Introduction

Core capabilities have been identified that define the elements by which the USA and communities throughout the nation may assess, develop, and maintain their readiness to address all plausible threats and hazards through effectively performing critical functions and tasks for the missions of prevention, protection, mitigation, response, and recovery [1]. A competent workforce, one in which individuals and teams have the necessary skills and training in the discipline of disaster health, is considered essential to public health core capabilities such as mass care [2]. A disaster health discipline must be built upon defined multidisciplinary competencies applicable to disaster and humanitarian workers in diverse settings domestically and internationally [3]. Competencies, ideally, describe the characteristics of workers that enable effective and/or superior performance in a job, role, or situation according to specified performance criteria [4]. These characteristics include knowledge and skills, but may also include a person’s motives, traits, self-concept, and behavior [5–8]. Disasters superimpose additional layers upon the everyday competency requirements of workers. Knowledge specific to disasters, such as knowledge of the National Incident Management System [9], is essential. Yet emergency response leaders and experienced disaster workers have recognized that not all knowledgeable people function well in disasters [6, 10]. For example, disasters demand of workers considerable flexibility and the ability to abruptly shift from their usual ways of practicing. Some workers are better able than others to make such adjustments and to perform their disaster roles effectively. The Institute of Medicine acknowledges and emphasizes the important distinction between knowledge and performance by including in all of its reports in recent years a quotation of Johann Wolfgang von Goethe: “Knowing is not enough; we must apply. Willing is not enough; we must do.” [11, 12]. An effective disaster health workforce must have individuals and teams who possess a diverse set of competencies and who consistently perform their assigned roles well.

The Pandemic All-Hazards Preparedness Act (PAHPA) of 2006 [13] mandated the establishment of competency-based curricula to guide the development of a public health workforce prepared to meet the needs of the nation and its communities in the event of disasters and other emergencies. This state of readiness was to be accomplished in part by making use of existing education and training programs and creating new programs as needed to develop and maintain a competent workforce. In 2007, Homeland Security Presidential Directive (HSPD)-21 [14] acknowledged the unique principles involved in carrying out the responsibilities of public health and medicine within the context of disasters and called for the establishment of a discipline of disaster health. A diversity of health care providers competent in this discipline would perform the essential capabilities of caring for survivors, attending to both their physical and mental health needs.

Disaster mental health has become increasingly recognized as an essential function in disaster preparedness and response, particularly with incidents involving terrorism, which has been characterized as an intentional attack on a nation’s mental health [15–18]. Federal all-hazards planning guidance for fulfilling the requirements of an effective disaster mental health response were identified in 2003 through a collaborative assessment of state disaster mental health plans by the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with the National Association of State Mental Health Program Directors (NASMHPD) [19]. This guidance was intended to compliment and augment FEMA’s earlier, more general, disaster planning guidance for states [20] by adding information specific to mental health care. It also compliments national standards for state and local planning of public health preparedness capabilities [2]. These documents describe the larger context in which disaster mental health competencies are needed and are likely to be operationalized.

Various sets of competencies have been created in attempts to describe the knowledge and skills needed by segments of the disaster health workforce that are pertinent to core capabilities. Existing competency sets have targeted various workforce segments or audiences including all disaster health responders (core), specific professions (e.g., public health workers, physicians, nurses, or EMTs), and organizations (e.g., hospital workers). Some competencies emphasize specific topics or focal areas, such as disaster mental health as a focal area for all disaster health workers [21•, 22]. In the literature, several articles have described existing disaster worker competency sets [5, 21•, 22], though none has provided an overview of competencies specific to disaster mental health. The development of a disaster health workforce competent to address matters of mental health in disasters requires well-defined competencies that can guide selection of personnel and the provision of comprehensive and effective training. The training to be guided by these competencies includes both the core training of all disaster workers to prepare them to address the ubiquitous mental health needs of disaster survivors while also caring for themselves and coworkers and the more specialized training needed to prepare those in the various mental health professions to work effectively in disaster settings that require significant departures from everyday work practices. This report identifies, describes, and discusses the existing competency sets pertinent to disaster mental health.

Methods

Searches of MEDLINE, PsycINFO, and EBSCO databases were conducted using the keywords “competencies AND (disaster OR emergency OR preparedness) AND (medicine OR health OR behavioral OR psychosocial OR psychological).” Other Web searches were conducted using Google and Google Scholar. Articles or other documents containing competency sets or reviews of competencies were selected for further review, and additional sources were found among the citations contained within these documents. The competency sets included in this report are those that addressed mental health, psychosocial, psychological, or behavioral health, whether being the primary focus or part of a broader set of competencies. A previously developed classification scheme [21•] was used to categorize the identified competency sets in terms of the breadth of intended target audience.

Results

Sixteen relevant competency sets were identified in this study. Some competency sets were intended for all disaster responders (i.e., core competencies), while others targeted specific groups of responders, i.e., members of specific professions. Only one competency set provided disaster mental health competencies specifically intended for mental health professionals, and its focus was limited to cultural competence.

The depth to which disaster mental health is addressed varies across these competency sets. Eight sets were not primarily focused on mental health but were instead geared toward identifying broader knowledge and skills relevant to disaster health, mainly to guide education and training for a variety of disaster responder audiences (Table 1). The other eight sets were specifically mental health focused (Table 2). In the former group (disaster health in general), two sets were categorized as core, being intended for all disaster health responders, and six were targeted at specific professions that would normally be represented in a disaster health workforce. In the latter group (mental health focused), six sets were categorized as core with a focal area of mental health, and two sets targeted specific professions. The competencies for professions outside of mental health resemble the core disaster health competencies. The one set of competencies specific to mental health professionals had a focal area of cultural competence.

