience hold the promise of being more proactive approaches to disaster mental health (Zakour & Gillespie, 2013). This article will review evidence-based literature on mental health issues in disaster and vulnerability and resilience theoretical frameworks to identify best practices in disasters and to derive some direction for preventing and ameliorating disaster mental health problems. Mental health issues will be viewed in a broader framework of psychosocial functioning and resilience in disasters.

The theoretical framework for these interventions will include resilience theory and an integration of vulnerability and resilience theory into V+ theory, as well as recommendations from these theories to reduce vulnerability and foster resilience. Developing high-quality resources, increasing access to these resources, and helping mobilize them in a networked fashion is a primary focus in application of these disaster theories (Norris et al., 2008; Zakour & Gillespie, 2013).

Literature Review

Mental health problems that are prevalent in disaster include PTSD, major depression, and anxiety disorders (Norris et al., 2002; Norris, Friedman, & Watson, 2002). Individuals who have experienced these disorders in non-disaster contexts are particularly vulnerable to a recurrence during disasters. Increased vulnerability to other mental health problems, related to severe stress, also occurs in individuals who have suffered from these problems in non-disaster conditions. These mental health problems are particularly frequent among people in communities and regions characterized by poverty, oppressive structures of domination, and a lack of social development (Zakour & Grogg, 2018; Zakour & Swager, 2018). People lacking adequate resources, such as the poor, the very young and very old, women and girls (Nahar et al., 2014), people of color, and people with disabilities, are less likely to receive aid from the altruistic community in disaster (Kaniasty & Norris, 2009).

An influential resilience model is that of Norris and colleagues (2008). In this model, resilience (a rapid and complete recovery) occurs because of networked resources including economic development, social capital, information/communication, and community competence variables. Resources should be rapidly accessible so that they are provided in a timely fashion. They should be redundant so that there are substitutes in case one or more resources are destroyed by the disaster. They should be robust so that they are resistant to deterioration in a disaster. An outcome of resilient recovery is a return to pre-disaster functioning or better and to community wellness. Wellness in this case includes a lack of both mental health problems and generalized distress (Norris et al., 2008).

Vulnerability-plus theory integrates disaster vulnerability and resilience concepts and theories through the use of causal chains (Zakour, 2018). In this conceptualization and theory of vulnerability and resilience, the balance of environmental liabilities (risk factors) and capabilities (protective factors) causes both vulnerability and resilience. The causal chains begin with the progression to vulnerability initiated by root societal causes of disaster and the structural constraints that combine with these root causes to produce unsafe conditions for community members and populations. When a hazard occurs, it interacts with community disaster vulnerability, and this results in a disaster as well as disaster losses, such as death and widespread injury. Access to high-quality resilience resources is important in disasters; these resources mediate between the presence of a hazard and the severity of disaster losses (Zakour & Gillespie, 2013). Root causes that are liabilities include economic inequality, social stratification, structures of domination, racial ideologies, geographic distance, and environmental ideologies. Root causes that are capabilities are community empowerment and community social development. The next two elements of the causal chains are structural pressures and safety of conditions. In this theory, hazards interact with vulnerability to cause disasters that result in different kinds of losses. Resources are similar to those in resilience theory (Norris et al., 2008), but they mediate between hazards and vulnerability to ameliorate losses (Zakour & Swager, 2018).

The interventions suggested in this article are supported by V+ theory as well as resilience theory (Zakour & Gillespie, 2013). Each of the interventions reduces vulnerability and facilitates resilience. Vulnerability reduction and improved resilience both result in loss reduction, including fewer deaths and serious injuries in a disaster.

Especially important are interventions to reduce vulnerability and to foster resilience after a disaster. These interventions are related because both rely on access to resources for community members and populations (Zakour & Swager, 2018). Vulnerability reduction is most effectively achieved by ensuring that survivors have adequate safety in daily living conditions and access to important resources (Wisner et al., 2004). Resilience is fostered by availability of and access to high-quality resources for survivors and the ability to mobilize these resources in a networked fashion. Resources are of high quality when they are rapid, redundant, and robust. Communities are resilient to the extent that their least privileged populations are resilient. A community cannot be said to be resilient unless all populations within it are resilient (Norris et al., 2008).

Each of the theories of macro interventions for promoting mental health is related either to the resilience theory of Norris and colleagues (2008) or to V+ theory (Zakour & Gillespie, 2013; Zakour & Swager, 2018). Vulnerability theory and resilience theory, the two theories underlying disaster mental health interventions, are integrated into V+ theory. These theories are most useful because they promote a proactive approach to disasters. It is difficult if not impossible to prevent hazards from leading to a disaster, and most communities are not completely resistant to hazards. Communities experience at least transient disruption of functioning in a disaster. However, the best approach to loss reduction in a disaster involves minimizing vulnerability and fostering resilience. Reducing disaster losses may be the best way to reduce the incidence of psychopathology, generalized distress, and loss of well-being in communities. Access to resources in both day-to-day contexts and disaster conditions is critical for recovery, and the level of vulnerability of a population is the baseline from which recovery takes place (Laska, 2012).

