DISASTER MENTAL HEALTH

1. DISASTERMENTAL HEALTH Thomas Hermes, LCSW Director of Assessment & Crisis Services Sinnissippi Centers, Inc. June 20, 2012

2. Presenter Background • MSW, LCSW • NOVA Training on Community Crisis Response • State of Illinois Joint effort/response to Columbine • SCAT Teams • NIU Response • Commercial/Industrial Critical Incidents

3. Overview of Presentation • Stress and Trauma • The Crisis Reaction • Trauma and Loss • Disaster Mental Health • Principles of Intervention • Recovery from Trauma (the NIU Experience) • Public Health/Mental Health Interface • PTSD

4. Disaster Mental Health • NOT traditional psychiatric or mental health service. • Trauma experienced by normal people. • Intervention is supportive in nature. • Natural Helpers are effective: Ministers, Teachers, Nurses, Law Enforcement, School Counselors, Funeral Home staff, etc.

5. Supportive Intervention • Often referred to in the literature as “Psychological First Aid” • Meet basic needs – food, water, shelter, pain, family reunification • Safety and security • Stabilize • Mitigate distress • Return to adaptive functioning or refer to next level of care

6. Public Health/Mental Health • (More psychological injuries than physical injuries can be expected from a disaster (1995 Sarin gas release) • Most post-disaster services likely delivered by non-mental health personnel • Effectiveness of Crisis Intervention well documented.

7. Stress and Trauma • Your Day-to-Day Life • Individuals exist in a normal state of “equilibrium” or balance. • That emotional balance involves everyday stress, both positive and negative. • Most people most of the time stay in a familiar range of equilibrium.

8. Stress and Trauma • When Trauma Occurs • Trauma throws people so far out of their range of equilibrium that it is difficult for them to restore a sense of balance in life. • Acute stress is usually caused by sudden, arbitrary, often random event.

9. The Crisis Reaction The normal response to trauma follows a similar pattern called the crisis reaction. • Physical Response: The physical response includes: • Physical shock, disorientation, immobilization and numbness

10. The Crisis Reaction • “Fight-or-Flight” reaction (when the body begins to mobilize): • Adrenaline • Physical senses • Heart rate • Exhaustion: physical arousal with fight-or-flight cannot be prolonged indefinitely.

11. The Crisis Reaction • Emotional Reaction • Stage one: shock, disbelief, denial • Stage two: anger/rage, fear/terror, sorrow/grief, confusion/frustration, self-blame/guilt • Stage three: reconstruction of equilibrium

12. Trauma and Loss Trauma is accompanied by multitude of losses: • Loss of control over one’s life • Loss of faith in one’s God or other people • Loss of sense of fairness or justice • Loss of personally-significant property, self or loved ones • Loss of sense of immortality and invulnerability • Loss of future

13. Trauma and Loss Because of the losses, trauma response involves grief and bereavement. One can grieve over the loss of loved things as well as loved people.

14. Disaster Mental Health Victim and survivor responses typically will follow the stages of grief: • Shock • Denial • Anger • Bargaining • Depression • Acceptance

15. Disaster Mental Health These stages are rough guidelines. Natural Helpers have always helped others through these reactions – ministers, counselors, medical professions, law enforcement.

16. Recovery From Trauma Many people live through trauma and are able to reconstruct their lives without outside help. Most people find some type of benign outside intervention useful in dealing with trauma.

17. Recovery From Trauma Recovery from immediate trauma is often affected by: • Severity of crisis reaction • Ability to understand what happened • Stability of victim’s/survivor’s equilibrium after event • Supportive environment • Validation of experience

18. Recovery From Trauma Recovery issues for survivors include: • Getting control of the event in the victim’s/survivor’s mind • Working out an understanding of the event • Re-establishing a new equilibrium/life • Re-establishing trust • Re-establishing a future • Re-establishing meaning

19. Goals of Mental Health Disaster Response: • Normalizing Feelings • Helping victims find effective ways of coping with their stress.

20. The NIU Experience: • Tragic Shootings February 14, 2008. • February 24th – over 500 volunteer counselors arrived at NIU from all over the country. • February 24th – Counselor Training and all-campus Memorial Service.

21. The NIU Experience: • February 25th & 26th – Counselors in every classroom for students’ return • Reviewed grieving process • Emphasized individuals recover at their own pace • Offered counseling • Reviewed resources • Suggestions for stress management

22. The NIU Experience: • February 25th & 26th – Counselors in every classroom for students’ return • Continuous message of support • On video screens • From Alumni • Coordinated campus theme and message: “Forward, Together Forward”

23. The NIU Experience: • Benefits of the 10-day closing: • Time at home in a safe environment • Time to adjust to the trauma • Time for funerals of the deceased • Time for those immediately impacted to get additional help

24. Application to Public Health Intervention: Public Health events would not include taking a 10-day break from the trauma But the same principles apply – your victims will also need a supportive environment, an understanding of the event, validation of their experience and re-establishing a new equilibrium

25. Principles for Intervention • Victims are normal people under severe stress, which temporarily disrupts their lives and functioning. They are not mental health patients. • Victim’s dysfunctioning is not pathological. Focus on strengths and coping skills.

