Texas Department of State Health Services

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Disaster Behavioral Health

• Texas Department of State Health Services
• Disaster Behavioral Health Services
• Joy Counce
• joy.counce_at_dshs.state.tx.us

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What do you expect to learn from this training?
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Training ObjectivesAfter this training you will
be able to

• Define Disaster Behavioral Health (DBH) and list
  the 8 key concepts of DBH
• Identify 6 Psychological Phases of Disaster
• Identify 6 Stressors of Crisis Response Workers
• Identify 10 ways to manage stress during and
  after a disaster

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Definition of Disaster (1)

• A disaster is a natural or human-caused
  occurrence (e.g., hurricane, tornado, flood,
  tsunami, earthquake, explosion, hazardous
  materials accident, mass criminal victimization
  incident, war, transportation accident, fire,
  terrorist attack, famine, epidemic) that causes
  human suffering.
• A disaster creates a collective need that
  overwhelms local resources and requires
  additional assistance.
• Adapted from the Center for Mental Health
  Services (CMHS) 2000.

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Definition of Disaster (2)

• A disaster is any natural catastrophe (e.g.,
  tornado, hurricane, storm, high water,
  wind-driven water, tidal wave, tsunami,
  earthquake, volcanic eruption, landslide,
  mudslide, snowstorm, drought) or, regardless of
  cause, any fire, flood, or explosion in any part
  of the United States that in the determination of
  the President causes sufficient severity and
  magnitude to warrant major disaster assistance
  under the Robert T. Stafford Disaster Relief and
  Emergency Assistance Act of 1974 (Stafford Act).
• Robert T. Stafford Disaster Relief and Emergency
  Assistance Act (1974).

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Characteristics and Repercussions of aDisaster
Natural vs. Human Caused

Natural Human Caused
Earthquakes, fires, hurricanes, floods, tornadoes Airplane crashes, chemical leaks, mass violence, terrorism
No one to blame People, governments, or businesses to blame
Beyond human control Seen as preventable and a betrayal by fellow humans
Advance warning is possible No advance warning
Post-disaster distress is high and felt mainly by survivors Post-disaster stress is often higher than that of natural disasters and felt by more people not directly affected
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In September 2008, Hurricane Ike, covering over
half of Cuba, makes its way west to Texas (NASA
Satellite)
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Definition of Disaster Behavioral Health
(DBH)http//www.phe.gov/Preparedness/planning/abc
/Pages/behavioralhealth.aspx

• Disaster behavioral health is the provision of
  mental health, substance abuse, and stress
  management to disaster survivors and responders.
• U.S. Department of Health and Human Services
  Office of the Assistant Secretary for
  Preparedness and Response

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What is DBH?www.disastermh.nebraska.edu/files-App
endix-D.pdf

• Disaster behavioral health is a departure from
  traditional behavioral health practice in many
  ways.
• Disaster behavioral health interventions are
  designed to address incident specific stress
  reactions, rather than ongoing or developmental
  behavioral health needs.

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What is DBH? (cont.)

• Outreach and crisis counseling activities are the
  core of disaster behavioral health services.
• Behavioral health professionals work hand-in-hand
  with paraprofessionals, volunteers, community
  leaders, and survivors of the disaster in ways
  that may differ from their formal clinical
  training.

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What is DBH? (cont.)

• The primary goal is to decrease the stress of an
  event and mitigate future problems
• Modalities may include Psychological First Aid,
  Spiritual Care, Substance Abuse services,
  Critical Incident Stress Management (CISM),
  Crisis Counseling, or other crisis intervention
  and disaster specific support services

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What is DBH? (cont.)

• Community based
• Focus on strengths coping skills
• Restore functioning
• Confirms reactions are common/normal
• Focus is educational

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Concepts of Disaster Behavioral Health Adapted
from DeWolfe, D. Field Manual for Mental Health
and Human Service Workers in Major Disasters.
DHHS Publication No. ADM 90-537, Washington,
D.C. U.S. Government Printing Office.

• 1. No one who sees a disaster is untouched by it
• There are 2 types of disaster trauma individual
  and community
• Most people pull together and function after a
  disaster but their effectiveness is diminished
• Stress and grief are common reactions to an
  abnormal situation

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Concepts of Disaster Behavioral Health

• Reactions often relate to survival and recovery
  issues
• People do not seek out mental health services
• Survivors may reject disaster assistance of all
  types
• Mental health assistance is often more practical
  than psychological in nature

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Preferred training/experience for disaster
behavioral health responders
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Preferred training/experience

• ICS (100, 200, 700, 800) (Free on-line through
  FEMA)
• Psychological First Aid, Crisis Intervention,
  Pastoral Counseling, CISM, or some other Early
  Psychological Intervention
• Ability to travel and work under adverse
  conditions
• Experience working with survivors of disasters
  and/or critical incidents or events
• Specialized training children and adolescents,
  cultural diversity, geriatric populations,
  victims of crime, grief and loss, special needs
  populations, death notifications, etc.