Community and Political Participation

An important community intervention to improve mental health after disaster is community-partnered participatory research (CPPR), a theoretical model of community engagement and citizen participation (Wells et al., 2013). This theoretical model is related to the vulnerability and resilience models, including V+ theory. The CPPR framework for this intervention starts with an understanding of community context. Then the community is engaged in promoting community resilience, with support from the policy and academic communities. Through engagement of people and organizations, knowledge of individual agency capacities is shared with the community, and evidence-based preparedness programs are designed. This process influences and is influenced by community partnerships involving information exchange, communication tools, resources, and trust. The final outcome of this process is improved community resilience for diverse populations, especially vulnerable populations (Solnit, 2009). Although the CPPR model of community resilience is meant for use pre-disaster, it is a resource that can be mobilized during disaster conditions.

The goals of this framework include provision of psychological first aid and referral to mental health programs and organizations. Social justice is also a goal, especially in terms of locating and providing disaster-relevant resources to vulnerable populations before and during disasters. Related to social justice for vulnerable communities, including minority communities, is development of a culturally relevant community engagement tool kit. This tool kit involves cooperation with local coalitions to operationalize a community resilience plan. It includes a plan for psychological first aid, incorporating practical social support as well as information on linkages to mental health services in emergencies. It also includes expertise for mapping the local community to identify resilience capabilities and locate vulnerable populations and related risk factors (liabilities), as well as technical information on developing community leaders and training field workers. Leaders and field workers are generally members of disaster response agencies and other community organizations, as well as community members.

Resilience Theories and Mental Health

Gil-Rivas and Kilmer (2016) used resilience theory to develop a number of ways to reduce both generalized distress and psychopathology in communities affected by disaster and related natural hazards. Their theoretical framework is also consistent with V+ theory. Facilitating resilience means that groups, institutions, and organizations need to engage in coordinated and collective efforts to produce new resources for a community. Economic resources--their number, diversity, and distribution--are especially important for producing and distributing new disaster resources. Economic resources include stable employment, adequate income, housing, access to clean water and sanitation, and a strong and diverse economy and financial system. These economic variables are similar to those in V+ theory.

A first recommendation derived from resilience theory by Gil-Revas and Kilmer (2016) is to focus on ecology in efforts to build a community's capacity for preparedness. Interventions and post-disaster aid need to be contextually grounded. Consistent with an ecological framework, disaster interventions to improve mental health and well-being need to occur at multiple levels--individual, family, neighborhood, organizational, and community. Intervention efforts need to be culturally appropriate with community member involvement. Community organizations, nonprofits, nongovernmental organizations, and informal sources can help communities to become more resilient and to promote well-being. Systems of coordination and collaboration need to be in place in non-disaster contexts so that networks of nonprofits and governmental organizations, as well as mental health services organizations, can effectively intervene in a disaster.

A second approach Gil-Revas and Kilmer (2016) have derived from vulnerability theory is the use of informal support. To build the capacity for informal support, the response system should establish contexts and opportunities for interactions and cohesion within the community. Informal support and resources are meant to complement the more formal action of organizations and networks to bolster community resources. Sources of informal social support, such as schools and faith-based communities, can provide opportunities for ties of mutual support in a disaster.

A final intervention based on resilience theory is equitable distribution of resilience resources, especially the economic resources that underlie resilience. Communities with equitable social, political, and information systems tend to have the capability to produce networked resilience resources. Before and during disasters, efforts to reduce disparities in access to economic, social, information, and political resources are needed. This should be done with special attention to vulnerable groups, who are more likely to be exposed to disaster and are less likely to have access to high-quality resilience resources.

In the resilience theory developed by Zahran and colleagues (2011), single mothers with small children are identified as a vulnerable population with less resilience to recover from disasters. The authors have adopted the framework of Norris and colleagues (2008), but have conceptualized resilience as both the level of resistance to disasters and the length of time until recovery from disaster. Overall, the resilience capacity of a population is conditioned by its vulnerability status, including physical health status, presence of social support, level of formal education, and especially income level. Resistance capacity is the ability to absorb or process catastrophic changes or shocks such as disasters. Recovery time, the time until the return to a normal state of affairs, is also conditioned by vulnerability status.

This theory and intervention are supported by a study examining the aftermath of Hurricanes Katrina and Rita (Zahran et al., 2011). A two-stage conceptualization of resilience shows that single mothers are less resistant to these hurricanes than the general population and that their recovery time is longer than that of the general population. These mothers develop more days of poor mental health than the general population, and they never return to their pre-disaster number of mental health days. An additional aspect of the resilience theory used in this study is a feedback loop between number of mental health days and income loss due to missed work days. Related to this feedback loop, single mothers experience a greater loss of social capital, particularly in regard to day care, schooling, or informal care for their children.

