NATURAL DISASTERS

The number of natural disasters that include for example floods, earthquakes, landslides, avalanches, wildfire, storms, or hurricanes, have increased in Europe in the past years. Statistically Norway will be affected by 2-3 large rockslide accidents, 2-3 large mudslide accidents , and 3-4 large avalanche accidents in the next 100 years (Source: The Norwegian Directorate for Civil Protection). Each of these accidents may claim 20-200 human lives. In addition, it is claimed that there will be an even higher number of smaller accidents. www.skrednett.no shows data and information about all types of landslides and avalanches all over the country. The low occurrence of natural disasters causes there to be a lot of worry when they do happen. However, because you cannot rule out that it might happen, written routines for psychosocial follow-up for natural disasters are presented.

1. The Mobilisation phase

Objectives: Gain a general view over and contact with all the people who are in need of psychosocial follow-up after large natural disasters to begin adequate measures for assistance as soon as possible. Bring in and coordinate those who are to be responsible for the help that is to be given.
Measures: The objectives are reached through written procedures that are clear regarding notification and referral, who are the target groups for assistance measures and criteria for the follow-up of those affected.
Notification happens through up-to-date name and phone number lists over the people responsible for follow-up who make the basis for the notification procedures.
    •Place of damage-leader (often the police) notifies the leader of the crisis team.
    •Mobilisation of the rest of the team.
    •Possible summons of the reserve personnel (defined in advance).
    •In the case of larger disasters with many people involved, it can be purposeful for the municipality to have organised the crisis ready team with a senior steering group, for instance containing department leaders with the power to authorise payments with regard to resources, and authority to summon employees within their area of responsibility (see Crisis team/Expanded crisis team).

Target group and criteria for follow-up:
The systematic caring work aims in different ways to reach the following target groups:
    •Injured and uninjured survivors and their next of kin.
    •Those left behind (defined as the closest next of kin, parents, siblings, partner, etc.)
    •Next of kin to missing persons.
    •The closest affected outside of the families (friends, peers from school, colleagues) and other “miniature communities”, are looked after in their own crisis plans.
    •Rescue team
    •Locally responsible leaders.
    •Witnesses/chance onlookers.
    •The local community.

2. The emergency phase

Objectives: Calm down and limit the experience of loss of control by reducing stress, contribute so that abrupt reactions for crisis are possible to control, re-establish as much order and structure as possible so that those affected can regain and resume their previous levels of functionality in the long run. Gain a general view over who will need longer follow-up.
Measures: The objectives are reached through clear written protocols for care, information meeting, reviews of facts individually and in groups, rituals, mobilisation of support from social networks and possibly mobilisation of practical help.

Coordination and responsibilities:
    •Leader of the crisis team or leader for the senior steering group will lead and coordinate the follow up within the municipality. This would be the coordination of the tasks the municipality has planned to put into effect and delegating tasks to suitable personnel (see crisis team/expanded crisis team).
    •The psychosocial work is split into different main areas and organised so that the affected are guaranteed emotional help and support and good practical frameworks.
    •Coordination of routines, within the municipality, for information to all involved personnel and all affected parties with regard to progress in rescue work, causal connection, and chain of events.
    •In cases of large disaster a “liaison person”, responsible for information between the disaster leaders and the psychosocial support service is needed.
    •Coordination of the municipality’s measures with regard to other bodies outside the municipality, such as measures that are put into effect in collaboration with other municipalities (for instance shelters for the affected), cooperative efforts with special health services (for instance hospital and policlinics) about preventive measures or treatment measures (see Measures), cooperation with governmental institutions (for instance Norwegian Radiation Protection Authority, transmission protection) or cooperation with private companies (for instance transportation companies).

Method:
    •Direct work form when there are measures such as emotional first aid, information procedures and practical help.
    •In addition to direct intervention, the crisis team will map, prioritise and plan the need for concrete further aid measures, resources, and authorities.
    •Indirect work form such as counselling to schools and institutions.

Measures for survivors:
    •Establish shelters for survivors or evacuated people who have not been hurt. So that someone has the complete overview, it is important that the municipality, either in advance or immediately after the incident, clarifies who will lead a shelter. The leader can for instance be: Police, health personnel or the clergy within the municipality. Working with volunteer organisation might also be a possibility (see Resources/cooperation).
    