26. Principles for Intervention • Crisis intervention in crisis situations must be time limited and problem-focused. • Victims needing mental health services should be referred to regular programs.

27. Basic Suggestions • Be a model of calmness. • Be thorough. Listen carefully. • Spend time being deliberate. • Be assured and confident.

28. Basic Suggestions Talk with and support the victims: • Tell them the facts (appropriate to age) • Listen to what they have to say • Be honest –if you do not know certain facts, tell them you don’t know • Tell them how you feel • Provide reassurance of safety • Allow people to grieve and mourn • Validate normalcy of reaction • Reaffirm life direction

29. Basic Suggestions If abnormal behaviors persist for longer than 3 weeks, please refer to a Mental Health Professional for help.

30. Mental Health/Public Health Some public health events will clearly include a need for disaster mental health intervention. • Epidemics • Widespread exposure to biological or chemical agents • Quarantine

31. Mental Health/Public Health Expect social and psychological distress. Panic is NOT common. Vast majority will cope quite well. Some will need assessment and intervention.

32. Mental Health/Public Health Fear is most likely when chemical or biological agents are involved • Invisible agents • Spread by person to person contact • Contagion/quarantine/evacuation • Uncertainty of dangerousness • Misinterpretation of autonomic arousal • These can mimic medical symptoms

33. Principles for Public Health/Mental Health Activities in Emergencies • Preparation/Planning • Map mental health resources • Coordination plan with each agency • Train relevant personnel • Have a contact list of resources (local, state, national) • Coordination among Agencies • Agencies need to work together

34. Principles for Public Health/Mental Health Activities in Emergencies • Integration into general health care/public health • On-the-job training and support for providing “psychological first aid”. • Access to services for all, not just high risk cohorts. • Monitor results • Inputs • Processes • Outcomes

35. Early Interventions – Mental Health/Public Health • Rapid information to health care personnel • Include information on any psychiatric effects of antidotes • Manage urgent psychiatric and neurological complaints in (emergency) medical facilities

36. Early Interventions – Mental Health/Public Health • Try to manage acute distress without medication (psychological first aid). • Can be taught quickly to health professionals and non-expert volunteers – teachers, clergy. • Psychological first aid should be available at general health care facilities and at family “waiting areas” for grieving relatives.

37. Group Intervention Process This is a recommended intervention for processing groups of victims and/or survivors or loved ones. Typically this would take 1-1/2 to 2 hours:

38. Group Intervention Process Use with small groups or large groups. Recent Examples: • Worker fatality, construction site • Factory explosion • Factory accident, worker’s hand severed.

39. Group Intervention Process This process is designed to help participants talk about and think about what happened, how they reacted, how it might affect their future, how they can recover. (It may well be indicated for relief workers, public health staff on the front lines).

40. Group Intervention Process Remember our two primary goals – normalizing feelings, and helping victims find effective ways to cope with ongoing stress.

41. Safety/Security: (10 min.) Introductions, explain agenda, review rules. (Use a Facilitator and a Scribe) Ground Rules: • Confidentiality. • Meeting is not a critique but a review of reactions. • May express any thought or feeling. • No physical violence, verbal abuse or making fun of one another. • May identify self or remain anonymous. • May step out for personal needs (with scribe).

42. Ventilation/Validation: (30 min.) • Participants describe what happened, where they were at the time of the event, who they were with, what did they see, hear, taste, touch, smell and what did they do.

43. Ventilation/Validation: (30 min.) • Participants describe what has happened in the aftermath. • What memories stand out, describe the last 48 hours. • What have been your emotional reactions?

44. Predictions/Preparation:(30 min.) • What might happen in the next few weeks? • What will happen in your job? At home? At school? • How will your family be affected? • What coping methods have you used in the past? Will they help now? • Discuss sources of help or information.

45. Summarize: (15 min.) • Review notes, reinforce that their reactions are normal. • Thank them for participating.

46. Post Group: • Distribute handouts, answer questions, plan future group meetings.

47. Long-Term Traumatic Stress Reaction: Long-term stress reactions are a natural response of people who have survived a traumatic event.

48. Long-Term Traumatic Stress Reaction: The most common type of long-term stress reaction is: • Post-Traumatic Stress Disorder (PTSD) • Re-experiencing the event both psychologically and with physiological reactivity

49. Long-Term Traumatic Stress Reaction: • Numbing, avoidance, and isolation • avoidance of thoughts or activities that remind one of the event • avoidance of previous habits or pleasurable activities • estrangement and isolation • reduced affect or feelings of “emotional anesthesia” • partial amnesia • a sense of foreshortened future

50. Long-Term Traumatic Stress Reaction: • Behavioral arousal • inability to concentrate • insomnia or interrupted sleep patterns • flashes of anger or irritability • startle reactions or hyperalertness