Social Capital Theories

Social capital refers to the social resources mobilized from the support networks of individuals, groups, organizations, and communities (Lin, 2001). This resource is critical in improving the safety of conditions in which people live (Wisner et al., 2004) and in improving the networked resources of communities in disaster (Norris et al., 2008). Social capital decreases the vulnerability of communities in disaster and increases the likelihood of a resilient recovery after disaster. The well-being of a community, including the lack of mental health problems, is improved through the provision of social capital (Abramson et al., 2015).

Abramson and colleagues (2015) developed a theoretical model and measurement strategy to study access to social capital, showing that social capital promotes improved mental health after a disaster. This model hypothesizes that access to social resources can activate resilience attributes inherent in individuals and communities, leading to better psychological adjustment and well-being. Their model is similar to that of resilience resources in V+ theory and examines social resources including social, human, economic, and political capital. Individual and community resilience attributes are conceptualized as two variables affecting resilience activation through access to or engagement of social resources, such as the types of capital mentioned above. The authors propose that post-disaster interventions link individual-level interventions to broader community-level resilience activities. Individual-level interventions may include improving coping strategies, stress management, or problem-solving skills, as well as referrals to comprehensive mental health services. Community resilience activities may include modifying relevant social networks or systems.

Abramson and colleagues (2015) assert that advances in the measurement of community resilience focus on measurement of social networks that link people to resources and institutions. Using actual or perceived social support--strong social networks, family cohesion, and bonding with others who are successfully coping with disaster--as a potential activator of resilience should enhance the resilience process and lead to better mental health outcomes. Pre-disaster interventions to support attributes of resilience and post-disaster interventions to activate those attributes are both necessary for sustained improvement in mental health in a community affected by disaster.

Cheung, McColl-Kennedy, and Coote (2017) examined the relative effects of different types of social capital on community resilience and well-being and thus on mental health. Through social network analysis, they operationalized three types of social capital: bonding, bridging, and linking. Bonding social capital is based on strong ties among social network members--marriage, kinship, and social group membership--ties that are enduring and familiar. Bridging social capital is based on weak ties, characterized as acquaintances rather than friends. Although acquaintances are not in frequent contact with each other, such weak ties can be very useful in accessing resources from various parts of a network. Linking social capital is based on connections to external sources of power and authority through the creation of new ties. With linking social capital, network actors may gain new or novel resources by spanning the network, creating new ties, and connecting to new networks.

Cheung and colleagues (2017) studied three social capital networks, one classified as bonding, a second as bridging, and a third as linking. A questionnaire collected information on psychological well-being and life satisfaction at two points: within six months of the disaster (T1) and two years after the first collection period (T2). Members of each network reported increases in psychological well-being from T1 to T2. There were no significant differences between networks in psychological well-being. However, the bonding social capital network was associated with significantly higher life satisfaction than either the bridging or linking network. Cheung and colleagues (2017) noted that high levels of cohesion within the bonding network may explain the greater life satisfaction of its members. Also, being prepared and located in a highly cohesive network enhances well-being, especially in terms of life satisfaction. This study and its theoretical framework suggest that, based on understanding of their clients' networks, disaster services organizations could position emergency workers to help enhance their clients' networks and psychological well-being (see Gillespie, Colignon, Banerjee, Murty, & Rogge, 1993).

Discussion and Conclusion

This article has documented the ways that general recovery in disaster promotes wellness with positive mental health outcomes. The person-in-environment approach followed by this treatment of mental health outcomes includes both the physical environment and the social and economic environments of survivors. Vulnerability-plus theory in particular is ecological because a broad range of variables are shown to be related in causal chains. This theory is inspired by a broad treatment of political ecology theory and aims to include socio-ecological systems (Renfrew, 2018). The theories in this article are generalist. Phenomena at different levels of abstraction are included in causal chains applicable from the individual to the societal level.

The evidence for each of these interventions, in terms of decreasing loss of life and injury and reducing mental health problems such as PTSD, depression, and anxiety, has not been rigorously tested in intervention research. The intervention programs derived from resilience and V+ theory should be used and tested in the field of disaster mental health.

The main finding from this review of the literature is that increased access to better quality disaster resources helps prevent mental health disorders by limiting disaster losses. These resources include involvement of citizens and organizations, enhanced economic and informal support, and equitable distribution of disaster recovery resources. Informal support, physical health, formal education, and income are also important resources to improve the resilience of otherwise vulnerable populations. Social, human, physical, and political capital are shown to be very important for reducing vulnerability and fostering resilience. Increasing the level of bonding social capital, as opposed to bridging and linking social capital, in individual networks is shown to have advantages for both psychological wellbeing and life satisfaction after a disaster.

The interventions described in this article for reducing disaster vulnerability and increasing the chances of a resilient disaster recovery have shown preliminary evidence of reducing harm and the frequency of serious mental health problems. Although the evidence for effectiveness of these interventions is from less rigorous research, these approaches to mental health improvement are promising. Further study is warranted, in the form of intervention studies based on theory, to reduce vulnerability and increase resilience.

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Michael J. Zakour, MSW, PhD, is professor in the School of Social Work, West Virginia University, Morgantown
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Publication:Best Practices in Mental Health
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Date:Sep 22, 2019
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