Mental Health Response Team Early Interventions to Disaster Nancy Pierce, MSW, LCSW Mental Health Cr

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Mental Health Response TeamEarly Interventions
to DisasterNancy Pierce, MSW, LCSWMental Health
Crisis ConsultantsMHRT Project Coordinator
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Traumatic Stress

• Threat, horror, loss
• Exceeds coping resources
• Breaks protective defenses
• Severity related to event being unexpected,
  inescapable, uncontrollable, without meaning
• Incongruous, intrusive, distressful, unremitting
  memories cognitive/behavioral responses
• May result in development of stress disorders
• ASD Acute Stress Disorder
• PTSD Post traumatic Stress Disorder

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Traumatic Stress Theory

• PTSD is not a normal stress response
• Trauma event may not be the sole cause of
  post-traumatic stress symptoms
• Stress response is not a sufficient cause of
  traumatic stress disorders therefore
• Efforts to reduce stress alone are not sufficient
  to prevent stress disorders (ASD, PTSD)

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Prevalence/Prevention of PTSD

• Prevention of PTSD focuses on
• Traumatic experience and/or
• Cognitive/behavioral response to trauma
• Not the level of stress experienced
• Majority require no treatment
• Focus on resilience vs. reactions
• ID risk and protective/resilience factors
• Prevalence of PTSD is much lower than
• prevalence of trauma

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Current Best Practices

• Support rather than supplant established internal
  and external resources
• Build resilience and protective factors
• Watchful waiting
• Careful, conservative referrals
• Many tools, no prescriptions

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Post-Trauma Distress

• Immediate reactions to traumatic events can look
  like stress disorder
• Most reactions fade away over time, less
  frequent, less intense
• Humans beings are equipped to have negative
  experiences, can learn and grow from them and not
  be debilitated

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Common Reactions to Trauma

• Re-experiencing trauma (cues and triggers)
• Flashbacks
• Unwanted thoughts
• Nightmares
• Avoidance
• Reminders of event
• Talking or having feelings, memories
• Increased arousal
• Hyper-vigilance, ? startle response
• Impatience, irritability/anger

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Common Reactions to Trauma

• Fear and anxiety
• Guilt and shame
• Grief and depression
• ? Intimacy and trust
• ? Use of alcohol and other substances
• Self-image/world view can become negative
• Symptoms of trauma adaptations to traumatic
  event in effort to protect self, our beliefs and
  how we find meaning

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Risk Factors for Stress Disorders

• Already suffering from anxiety and mood
  disorders, mental illness, substance abuse
• Proneness to experience irritability, depression,
  anxiety
• Cognitive style/ability or disability
• Prior trauma/abuse or neglect
• Family instability
• Poor/unstable social supports
• Not engaged with community

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Protective Factors

• Resilience, psychological hardiness
• Cognitive and emotional stability/ability
• Positive competent social supports
• Functional family/home life/role models
• Involved in community and/or school
• Self-control, mood management, effective coping,
  problem solving
• Spirituality or religion
• Ability to ask, accept and use help

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What is Normal?

• Changes after trauma are normal
• Major trauma may produce severe problems in
  immediate aftermath
• Many feel better within 3 months after event
• Others recover more slowly/some dont recover
  without help
• Becoming more aware of changes since trauma may
  be the first step toward recovery

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Many Traumatized Victims

• Dont believe they need help
• Wont seek out services despite emotional
  distress
• Report better off than others less affected
• Believe help sign of weakness
• Prefer to seek informal support from friends and
  family
• More likely to accept help with problems in
  living than accept mental health counseling

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Crisis Response to Communities

• Practical field application of crisis
  intervention to help persons learn to cope with
  extreme stresses they may face in aftermath
• Objectives to prevent PTSD, or return to
  pre-disaster functioning have been modified
  since there is no clear evidence as to what early
  interventions help or work
• Still victims of disasters hope they will return
  to their pre-disaster functioning

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Trauma Recovery/Resilience
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Processing Trauma Experience

• Integration of trauma recollections takes time,
  repetition and support
• Allow time for the natural recovery process to
  occur intermittently and in small doses
• Use avoidant behaviors as natural way to tolerate
  trauma
• Educate family/friends how to be empathic,
  patient listeners
• ID and accept help/support from family, friends,
  community structures like neighbors, churches,
  schools, support groups

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Resilience

• Different from recovery or adjustment
• Capacity to maintain normal functioning despite
  adversity
• Successful operation of basic human adaptational
  systems
• Ability to bounce back from crisis
• Persevere through difficult times