In the case of natural disaster a need to establish a temporary shelter for the survivors might arise, before they are offered help, a temporary place to live, information on moving back and so on. The following important functions should be covered:
    •Registration of those who come to the centre with name, address, phone number. It is important to use a system for registration (Note: Chief responsibility of the police)
    •Care in the form of meeting physical needs, for instance access to water and food, dry clothes, warmth, rest and telephone.
    •Someone to talk to.
    •Regular information about the progression within any rescue work, for instance information every hour (Note: Chief responsibility of the police).
    •Help to get in touch with next of kin (Note: Chief responsibility of the police).
    •The opportunity to go through the chain of events, either individually or in a group, before everyone goes to their own (see Measures).
    •Information about any further offers for follow-up such as debriefing in the course of the next days (see Measures).
    •If many survivors are from different municipalities, or have to sleep over in the municipality, a place to spend the night has to be procured (Note: requisition authorisation, economy).

•Injured survivors should not be left alone, and parents should be reunited with their children as soon as possible. Make sure the most heavily affected has someone with them or close to them the first days and nights after the disaster.
•The crisis team checks whether close family/social networks are called in to help their family/closest affected through the first days, or if the affected can live with them in cases where their home is destroyed.
•Minors and the elderly should be especially cared for, with competent guidance for the caretakers.
•Mapping of further psychosocial needs for follow-up. It is important to especially observe those who show symptoms of severe anxiety and unrest (see Reactions).
•Referral to special health services for those who need it.
•Professionals can give information about how small children can be spoken with, included and cared for (www.krisepsyk.no).
•Note: It is important to map and care for ethnic minorities such as immigrants, guest workers and foreign groups/guests.
•Investigate the necessity of informing school and work place and any needs for sickness benefit or temporary adaptation of the work or school situation.
•Gaining permission to contact and inform the local support for those who are from other municipalities.
•Information about any rituals or events such as memorial services and other memorial ceremonies (see Rituals)
•Young people and adults are given psycho-educational information and counselling to contribute to self-mastery.
•Survivors are given an offer for systematical reviews (debriefing) in the course of the first weeks after the disaster (see Measures). In might be helpful to work with the special health services if the municipality does not have the competency for this type of follow-up.
•Information about offers for further follow-up, for instance follow-up debriefing (see Measures).

Measures for the next of kin/surviving relatives:
•Establish a contact phone for next of kin. Frequently the police will cover this service (or others in cooperation with the police).    
•The form of the information service will be evaluated according to the type and size of catastrophe. Generally the service is organised according to two main principles:
•    Fast start-up of 24 hour telephone help line – a phone service for survivors, next of kin or surviving relatives who phone in or who phone the police, hospital, media, etc. (this should continue in a period past the emergency phase, and eventually only during the day). The phone service can use a checklist in their work, for instance, procedures prepared by psychologist Grønvold Bugge (1987).
•    A reception service for the psychosocial support service. This department has the responsibility for care and information to the surviving relatives and next of kin who personally show up.
•Shelter for the next of kin. The establishment will be a task for the police. Hospitals that receive the injured and dead, also have to have plans to receive the next of kin. The centre may be manned by the police, local authorities or responsible people from the crisis team (for instance a psychologist, a general practitioner, a member of the clergy, or health/psychiatric assistance personnel). In the case of some lager disasters, the local clergy is responsible for this facility. Voluntary organisations can also be involved. To avoid too many participants and chaos, it is important that the coordination and the responsibilities for the centre are clear from the beginning, and that other participants only join in after being asked by the coordinator/leader for the psychosocial work.
•Media strategy. The centre has to be screened from the media and “voluntary” helpers (for instance outsiders who, meaning well, swarm in to help) (see Media).
•The following tasks are important:
•    Everyone has to be met personally and registered with personal data and possible people to contact.
•    Registration of name, phone number, and address, as well as who they are the next of kin to. This function of registration can easily be forgotten in a stressful situation. Because of this, it is important to plan this function from the get-go.
•    It is important to separate next of kin to the diseased and next of kin to the survivors as this becomes clear.
•    Regular and predictable information to the next of kin who are staying at the centre. Usually the police with take on this responsibility. If possible, it is good to be able to tell them when the next bit of information will be given, and to give information as frequently as possible.
•    If it is impossible to reunite the family, it is important to give information about family and friends as far as possible.
•    Give them time to express their emotions.
•    Explain that it is normal for people to experience strong reactions after a crisis, accident or disaster.
•    Contact with any injured at the hospital.
•    Help with transportation to meet the survivors who have been found, or offer to come with someone to the hospital to identify and give information about someone if they have passed away.
•Mapping of needs for further follow up. For the next of kin from other municipalities, acquiring permission to inform the local aid services for further follow-up of the family.
•    Information about any offers for general follow-up and who is responsible for getting in touch.
•    Mapping the need for support measures in the home, looking after children, possibly relief with other caring tasks.
•    Advice about how to generally care for children after a crisis (www.krisepsyk.no / Theme pages – Children in crisis).
•    Conversations giving information to any affected children with a focus on information about the event adapted to the age and maturity of the child.
•    In cases of many casualties, information about any communal ritual, such as memorial services and funerals (see Rituals).
•    Give the surviving relatives support through making their peace (viewing/memorial service).
•    Advice about including children in any communal rituals, such as viewing, memorial service, and funeral.
•    Evaluate the need to inform school or place of work, and need for any adaptation of the work or school situation for those affected.
•    Investigate the need for sick leave.

