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

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


1
Mental Health Response Team Early Interventions
to Disaster Nancy Pierce, MSW, LCSW Mental Health
Crisis Consultants MHRT Project Coordinator
2
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

3
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)

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
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

12
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

13
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

14
Trauma Recovery/Resilience
15
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

16
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

17
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

18
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)

19
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

20
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

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
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

32
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

33
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)

34
Who is at Risk and Why?
35
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

36
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

37
? 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

38
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

39
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

40
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

41
Early Interventions Psychological First
Aid Psycho-education Coping Skills
42
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

43
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

44
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

45
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

46
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

47
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

48
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

49
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

50
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

51
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

52
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

53
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

54
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

55
Cognitive Coping Cognitive Reframing Cognitive
Re-Structuring
56
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

57
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

58
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

59
Next Steps
60
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

61
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

62
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

63
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

64
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

65
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

66
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

67
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
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