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Resilience Factors/Examples

• Psychological hardiness
• Confidence, commitment to find meaning in life
• Belief in benefits from good and bad experiences
• Shift locus of control from external to internal
• Cognitive flexibility and acceptance
• Able to flexibly shift expectations and
  priorities
• Active coping style problem solving and managing
  emotions
• Engage in physical exercise for mood health
• Meaning in religion, spirituality, benevolence
• Positive social support/resilient role models

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Promoting Resiliency

• Resiliency more common than we think with
  uncommon ways to promote it
• Over-optimism about oneself
• Repressing/avoiding unpleasant thoughts emotions
• Moving forward as a necessary life task
• Use of humor and positive emotions
• Flexible problem-solving, learning to face fears
• Resilience is about people reaching out and
  helping each other (altruism)

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What Does Help?

• Focus on practical issues and needs
• Give accurate, simple info about plans/events
• Help without intruding or forcing interventions
  when victims arent ready or able to use them
• Recognize the need for passage of time after
  survival is ensured when people have emotional
  stability/strength to face what was lost
• Explore risk and protective factors
• Discuss self-care and strategies to reduce
  anxiety like grounding and relaxation techniques

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What Can We Do?

• Provide active yet calming presence to ID signs
  of distress and immediate needs
• Bear witness/be present to provide emotional
  ballast/balance and provide advocacy
• Actively listen, empathize, normalize/reassure to
  help make sense and find meaning
• Assist in resiliency building by modeling
  positive coping skills effective problem solving

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ID Vulnerable Persons

• Needs may be more complex or intense
• May exceed traditional services provided
• Increased susceptibility due to needs
  disability
• Cant access and use standard support resources
  in relief/recovery
• Higher risk during traumatic chaos, needing
  assistance and services tailored to their needs
• ID persons with special needs current or past
  trauma, behavioral or emotional disorders,
  impulsive risk behaviors

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Children

• Dependent on adults for security
• Lack authority/ability to control environment
• Underreport due to difficulty verbalizing trauma
  experience or downplay feelings
• Nonverbal signs of distress are mistaken for
  other disorders
• Traumatic effects more damaging to
  still-developing/malleable minds and alter path
  of childs development
• Developmental stage in which trauma occurs may
  help predict impact on child

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Children and Trauma

• Children and adolescents are affected by how
  adults closest to them conduct themselves
• Children thrive on consistency, routines and
  rituals so restore familiar childhood activities
• Encourage expression of thoughts and feelings by
  talking/explaining what happened
• Protect children from overexposure to
  graphic/disturbing images, but provide factual
  info in simple and direct language
• Parents should be encouraged to provide social
  support and keep families united

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What Children Need

• If disoriented/shock, needs 11 support with
  protective adult, parent/family
• Physical comforts
• Cuddle toys
• Blankets for warmth and nesting
• Snacks for nurturance
• Repeated concrete explanations about what
  happened, what is going to happen
• Repeated assurances they are safe/secure
• Access to materials to play, draw, familiar play
  activities
• Opportunities to talk

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Help Children Grieve

• Advice on loss and death depends on culture,
  religious faith and beliefs of survivors
• Children often mirror parents responses
• Depends on age and maturity of child
• Keep it short, simple and accurate
• Use patient listening, dont force talking
• It helps to make it safe for child to grieve
  losses, to know they are not alone in their grief
• Include children in recovery efforts preparing
  and planning for future

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Educate Parents to Help Children

• Parents most concerned about children who are
  vulnerable
• Parents usually best helpers for children
• Parents feel helped when they are taught how to
  help their children
• Parents feel empowered when workers consult and
  advise parents on how to help

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How Parents Can Help

• Model calmness and control
• Reassure child they are safe
• Reassure trustworthy people in charge
• Let child know okay to feel upset/angry
• Observe childs behaviors
• Changes in sleep, appetite, etc
• Tell the truth
• Stick to the facts
• Keep explanations age-appropriate
• Keep explanations brief and simple for young
• Separate fact from fantasy for older
• Be a empathic, patient listener

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What Parents Can Do

• Focus child on next day or two
• Make time to talk with child
• Stay close to child to reassure and monitor
• Limit TV time watching disaster
• Maintain normal routine but be flexible
• Spend extra time before bedtime
• Make sure child is eating, sleeping, being active
  to ? stress
• Offer prayers, thinking hopeful thoughts, going
  to community gatherings, religious services
  instills sense family being supportive
• Find out what school counseling is in place

