Disaster Behavioral Health

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Tools and Resources for Idaho Emergency
  Responders

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Panhandle Health District 1
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What type of organization do you work for?
Participant Poll

• A. Hospital
• B. EMS, pre-Hospital
• C. Health District
• D. Other

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Research Professor Schools of Nursing and
Public Health and Community Medicine
Randal Beaton, PhD, EMT
Faculty Northwest Center forPublic Health
Practice University of Washington

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Relevant Clinical Experience

• Volunteer EMT
• Counseled victims of 9/11 who lostco-workers
• Psychological casualties of Nisqually
  earthquake (2001)
• Stress management for First Responders mostly
  firefighters and paramedics in private practice

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You can observe a lot by watching
Berra, 1998
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Relevant teaching and research background

• Published studies on benefits of disaster
  training and drills
• NIOSH funded research into cause and effects of
  PTSD in firefighters
• Core faculty of HRSA funded BT Curriculum
  Development Grant(UW 03 present)
• Helped to write and drill UWSchool of Nursing
  Disaster Plan 2002

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NMDS drill (May 13, 2004)
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Preamble/Assumptions

• Disasters generally refer to natural or human
  caused events that cause property damage and
  large numbers of casualties.

Community wide disasters generally require
outside assistance and/or assets.
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Tsunami Disaster
Photo by Dr. Mark Oberle, Phuket, Thailand
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Effects on Victims Care Givers

• Disasters can also affect the psychological,
  behavioral, emotional and cognitive functioning
  of the disaster victims (primary, secondary,
  tertiary, etc.) and rescue workers, first
  responders and first receivers.

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Tsunami Disaster Victims
Photo by Dr. Mark Oberle in Phuket
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Overarching Goal

• Enhance the networking capacity and training of
  state of Idaho healthcare professionals to
  recognize, treat and coordinate care related to
  behavioral health consequences of bioterrorism
  and other public health emergencies.
• HRSA critical benchmark 2-8

• These training modules will address
• behavioral health aspects of disasters

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Disaster Cycle
There are a number of distinct conceptual stages
in the disaster cycle
Pre-event warning threat stage
Preparedness Planning
Disaster Cycle
Impact/Response
Evaluation
Recovery
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NMDS drill (May 13, 2004)
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Disaster Behavioral Health
Disaster behavioral health interventions differ
from traditional behavioral health practice by

• Addressing Incident-specific, stress reactions
• Providing outreach andcrisis counseling to
  victims,both immediate and long-term
• Working hand-in-hand with paraprofessionals,
  volunteers, community leaders, and survivors
  ofthe disaster

Source http//www.disastermh.nebraska.edu/state_
plan/Appendix20D.pdf
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Aims of Disaster Behavioral Health

• To prevent maladaptive psychological and
  behavioral reactions of disaster victims and
  rescue workers
• and/or
• To minimize the counterproductive effects such
  maladaptive reactions might have on the disaster
  response and recovery

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Questions
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Disaster Behavioral Health

Randal Beaton, PhD, EMT

• Modules 1-4

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Learner Objectives Modules 1 - 4

• Identify the psychosocial phases of a
  community-wide disaster and to describe the
  behavioral health tasks of disaster personnel
  during each phase
• Describe the various temporal patterns of
  behavioral health outcomes following a disaster,
  including resilience
• Identify the signs and symptoms of disaster
  victims, first responders and first receivers who
  may need a psychological evaluation

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Module 1 Psychosocial Phases of a Disaster

From Zunin Myers (2000)
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Implications/Tasks of each Phase for Disaster
Personnel - Pre-disaster

• Warning e.g. weather forecast
• Educate
• Inform
• Instruct
• Evacuate or stay put

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Pre-Disaster

• Threat, e.g., impending terrorist activity
• Risk communication To reduce anxiety, must also
  tell people what they should do (without jargon)

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TopOff 2 Seattle, May 2003
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Impact

• Prepare for surge
• Advise/instruct/give directions
• Risk Communication update
• Leadership

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Heroic

• Disaster survivors are true First Responders

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Honeymoon (community cohesion)

• Survivors may be elated and happy just to be
  alive
• Realize this phase will not last

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Disillusionment

• Reality of disaster hits home
• Provide assistance for the distressed
• Referrals to disaster mental health professionals

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Inventory

• Psychological community needs assessment
• Short-term
• Mid-range
• Downstream needs

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Working Through Grief (coming to terms)

• This is when disaster victims actually begin to
  need psychotherapy and/or medications (only a
  small fraction)
• Trigger events reminders
• Anniversary reactions set back

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Reconstruction (a new beginning)

• Still, even following recovery, disaster victims
  may be less able to cope with next disaster