Table 1 Competency sets in which mental health is not the primary focus
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Table 2 Competency sets in which mental health is the primary focus
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Two competency sets of particular importance for disaster health are Subbarao et al. [23] and Walsh et al. [22]. These competency sets were aimed at the broadest audience within the disaster health discipline and reflected a consensus of a wide group of experts, resulting in a robust set of consensus-based baseline core competencies for the discipline of disaster health (alternatively called disaster medicine and public health). Only a few competencies within these competency sets are specific to mental health, such as knowledge of the psychological sequelae of disasters, the ability to assess and manage mental health issues, and the ability of responders as care givers to attend to their own mental health needs. These and other competency sets that are specific to public health professionals [2, 27, 28] also contain competencies to do with family concerns, such as bereavement, and community level concerns, such as risk communication and the promotion of community resilience.

Competency sets that are focused specifically on mental health naturally provide considerably more details relevant to what responders need to know concerning disaster mental health needs and care. Examples of this detail include principles of psychological first aid; differentiating normal distress from pathological stress responses; use of the Haddon matrix in planning to prevent and mitigate injuries; cultural considerations and vulnerable populations in mental health response, assessment, triage, intervention, treatment, referral, and advocacy; and dealing with substance abuse and severe mental illness.

Discussion

It appears from the competencies identified in this study that although a wealth of competency sets for disaster health workers in general and a variety of specific professions [21•] have emerged in the post 9/11 era, competency sets specifically for disaster mental health professionals are lacking. Only one set of disaster mental health competencies was found that is directed toward mental health professionals [40], and it focused only on cultural competence. Disaster mental health competencies are either broadly written at a core level for all disaster health workers or are geared toward professions other than mental health professions, such as public health or nursing.

Teams of multidisciplinary responders need members who possess a variety of disaster mental health competencies appropriate for each member’s discipline, as well as cross-cutting competencies, such as those having to do with safety and functioning within an incident command structure [41]. Mental health professionals, of course, require the most specialized mental health competencies, such as diagnosis and treatment of post-disaster psychiatric disorders, differentiation of psychopathology from other emotional distress, and directing psychosocial interventions to distressed individuals without post-disaster psychopathology. Other disaster health team members need general mental health competencies such as managing medical conditions in the context of acute emotional distress in a post-disaster setting. All disaster workers, including non-health professionals, should possess basic mental health competencies such as skills in psychological first aid.

Collectively, the existing disaster mental health competency sets present many essential competencies, and in doing so, they significantly advance the field of disaster mental health and the broader discipline of disaster health. A major purpose in creating the existing disaster mental health competency sets was to gain a broad consensus as to the requirements for workforce education and training. With regard to the general disaster health workforce, this purpose has been considerably advanced, keeping in mind that ongoing improvement and revision of the competency sets will be needed as they are put to use in response to an “ever-evolving list of public health threats” [2] that may require new response capabilities.

A next step should be the development and validation of a comprehensive set of competencies specifically for mental health professionals working in disasters. To enable validation, these competencies should, ideally, be criterion-based, i.e., they should predict actual performance based on identified performance criteria and standards. Consensus-based approaches to competency definition have inherent limitations of validity in that, although the competencies represent a wide group of experts’ opinions, there is little direct evidence of how such competencies relate to actual performance in a disaster. Face validity of the content is insufficient to serve as evidence that these competencies would necessarily result in, or predict, effective performance [4, 5, 8].

Consensus methods of competency definition also tend to operate from the somewhat limited conceptualization of competencies as knowledge, skills, and perhaps certain attitudes. Competencies for roles as complex as disaster health and disaster mental health are multidimensional, including trainable knowledge and skills, but also including personal characteristics such as self-concept, motivation, and traits. Prior studies [6, 10] have demonstrated that experienced emergency responders and leaders consider a number of personal traits, such as flexibility, adaptability, patience, and a sense of humor, as differentiating the more effective performers in actual disasters. Those who use the competency sets primarily for education and training may not find this limitation too severe, as such attributes are difficult to instill through training. A number of other competency-based workforce development processes, however, such as job design and description, recruitment, assessment, hiring, compensation, performance management, and career development, for which competencies focused on knowledge and skills alone are inadequate, can benefit from applying a more inclusive model of competencies. The existing disaster mental health competency sets will need to be augmented if they are to be made useful for such purposes.

Conclusions

The competency sets identified in this study represent significant progress toward determining the relevant disaster mental and behavioral health knowledge and skills that can guide disaster health workforce planning in support of core preparedness and response capabilities. These competency sets provide a useful starting point for educators in designing and developing curricula and instructional activities for disaster mental health. They also can serve as a learning guide for disaster health workers who wish to acquire and maintain disaster mental health competencies. Instructional objectives have been written and corresponding learning resources identified for disaster mental health [36••], and these objectives have been linked to existing core disaster health competencies [22]. Such curriculum development efforts could be strengthened, however, by having a comprehensive set of competencies specific to disaster mental health on which to base curricula. Competency-based disaster mental health curricula are essential to the nation’s disaster preparedness and are needed to support the international call for professionalization among aid workers, a setting where mental health casualties dominate the health morbidity outcomes [42].

Future efforts to define disaster mental health competencies specifically for mental health professionals may benefit from studying the characteristics of identified superior performers using appropriate methods [4, 8]. It has been observed that people tend to agree more readily on who is outstanding than on what makes them outstanding [8]. If performance criteria are first identified to define what is meant by outstanding performance and how it is to be measured, then superior performers can be identified based on those criteria. In-depth studies of such performers can yield competencies with both criterion validity and predictive validity. In developing criterion-based competencies for disaster mental health professionals, consideration should be given to the requirements of both domestic and international disaster response efforts.