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Elderly

• Reluctant to ask for help
• Need to provide verbal assurance and attention
• Loss of independence, not enough time in their
  lives to rebuild or recreate
• Recovery of possessions, make home visits,
  arrange for companions, provide transportation
• Relocation to familiar surroundings
• Re-establish family and social contacts
• Reduce barriers to accessing resources
• Assist in obtaining medical, financial assistance
• Re-establish medication regimens

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People with Serious Mental Illness

• Disruption of medications, treatment, routine
• May not adapt well to unfamiliar and
  over-stimulating environment of shelters
• Need monitoring of case management teams
• Involve family/friends to help with treatment
• Dont typically experience long-term problems

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People with Physical Disabilities

• Feel vulnerable because of ongoing physical
  problems
• Perceptions of lost control and autonomy
• Disruption in normal patterns of care or
  assistance leading to anxiety/stress
• Vulnerable to marginalization, isolation

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Culture Counts!

• Cross-cultural differences related to ethnic,
  religious identity or place of origin
• Variations in meaning
• Expression of thoughts, feelings, behaviors
• Cross-cultural differences may influence
• Validity of assessment
• Response to treatment
• Ways of interacting with survivor
• Response sensitive to local customs culture
• Use culturally competent assessments and
  interventions

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Cultural Competence Checklist

• Meanings associated with current disaster and
  emergency response
• Beliefs and practices regarding death, burial,
  mourning, trauma and healing
• Trauma and violence in country of origin/USA
• Views about mental health and responders
• Cultural courtesy (who to talk to first, who is
  considered family)

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Who is at Risk and Why?
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Disasters Communities

• Disasters and major critical events test
  functioning of communities
• Affect those directly/indirectly impacted and
  those who come to help
• Lives, culture, beliefs may be altered and new
  coping skills required
• Multiple losses related to incident
• Think of concentric circles to see broad range of
  persons involved in disasters

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Continuities of Life Disrupted

• Conducting normal life disrupted by disaster
• Functional continuity
• How to maintain usual routines, roles
• Historical continuity
• Lost home, community, place of work, personal
  objects/memorabilia loss of ID, sense of
  history
• Interpersonal continuity/social network
• Relocation, loss of home/neighborhood
• Spiritual continuity
• Loss of faith, feeling vulnerably, unable to deal
  with a world no longer good, safe or predictable

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? Risk of Mental Health Problems

• Severe exposure to disaster
• Injury, threat to life, extreme loss
• Living in highly disrupted/traumatized community
• Female gender, middle years 40-60
• Presence of spouse who is highly distressed
• Membership of ethnic minority group
• Poverty, low socio-economic status
• Presence of children in home
• Psychiatric history
• Secondary stressors
• Weak or diminishing psycho-social resources

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Pre-Trauma Event

• Recognize both capacity for vulnerability and
  resiliency
• ID vulnerable populations with inherent or
• pre-existing characteristics
• Fragile/prone to anxiety/depressions
• Elderly, disabled, refugees, severe mentally ill
• AODA, socially/economically disadvantaged,
• Family instability, prior history for trauma,
  parent pathology, middle-age women, children

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During Trauma Event

• Disaster experience greatest exposure leads to
  greatest suffering dose-response relationship
• Bereavement/loss, injury may predict more
  negative outcome
• Dissociation/panic may predict worse outcome
• Relocation, displacement, separation are
  especially difficult for youth and elderly

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Post-Trauma Event

• Positive social support protective factor
• Belief they are cared for by others
• Negative or losing social support risk factor
• Criticism, blame, impatience, second guessing
• Additional or secondary life stressors
• Coping belief in ones ability to cope more
  important than specific coping mechanism
• Avoidance, extreme denial, blaming are
  detrimental ways of coping

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Early InterventionsPsychological First
AidPsycho-educationCoping Skills
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Psychological First Aid (PFA)

• Used during earliest stage post-event when
  survivors need help taking in information or
  seeing beyond immediate needs
• Non-intrusive way of being present for victims
• Meets basic needs first, restoring sense of
  safety, providing comfort and support
• Targets any acute stress reactions and immediate
  needs to help recovery take place
• PFA is not about having victims speak about
  traumatic experience, but willingness to listen
  to those who choose to share