Measures for helpers:
Helpers may be police, fire brigade, ambulance personnel, emergency medical personnel, the civil defense, Red Cross, other voluntary organisation or private citizens. The second line personnel (rescue personnel at the scene, psychosocial support personnel, and hospital personnel) give aid at the meeting points and reception points for injured, surviving relatives, and next of kin.
Many departments have prepared their own procedures for their contributing personnel, for instance fire brigades, police, and aid corps. In the preparation of the plan, people responsible in the crisis team can map which plans are in place and prepare their own plans for follow-up in correlation with these. Measures for contributing personnel/helpers may include:
•Systematic review of the chain of events, reactions and thoughts, following a model of defusing and debriefing (see Measures).
•Information about common reactions after being exposed to strong impressions.
•Advice on how to handle reactions (www.krisepsyk.no / Theme pages – Self-help methods, Advice on how to stop uncomfortable thoughts). Information about criteria for seeking professional help and information about where that help can be found.
•Mobilising colleague support through focusing on what the individual can do to support their colleagues, and on what kind of support the individuals need.
•Guidance of leaders with a view to care for the employees.
•Information about the further follow-up provided by the municipality, for instance follow-up debriefing.
•Continuous evaluation of the measures and advice for any changes to be made.

Measures in local communities, schools, and nurseries:
Many schools and nurseries have their own contingency plans. Coordinating with them and collaboration between the school and the municipal crisis team is important to plan when preparing the plan (see Resources/collaboration).
•Information about the event at schools/nurseries, a review in the class and the opportunity to ask questions about what has happened (see Resources/collaboration). Concrete and correct information about dramatic incidents is important to avoid the spread of rumours and too many questions to any children affected by the incident.
•Rituals if classmates have passed away (see Rituals)
•Plans for adjustments to the educational situation of affected children.
•Contact with the affected families to investigate the need to inform the class, nursery group, and any adjustments to the educational situation.
•Even if no one is directly affected, it might be a good idea to go through what has happened, in schools and nurseries, and give the children the opportunity to talk about what they might have been exposed to through media or rumours.