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Behavioral Health Tasks, by Phase
Disaster Phase Pre-event warning Impact Heroic Honeymoon
Behavioral Health Tasks - Implications Risk Comm., Educate, Inform, Forecast, Instruct, Evacuate Advise, Risk Comm., Mitigate First responders are often disaster survivors, citizens and rescue workers rise to the occasion Realize it will not last
Available at http//www.son.washington.edu/port
als/bioterror/Table20120ID20Needs20assessment.
doc
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Behavioral Health Tasks, by Phase, Continued
Disillusionment Inventory Working through Grief Reconstruction
Assistance for distressed Psychosocial needs assessment, short-term, mid-range, and down-stream needs Psychotherapy and/or medications Psychoeducational Need to re-establish sense of safety Anniversaries Triggers Reminders can rekindle dormant trauma/symptoms Even when this is completed, survivors are still more susceptible to trauma from future disasters.
Available at http//www.son.washington.edu/port
als/bioterror/Table20120ID20Needs20assessment.
doc
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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Resilience

• Differs from recovery
• Individuals thrive
• Relatively stable trajectory

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Acute Distress and Recovery

• Post-disaster recovery usually occurs within
• Days
• Weeks
• A few months

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Chronic Distress

• Acute/Chronic Distress and/or Lasting Maladaptive
  Health Behavior Outcomes

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
Delayed Onset Distress
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For more information

• Coping With a Traumatic Event
• CDC Publication
• Available at http//www.bt.cdc.gov/masstrauma/co
  pingpub.asp

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Module 3 Resilience

• Definition
• The ability to maintain relatively stable
  physical and psychological functioning(not the
  same as recovery)

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Module 3 Resilience (continued)Risk Factors

• Risk factors that deter resilience
• Job loss and economic hardship
• Loss of sense of safety
• Loss of sense of control
• Loss of symbolic or community structure

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Ways to Promote Community Resilience in the
Aftermath of Disaster

• Reunite family members
• Engage churches and pastoral community
• Ask teachers, community leaders and authorities
  to reach out

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Environmental Factors That Promote Community
Resilience

• Availability of social resources
• Community cohesion
• Sense of connectedness

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Individual Characteristics Associated with
Resilience

• Positive temperament
• Ability to communicate
• Problem-solving and problem-focused vs.
  emotion-based coping
• Positive self-concept
• Learned helpfulness vs. hopelessness

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How Can First Responders and First Receivers Cope?

• Can emotional coping skills to deal with emergent
  disasters be taught?
• Doubtful, but some hints
• Stay focused on duties out focused
• Stay professional maintain professional
  boundaries
• Sort out family/roles/conflicts ahead of time

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How can First Responders and First Receivers
cope? (continued)

• Drill, drill, drill automatic, over-learned
  responses can be recalled under stress, also
  instills confidence
• Self-talk I will survive versus catastrophizing
• Importance of social support especially in
  aftermath

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Pathways to Resilience

• Denial/avoidance
• Useful illusions/distortions
• Disclosure helpful for some

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For more information

• APA Fact Sheets on Resilience to Help People Cope
  With Terrorism and Other Disasters
• Available at
• http//www.apa.org/psychologists/resilience.html

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Module 4 Signs Symptoms Suggesting Need for
Psychological Evaluation

• Suicidal or homicidal thoughts or plan(s)
• Inability to care for self
• Signs of psychotic mental illness hearing
  voices, delusional thinking, extreme agitation

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TopOff 2 Seattle, May 2003
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Signs and Symptoms, continued

• Disoriented, dazed not oriented x 3 recall of
  events impaired (R/O TBI)
• Clinical depression profound hopelessness and
  despair, withdrawal and inability to engage in
  productive activities

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Signs and Symptoms, continued

• Severe anxiety restless, agitated, inability to
  sleep for days, nightmares, overwhelming
  intrusive thoughts of the disaster
• Problematic use of alcohol or drugs

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Signs and Symptoms, continued

• Domestic violence, child or elder abuse
• Family members feel their loved ones are acting
  in uncharacteristic ways

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For more information

• Field Manual for Mental Health and Human Service
  Workers in Major Disasters
• Available at
• http//www.mentalhealth.org/publications/
• allpubs/ADM90-537/default.asp

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 10
• Post-Disaster Assessment

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Learner Objective Module 10

• To identify and describe some basic principles of
  a post-disaster assessment of community
  psychosocial needs.