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PFA Approach

• Empower survivors by acknowledging and supporting
  strength, competence and courage
• Let survivors determine kind of assistance they
  receive and the pace of self-disclosure
• Listen to shared stories which help create order,
  management and meaning, without leaving them with
  unmanageable feelings
• Help survivors recognize own strengths by asking
  about past coping, skills they have used
  successfully in past
• Encourage survivors to support and assist others
• Give children active role caring for self/sibs

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PFA Practice Points

• Be calm and grounded
• Know your limits
• Physically available and emotionally present
• Normalize by providing acknowledgment and
  recognition of suffering and strength
• Express empathy enter into their world, bear
  witness, communicate understanding/respect
• Support choice not to self-disclose
• Dont assume all people need or want more
  help/interventions in the immediate aftermath
• PFA is based on belief that most people will
  recover naturally on their own

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Create Sense of Safety Security

• Physical security
• Give directions of what to do, where to go
• Food, clothing, shelter
• Emotional safety from media, onlookers
• Establish personal space to preserve privacy
• Provide human contact and support
• Provide safe place to express emotions
• Assist in contacting reuniting with supports
• Help children understand what has happened
• Facilitate problem solving by starting small
• Provide sense of future and hope

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Ventilation and Validation

• Survivors may want to
• Tell their disaster story
• Ventilate feelings and reactions
• Be heard and feel validated
• MHRT can help with storytelling process
• Ask questions to facilitate flow of story telling
• Echo key words or phrases to acknowledge
• Support and honor silence by waiting for survivor
  to decide if wants to continue story
• Listen and summarize to help survivors develop
  narrative for event and to find words to describe
  their reactions
• Reassure reactions are acceptable and not uncommon

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Prediction and Preparation

• Help in predicting and preparing for
  post-disaster possibilities/challenges
• Set small, doable goals
• Focus on daily planning using simple problem
  solving techniques
• Talk or write about event to bring order to
  chaotic feelings
• Plan time for memories and memorials
• Find someone in community to support them
• Educate survivors about stress reactions that
  might occur for them or children

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Is PFA Effective?

• Continues to be a lack of evidence regarding
  effective early interventions
• Appears promising and probably is effective
• Less specific intervention geared to be broader,
  flexible, which uses empathy and collaboration
• Allows mental health to be visible and helpful
  during early phase after disaster
• Helps to establish rapport without intruding by
  supporting the natural recovery process
• May lay groundwork for more intensive
  interventions during recovery phase

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PFA as Pre-Screening Tool

• May serve as a prescreening tool by
• Knowing who and where are vulnerable populations
• Targeting resources for them
• May help to determine best time for intervention
  so not too soon or too late
• May help survivors accept possible referral for
  follow up treatment if needed

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Psycho-Education

• Least controversial/most accepted, recommended
• Info on typical reactions/symptoms experienced
  by survivors resilience effective/ineffective
  coping strategies loss/grief ways for parents
  to help children treatment resources
• Doing outreach, using media, flyers, websites,
  established community structures like churches,
  schools, community centers
• Goal to let survivors know what they might
  experience without alarming them or causing them
  to anticipate future distress

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Psycho-education

• Normalize/validate reactions to stress
• Recognize some will have extreme reactions and
  some will have no reactions
• Avoid using heavy-handed prediction of symptoms
  or stages
• Suggest reactions typically go away in time
• Encourages past positive coping strategies
• Offer stress-reducing strategies social support,
  emotional sharing, exercise, journaling,
  relaxation/meditation, spiritual practices

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Coping Strategies

• Behavioral/problem-focused coping
• Used in situations that are changeable
• Actions taken in response to problem
• Involves info-gathering, problem solving,
  decision-making and direct action
• Emotion-focused coping
• Used in situations that are unchangeable
• Regulates emotional distress aroused by problem
• Involves compromise, acceptance, distortion/
  denial
• Used to alter meaning of situation
• Need combination of skills in both areas

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Model and Teach Coping Skills

• Active/problem-focused coping doing something
  about situational, concrete problems
• Make action plan and take direct action
• Work on keeping focused/not distracted
• Seek support/assistance
• Emotional coping best used when problem does not
  allow for any intervention
• Not thinking about problem using avoidance,
  denial, or distraction
• Accepting problem using patience, meditation,
  mindfulness, or prayer
• Expressing feelings through emotional venting,
  talking, journaling, drawing, singing, movement

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Positive Coping Negative Coping