Measures in the local community:
•Regular updates to the populace are very important in a disaster. Due to this, it is important that the plan appoints people who have specific responsibility for communicating and cooperating with media to give information that is useful to the general populace.
•Information to the population of the municipality though town meetings with police, the leaders of the rescue workers, leader of the health services, political leaders, and any representatives for governmental services (for instance the Norwegian Department of Geography, Norwegian Water Resources and Energy Directorate). The purpose is to reduce the spread of rumours, unnecessary worry, and in worst-case scenarios panic by providing relevant information and the opportunity to ask questions.
•It is important for the municipalities to send out information and requests to the people through radio (especially localised radio shows), press reports, and local radio and TV. Even if there is not that much information to give, people often have a need to talk, and it is important for people to feel that the municipality cares and is taking on the responsibility.
•You can also create your own website with information-bulletins where different topics are brought up. In this case, there should be a responsible web editor.
•Information is an important part of emotional first aid, and it is important to use media fast to inform people of:
•    Facts about what has happened, the likelihood of it happening again, general and personal risk, expectations, among other things. To avoid the spread of rumours it is important to spread facts about the disaster. As disasters are characterised by chaos it is important to give clear, precise information. Information about the chain of events, causes and the level of risk.
•    Information about what is being done locally and centrally to reduce the damage.
•    In which way the local community is affected, for example, broken roads, and bridges. Give detailed information about the affected areas that are used by the families.
•    Practical measures to limit the damage and reduce the risk.
•    Practical things that can be done to avoid panic, over activity, and unnecessary unrest, possibly give aid in clearing up and generally helping.
•    Facts about where people can be given aid, what type of aid is available, for instance, different centres of contact.
•    Information about common reactions in a crisis, and advice about how to handle them. Written information (reactions, advice, further places of contact)
•    Encouragement and advice for the people about how they can be of help to each other.
•    Expected reactions from social settings.
•It is important to encourage people for open and direct communication, work against isolation and alienation within the family, avoid shaming and secretiveness and give help in rearranging roles.
•It is the task of the helper to support the individual activity of the affected, and to encourage them to participate in the aid and rescue work. An increase in the individual feeling of accomplishment leads to an increased feeling of control. Constructive activity helps the people affected by crisis to avoid helplessness and is tied to better mastery of disasters.
•Mobilising social support – the most important support comes from friends, colleagues, and neighbours. This can be difficult if many people are affected by the disaster. Self-help and support can, in those cases, be strengthened in group meetings, or parent-teacher meetings in schools, or meetings for all the teachers. The classroom can be utilised to reach as many children as possible.
•Making it possible to get in touch with a professional about support conversation, insurance, economic, and judicial support.

Time frame and transference to further follow-up:
•The emergency phase is defined as the first week after the accident/disaster.
•After this period, transference to further follow up should be evaluated. Some measures will already have been planned past the emergency phase, such as follow-up briefing and any information meetings.
•In the case of natural disasters, it can expand to a longer time due to large economic losses, loss of home and possessions. Because of this, it will take longer to adapt.
•Some central criteria that increase the need for further, more intensive follow up:
•    Being highly exposed (to danger, among other things), or a high degree of traumatic delayed reactions.
•    Individual/family/groups (for instance youth) with psychosocial difficulties before the disaster.
•    When it is noticeable that adults are not working in their role as a carer, for instance with minors, sick, and children.
•    Surviving relatives with a bad/small social network.

3. Further follow-up

Objectives: Give the affected the psychosocial help and support over time that they need to gradually resume their normal everyday life. Try to avoid that the traumatic event leads to physical or mental illness or unnecessary suffering in a way that keeps the affected from functioning normally in work, school and social life.
Measures: The objectives are reached through clear written procedures for regular contact with the affected and with them to continuously evaluate the need for measures, further examinations and give any necessary help and support.

Coordination and responsibilities:
•In the case of large disasters, the inhabitants of several municipalities and possibly governmental institutions will be involved. It is important that one or more of the members of the crisis team have the responsibility to coordinate measures that are put into effect by the municipality, other affected municipalities and with measures that the special health services put into effect.
•To ensure as much stability as possible for the affected, the same person from the crisis team (for instance community nurse, minister, psychiatric nurse, municipal psychologist, general practitioner) who they have had the most contact with should be the contact for the individual/family in the further follow-up as well. This person should communicate closely with the general practitioner of the family, as the general practitioner will be central in the further follow-up.
•If the further follow-up happens from the hospital it is desirable for the team (doctor/nurse) who received the affected also is responsible for the psychosocial further follow-up.
The team for the further follow up should be operational within the first weeks and can, in the case of larger disasters, be operational across several years.

Method:
•If needs for further help are revealed (medical, traumatherapeutical treatment, family counselling, specific child professional help, spiritual guidance, support conversations, or practical, economical or legal help) at routine inquiries from the contact from the crisis team, the contact should contact the relevant help services in the municipality to acquire such help.
•Indirect help through advice and guidance, for instance to schools and work places.