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Possible DBH Outreach Locations

• Disaster Recovery Center (DRC)
• Incident Command Post (ICP)
• Points of Distribution (POD)
• Mass Care Shelter
• Joint Field Office (JFO)
• Disaster District Committee (DDC)
• Regional Medical Operations Center (RMOC)
• Family Assistance Center (FAC)

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Phases of Disaster
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Phases of Disaster

• Emotional Highs

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6 Psychological Phases of Disaster

• Pre-disaster Phase
• Impact Phase
• Heroic Phase
• Honeymoon Phase
• Disillusionment Phase
• Reconstruction Phase

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Pre-Disaster Phase

• Disasters with no warning
• Feelings of vulnerability
• Lack of security
• Fears about the future
• Loss of control
• Inability to protect self and family
• Disasters with warning
• Guilt and self-blame for failure to heed warning

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Impact PhaseUsually the shortest phaseReactions
vary dependent on length and type of disaster

• Range of intense emotional reactions from shock
  to overt panic
• Fear and isolation
• Anxiety
• Stunned and disorganized
• Confusion and disbelief
• Self preservation

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Impact Phase Needs

• Explanation of incident
• Safety/security
• Basic physical needs (Maslows Hierarchy of Need)
  
• Support/caring

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Inventory

• Immediate assessment of damage
• Overwhelmed by disaster
• Attempt to locate and assist survivors
• Initial discovery of non-survivors
• Inability to locate loved ones
• High need for information

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Heroic Phase

• Evacuation and relocation has psychological
  significance
• Family separation
• High level of activity with low level of
  productivity
• Adrenaline-induced rescue behavior
• Risk assessment may be impaired

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Honeymoon PhaseUsually only lasts a few weeks

• Disaster assistance readily available
• Community bonding occurs
• Optimism exists
• Opportunity to build rapport and relationships
  between providers, resources, affected people,
  and stakeholders

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Disillusionment Phase

• Stress and fatigue take a toll
• Optimism turns to discouragement
• May have an increased need for substance abuse
  services
• Larger community returns to business as usual
• Reality of losses sets in
• Diminishing assistance leads to feelings of
  abandonment

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Reconstruction Phase

• Long-term process of rebuilding (1-3 years)
• Ongoing struggles with agencies
• Stress of temporary housing/finances
• Requires committed community support
• Adjustment to new circumstances/the new normal
  while possibly still grieving
• Good news most people rebuild and discover new
  meaning

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Psychological Consequences of a Disaster
Distress Responses
From IOM publication Preparing for the
Psychological Consequences of Terrorism
www.nap.edu NOTE Indicative only not to
scale
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Typical Individual Outcome of Disaster

• Most will return to normal function with no
  significant problems
• Some will have severe reactions
• Few will develop diagnosable conditions
• Most do not seek help or treatment
• Survivors often reject help

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Common Reactions to a Disaster

• Trouble concentrating
• Difficulty making decisions
• Preoccupation with the disaster
• Frequent dreams or nightmares
• Increased alcohol/drug use
• Feeling depressed, sad, irritable or angry
• Tiredness or low energy for no reason
• Increase or decrease in appetite

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Disorders that may result from severe reactions

• Depressive disorders
• Social isolation
• Anxiety disorders
• Substance Abuse
• Posttraumatic Stress Disorder (PTSD)
• Suicidal ideation and behavior
• Paranoia

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It is likely that early psychological
intervention (i.e., response oriented crisis and
disaster mental health intervention) is best
thought of as a means of enhancing
resiliency.Kaminsky, et al, (2005) RESISTANCE,
RESILIENCE, RECOVERY. In Everly Parker, Mental
Health Aspects of Disaster Public Health
Preparedness and Response. Balto Johns Hopkins
Center for Public Health Preparedness.
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ALL Crisis Intervention should be based upon the
Assessment of NEEDand the further ASSESSMENT of
the most appropriate intervention.
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Helpful guidelines

• Never presume to know what the person is
  experiencing.
• Do NOT assume that everyone is traumatized.
• Do NOT label/diagnose or patronize.
• Do NOT debrief.
• DO refer to professional help if out of your
  comfort zone or beyond your skill level.