• Talk to others for support
• Adequate rest
• Distracting/pleasant activities
• Spend time with others
• Exercise (moderation)
• Use support groups
• Seek counseling

• Alcohol/drugs to cope
• Isolation/withdrawal
• Passive coping style
• Extreme avoidance of thinking, talking about
  event
• Workaholism
• Anger/violence

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Cognitive CopingCognitive ReframingCognitive
Re-Structuring
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Self-Doubt and Self-Blame

• Common reactions of survivors of disasters or
  traumatic events
• Unhelpful/hurtful reactions vs. understand they
  did the best they could given circumstances
• Cognitive distortions or problematic thinking
  styles usually not accurate and causes distress
• Cognitive coping IDs strongest inaccurate
  thought, challenges and changes thought

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Cognitive Reframing

• Victims get stuck in negative thinking about
  distressful events
• Putting event, thought, feeling in different or
  new context/ frame creates a different way to
  think or view it
• Thinking about it in a different way often brings
  up emotionally or factually new information may
  change way you view incident
• Helps survivor move away from negative pattern of
  thinking and towards a more realistic and
  hopefully positive way of thinking

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Informal Cognitive Re-Structuring

• Strategy used in cognitive coping and is
  informally used in early disaster interventions
• Cognitive restructuring is learning to disprove
  inaccurate/unhelpful thoughts or ideas/faulty
  thinking and replacing them with more accurate
  and beneficial ones
• Use care not to correct valid cognitions
• Goal is to change problematic feelings and
  behaviors by putting thoughts in more realistic
  and balanced perspective

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Next Steps
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Assess, Identify and Refer

• Assessment
• Triage who needs help first and most
• Target Acute Stress Disorder, traumatic grief,
  other symptoms from prolonged and intense
  exposure to trauma or pre-existing disorders
• ID/treat those at risk for developing symptoms,
  but havent shown signs or
• Refer only when symptoms are not subsiding
  naturally on their own

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Stepped Care

• Most people respond to early interventions
  provided at disasters or major trauma events
• Some victims may need higher level of care
• Stepped care concept used in disaster response
  which identifies victims whose needs may be
  beyond scope of what is available in the field or
  at disaster site
• Stepped care is the process of stepping up to
  next level of care via transport or referral

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Referrals for Treatment

• Occur when person is unable to
• Perform daily functions, care for personal needs
• Apply for necessary assistance
• Make simple decisions
• Flat affect, unable to act, serious withdrawal
• Preoccupied, obsessive thinking, compulsions
• Dissociation or severe reactions to triggers
• Excessive flashbacks, nightmares
• Substance abuse/withdrawal
• Symptoms of psychosis
• Suicidal or violent behaviors

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Follow up Care

• Where and how to make referral for follow up care
  for
• Individuals, families, groups
• Medications
• Spiritual support
• Hospitalization
• Know local resources and community culture
• Help lines for domestic violence, child respite,
  crime victim services, special needs, burial
  assistance, elderly, interpreters/translators

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Tips to ? Accepting Help

• Often most affected refuse to accept help
  indicative of weakness
• Fear stigmatization from family, community,
  coworkers if not recovering quickly
• Use direct/matter-of-fact approach discussing
  available mental health services, normalizing how
  many are helped
• If parent of child is reluctant, offering
  treatment to help family may be more acceptable
• Encouraging self-care for parents and their
  families provides permission to seek help

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Community Outreach

• Outreach valuable tool for reaching special
  populations or at-risk survivors
• Initiating contact at gathering sites
• Reaching out via media, internet, crisis lines
• Participating in conducting meetings for
  pre-existing groups like faith-based orgs,
  schools, employers, community centers
• Providing psycho-ed resources and referral info
  to health-care clinics, human services, police,
  fire/EMS, local county government

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ID Key Post-Disaster Events

• Identify events with potential mental health
  implications
• Examples death notifications, ending rescue and
  recovery operations, criminal justice
  proceedings, returning to scene/impact area,
  memorials/funerals, cultural rituals/honoring
  ceremonies, community gatherings
• Determine mental health roles
• Implement mental health interventions

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Final Points to Remember

• Assist individuals in coping with extraordinary
  stress of disaster/trauma
• Dont pressure survivors to disclose details
• Listen to what survivor wants to discuss
• Dont pathologize reactions, make formal
  diagnoses, use mental health labels or jargon
• Provide short-term interventions to individuals
  groups experiencing psychological reactions
• While early interventions are not formal mental
  health treatment, they are an essential component
  of mass disaster response