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Principles of Psychological Needs Assessment
Post-disaster

• Type of Disaster
• Vulnerable populations
• Scope of the disaster
• Down stream factors

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TopOff 2 Dirty Bomb Scenario
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Disaster Typology
Natural Man-made Technological Biological
Unintentional Floods, Hurricanes, Earthquakes, etc. e.g., Bhopal, Haz-Mat, Nuclear Power plant accident Epidemic e.g., 1918 Influenza Pandemic
Intentional Act of God Chemical, Nuclear, Radiological, Explosion, Acts of Terrorism Bioterrorism
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It is not the event but the effect that makes
the disaster.
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Vulnerable Populations(Community Composition)

• Psychiatric populations
• Children/infants Schonfeld Hot Topic Archive
• Elderly
• Pregnant Women
• Women with young children
• Native American Tribes

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Population Exposure Model
DeWolfe, see SAMHSA publication
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Population Exposure Model (DeWolfe)

1. Seriously injured victims bereaved family
   members
2. Victims with high exposure to trauma victims
   evacuated from the disaster zone
3. Bereaved extended family members and friends
   rescue and recovery workers with prolonged
   exposure medical examiners office staff
   service providers directly involved with death
   notification and bereaved families

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Population Exposure Model (DeWolfe) (continued)

1. People who lost homes, jobs,pets, valued
   possessions mental health providers clergy,
   chaplains, spiritual leaders emergency health
   care providers school personnel involved with
   survivors, families, of victims media personnel

1. Government officials groups that identify with
   target victims group businesses with financial
   impacts
2. Community-at-large

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Downstream Factors

• Economic impact on community
• Job loss
• Housing needs
• Community Disruption
• Loss of symbols

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Red Cross Role (in needs assessment)

• Can assist disaster victims
• Make appropriate referrals

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Disaster Response and Recovery

• Disaster Response and Recovery A Handbook for
  Mental Health Professionals available at
  http//www.empowermentzone.com/disaster.txt
  accessed 01/24/05

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 13
• Providing Post-Disaster Behavioral Health
  Assistance

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Learner Objective Module 13

• To describe some basic approaches to (early)
  post-disaster behavioral health assistance for
  disaster victims

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TopOff 2
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Key Principles of Post Disaster Behavioral Health
Approaches

• No one who experiences a disaster first hand is
  unfazed

• Disaster stress and grief reactions are normal
  and expected normalize these reactions

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Key Principles of Post Disaster Behavioral Health
Approaches (continued)

• Many emotional reactions of disaster survivors
  stem from problems of living brought about by the
  disaster

• Most disaster survivors do not see themselves as
  needing behavioral health services following a
  disaster

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Key Principles of Post Disaster Behavioral Health
Approaches (continued)

• Disaster survivors may reject all forms of
  disaster assistance
• Disaster behavioral health assistance is more
  practicalthan psychological

• Disaster behavioral health services need to be
  uniquely tailored to the communities they serve

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Therapy by just walking around.
Things to Remember
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Highest priority for counseling efforts
Disaster workers
Things to Remember
Disaster counselors assume a variety of roles
carry water, pitch tents, serve meals and
listen.
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Helping Survivors in the Wake of Disaster Resource

• A National Center for PTSD Fact Sheet. Available
  at http//www.ncptsd.org/facts/disasters/fs_help
  ing_survivors.html

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 16 Rural Issues

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Learner Objectives Module 16

1. To identify some special considerations for rural
   settings in terms of disaster behavioral health
   preparedness, response and recovery

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Module 16

• Rural Mental Health Preparedness versus Urban
  Settings

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Rural America

• 65 million Americans
• Frontier/Small towns
• Transportation/highway systems
• Rural attitude

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(No Transcript)
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Rural America

• Sites of Farms (food supply)
• Sites of power facilities (including nuclear)
• Sites of headwaters and reservoirs (water supply)

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Rural Emergency Preparedness

• Rural health departments have less
  capacity/resources/range of personnel.
• Downsizing of rural hospitals has
  decreased/eliminated infrastructure.
• EMS systems rely on volunteers.
• General lack of funding and equipment.

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Rural Preparedness

• Several preparedness planning challenges are
  relatively unique to rural areas (e.g.
  coordination between state bioterrorism staff and
  Tribal nations).

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Rural Preparedness

• Rural areas are affected by weather, tourism, a
  fragile financial and economic based and are
  geographically isolated, making it difficult to
  support medical systems.

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Rural Preparedness Barriers

• The main barrier to rural preparedness is lack of
  funding.

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Rural Preparedness

• The Federal Government and the States must be
  financial partners but implementation must occur
  at a local level.

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Rural Mental Health Preparedness

• Not much good research
• Perceived risks terror vectors
• Agri-terrorism water sources
• Paucity of resources personnel and PPE
• Evacuation issues
• Communication
• Pathogens will not spare rural communities
• Native Alaskan Flu of 1918

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Rural Risk Communication

• Local news broadcasters viewed as more credible
• Perception is that terrorists will target urban
  population centers
• Terrorists might target rural settings so no
  one feels safe!

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Rural Health Concerns Resource

• Bridging the Health Divide The Rural Public
  Health Research Agenda available at
  http//www.upb.pitt.edu/crhp/Bridging20the20Heal
  th20Divide.pdf accessed 01/24/05. University of
  Pittsburgh publication.