Measures for the survivors:
•The need for further follow-up can vary strongly among the affected. The long-term follow-up also has to be flexible and adapted according to the needs of the families. This depends on the type of disaster and the degree of exposure (the risk of death).
•It is important for the aid to stretch out towards the affected and offer collective gathering in addition to other help measures. This takes advantage of the resources in the community and thus relieves the local support (see Measures in the local community above).
•Follow-up assemblies for instance three and six months after the incident (see Measures).
•A memorial service on the one-year anniversary of the incident.
•If the whole family were exposed to the disaster, it would be appropriate for the whole family to attend the follow-up conversations.
•Even if the whole family was not struck by the disaster, it can be helpful for other members of the family join for part of the follow-up. This will help to normalise reactions and mobilise family support.
•The presence of psychosocial support personnel in meetings for the affected when hearings and investigative reports are being announced, as well as any court cases.
•Survivors can also be followed-up over the phone, as for instance:
•    1st alternative: A person from the crisis team contacts the family or other strongly affected people using the telephone regularly throughout the year. The phone inquiry will be for instance 4-5 weeks after the incident, and after that 6 and 12 months after the incident. Every conversation will have the main objective of catching any problems and needs for help that can arise with the family over time. Possibilities for help and offers of possibly obtaining these should be discussed with the person.
•    2nd alternative: The crisis team will notify the general practitioner of one or more of the affected, according to an agreement made with them. The general practitioner is thus made aware of what the affected have experienced and can make their own plan for the follow-up for the affected and their families. In this case, the knowledge of the general practitioner of the affected’s prior health situation and prerequisites will be central to the evaluation of frequency of contact and caring measures in the further follow-up.
•When commission reports are published, it is important that the conclusions are presented to the affected before they are released to the press.
•Information about the further follow-up for those who do not live in the municipality.
•Support conversations with the minister, psychologist, psychiatric nurse, psychologist, etc., that have been started should be continued. If there is need for it, the medical treatment/consultation, practical assistance and so on, that has been started in the emergency phase, should also be continued.
•Follow-up with support conversations with a focus on handling uncomfortable symptoms, handling everyday life and how to work against the traumatic experience having an effect on the level of functioning in social and family life (see Reactions)
•Trauma specific mapping/screening of PTSD, anxiety, depression, and complicated grieving.
•Potentially reference to the special health services based on the results of screening (see Mapping)
•Evaluation/offer of extended sick leave, and potential adjustment of the work situation.
•Practical help, for instance with assistance in caring tasks.
•Individual and local community groups/community meetings for specific needs (see Measures in the local community above)
•Counselling handling grief/crisis reactions, handling difficulties as a couple, handling the grief of the children.
•Offer/referral to family counselling and couple’s therapy.
•Offer of insurance, economic, and legal counselling.
•Offer of getting in touch with other survivors it that is desirable (see Resources)

Measures for the next of kin and surviving relatives:
•Offer support conversations, counselling, running evaluation of the need for referral to the specialist health services.
•Gatherings for reflection after 1-2 weeks, 6 months and after 1 year (see Measures).
•A memorial service on the one-year anniversary of the incident.
•Advice for parents regarding looking after the children who are surviving relatives.
•Offer for contact with other who are left behind.
•Offer of continued sick leave/reduced workload, reduced work time, and adjustment of the work/school situation.
•Practical help for instance with assistance in caring tasks, watching children and similar tasks.
•The surviving relatives can also be followed-up by phone using the template above.

Time frames:
•Direct intervention in the first six months.
•Stay in touch and keep an eye on the development of needs throughout the first year.
•The contact with the next of kin and surviving relatives should last at least until the one year anniversary of the disaster, while the survivors should be followed-up over time where needs have been discovered.
•If the affected expresses a lack of interest in contact, for instance in the beginning or by one of the suggested points of contact, one should respectfully withdraw after asking for permission to contact them at a later (given) time. The affected should be informed of the knowledge possessed about the variation in experiencing need for help over time. If the affected does not wish for further contact, they should be informed about a person or a phone number that can be contacted in the case of a later experienced need for help.

Criteria for ending the contact:
The affected should feel they could participate in everyday life and hobbies without the reactions from the disaster hindering their participation or self-expression.