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Goals of DBH and early psychological interventions

• To help survivors
• Understand their situations and reactions
• Regain a sense of mastery and control
• Identify, label, and express emotions
• Adjust to the disaster and losses
• Manage stress
• Make decisions and take action
• Develop coping strategies
• Use community resources

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• Characteristics of Early Psychological
  Interventions

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Crisis Counseling

• Engage
• Identify immediate needs
• Gather information
• Prioritize needs
• Provide practical assistance
• Educate
• Provide emotional support
• Determine next steps and follow up

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Psychological First AidCore Actions

• Contact and engagement
• Safety and comfort
• Stabilization
• Information gathering currents needs and
  concerns
• Practical assistance
• Connection with social supports
• Information for coping
• Linkage with collaborative services

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Critical Incident Stress Management (CISM)
icisf.org

• A comprehensive, integrative, multicomponent
  crisis intervention system that functionally
  spans the entire temporal spectrum of a
  crisispre-crisis, into acute crisis, and into
  the post-crisis phase.
• May be applied to individuals, small groups,
  large groups, families, organizations, and even
  communities.
• Founded in the emergency services professions in
  the late 1970s

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Spiritual Caresource Nebraska Disaster
Chaplain Network

• Disaster Spiritual Care Devoting presence,
  attention, and respectful assistance to helping
  people discern what is the meaning in their lives
  now, in this new environment of destruction and
  pain and how they will seek to live out that
  meaning as the recovery unfolds.
• Foster McCurley, 2003

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Ethics(FEMA Crisis Counseling Assistance and
Training Program Participant Workbook Module 1
Core Content Training, SAMHSA DTAC)

• Maintain confidentiality
• Get a release of information before sharing any
  information
• Follow the state and local regulations on
  mandatory reporting for child and elder abuse and
  neglect
• Follow state and local reporting regulations in
  cases of suicidal or homicidal intent
• Safeguard the interests and rights of individuals
  who lack decision making abilities

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Ethics (cont.)

• Ethical Guidelines
• Do no harm
• Participation is voluntary
• Consider reactions in relation to the disaster
  phase and context
• Individual coping styles should be respected
• Immediate interventions are supportive

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Ethics (cont.)

• Talking with a person in crisis does not always
  mean talking about the crisis
• Be aware of the situational and cultural contexts
  of the survivor and the intervention itself

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Typical Stressors for Crisis Counselors Working a
Disaster

• Repeated exposure to traumatic stories
• Exposure to survivors reactions to disaster
• Approaching survivors who may reject their help
• Feeling overwhelmed by the sadness of others
• Feeling helpless to alleviate the pain of others

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Typical Stressors for Crisis Counselors Working
a Disaster

• Staff shortages
• Working long hours
• Away from family and friends for extended periods
  of time
• Personal experience with the disaster

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Signs That You May Need Stress Management
Assistance

• Disorientation or confusion and difficulty
  communicating thoughts
• Difficulty remembering instructions
• Difficulty maintaining balance
• Becoming easily frustrated and being
  uncharacteristically argumentative
• Inability to engage in problem-solving and
  difficulty making decisions

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Signs That You May Need Stress Management
Assistance

• Limited attention span and difficulty
  concentrating
• Colds or flu-like symptoms
• Headaches/tremors/nausea
• Loss of objectivity

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Ways to Manage Your Stress

• Drink plenty of water, and eat healthy snacks
  like fresh fruit, whole grain breads, and other
  energy foods.
• Stay in touch with your family and friends.
• Pair up with another responder so that you may
  monitor one anothers stress.
• Take frequent breaks as is practical.
• Do not over identify with survivors.

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Ways to Manage Your Stress

• Talk out your stress- process your thoughts and
  reactions with someone else (coworker, therapist,
  clergy, friend, family, supervisor).
• Learn about Compassion Fatigue.
• Build a positive support system that supports
  you, not fuels your stress
• Participate in memorials, rituals, and use of
  symbols as a way to express feelings.

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Ways to Manage Your Stress

• Take care of yourself Exercise, Meditate, Get
  enough sleep, nutrition.
• Do things outside of work that bring you joy and
  fuel your passion(s).
• Find some alone time for yourself, nurture your
  spirit.
• Humorit can help to keep problems in
  perspective.
• Use time off to decompress and recharge your
  batteries (music, exercise, read, relaxing meal,
  movie)

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• Top 10
• Things To Do
• In Coping with Stress

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10Exercise
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9Spend Time With Others
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8Reach Out To Others
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7Stay Calm
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6Eat a Healthy Diet
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5Do Things That Make You Feel Good
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4Use the Power of Prayer
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3Get Plenty of Rest
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2Remember, Youre Not Crazy!
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1Talk To Friends
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Resources

• National Child Traumatic Stress Network (free PFA
  course)
• http//learn.nctsn.org/
• FEMA (free ICS courses)
• http//training.fema.gov/is/nims.asp
• SAMHSA
• http//www.samhsa.gov/dtac/
• International Critical Incident Stress Foundation
• http//www.icisf.org/

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Resources

• DSHS acronym list
• http//online.dshs.state.tx.us/library/acronym.htm
  
• TDEM website
• http//www.txdps.state.tx.us/dem/index.htm
• FEMA acronym list
• http//www.fema.gov/plan/prepare/faat.shtm
• Centers for Disease Control
• http//www.bt.cdc.gov/mentalhealth/

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Contact Information

• Disaster Behavioral Health Services
• 909 West 45th Street
• Austin, TX 78751-2008
• [phone]
• DBHS_at_dshs.state.tx.us
• http//www.dshs.state.tx.us/mhsa-disaster