Federal Disaster Mental Health Response Policy: Building Resilient Communities

1. Federal Disaster Mental Health Response Policy: Building Resilient Communities LCDR Nicole L. Frazer, PhD, USPHS Office of the Deputy Assistant Secretary of Defense (Force Health Protection & Readiness) LCDR Jeffrey L. Goodie, PhD, ABPP, USPHS Assistant Professor of Family Medicine/Health Policy Analyst Uniformed Services University/Office of ASPR CDR Harvey Ball, USPHS Office of Assistant Secretary of Preparedness and Response UNCLASSIFIED

2. Overview • Models of Community Resilience • The Roles of the Office of the Assistant Secretary for Preparedness (ASPR) and Division of At-Risk, Behavioral Health, & Community Resilience (ABC) • The National Health Security Strategy (NHSS) • The Roles of the Office of the Assistant Secretary of Defense, Force Health Protection and Readiness (FHP&R)

3. What is Resilience? New Orleans 2005 Haiti 2010 Japan 2011 Memphis 2011

4. Post-Event functioning adapted to altered environment Post-Event functioning adapted to pre-event functioning Pre-Event Functioning crisis Resistance Resilience Transient Dysfunction Persistent dysfunction Vulnerability Stressor Severity Duration Surprise Resource Robustness Redundancy Rapidity Resource mobilization/ deterioration Model of Stress Resistance and Resilience Norris et al. (2007). Am J Community Psychol. 41:127-150.

5. Resilience Definition “A process linking a set of adaptive capacities to a positive trajectory of functioning and adaptation after a disturbance” Norris et al. (2007). Am J Community Psychol. 41:127-150.

6. Research-Based Conclusions Behavioral Health Interventions Ruggiero KJ et al. Beh Therapy 2006:37;190-205 Behavioral and cognitive early interventions may prevent problems Psychological debriefing approaches are contraindicated It is inappropriate to prescribe formal psychological services to all victims of disasters It is reasonable to expect that most people will be resilient and/or demonstrate a normal recovery Disaster-response professionals should not wait to provide psychological care until problems have become chronic

7. Information and Communication Economic Development Community Competence Social Capital Community ResilienceNetworked adaptive capacities Norris et al. (2008). Am J Community Psychol. 41:127-150.

8. Networked Adaptive CapacitiesEconomic Development • Number/Amount of economic resources • Diversity of economic resources • Capacity to distribute resources to those who need it most

9. Networked Adaptive CapacitiesSocial Capital • Network structures and linkages • Loosely coupled organizations that coordinate/collaborate • Tight coupling may increase danger; encourage group think • Social support • Provide actual assistance, embed into social relationships • Received • Perceived (twice as likely to evacuate) • Community bonds, root, commitments • Sense of community–attitude of trust , belonging to others • Place attachment--emotional connection to community • Citizen participation–engagement in formal organizations

10. Networked adaptive capacitiesInformation and Communication • Systems and Infrastructure for Informing the Public • Survives only if it is correct and correctly transmitted • Communication and Narrative • Shared meaning and purpose

11. Networked Adaptive CapacitiesCommunity Competence • Collective Efficacy and Empowerment • Shared belief that a group can effectively meet demands and improve lives through concerted effort

12. Building Community ResilienceRAND report (Chandra et al., 2011) Levers of community resilience Core components of community resilience Wellness Promote pre-/post-incident health Access Ensure health/social services access Social/Economic well-being Physical/Psychological health Community context Education Info preparedness, risks, resources Effective risk communication Engagement Promote participatory decision-making Self-Sufficiency Individuals /communities assume responsibility for preparedness. Developing Community Resilience Social connectedness forresource exchange, cohesion, recovery Integrating /involving govt & NGO in planning, response, and recovery Ongoing disaster experience Partnership Develop strong partnerships within and between government and NGOs

13. Research Implications Yun K, Lurie N, Hyde PS. N Engl J Med 2010; 363:1193-1195. “Although there is consensus that early behavioral health interventions should be routinely incorporated into disaster response, there is mixed evidence on which strategies are most effective and how best to deploy them. Furthermore, best practices for surveillance for mental health problems and substance abuse during disasters remain largely undeveloped.”

14. Basic/lab-based research past and future? Other research literatures? Testing models in disasters Real-time data collection Can community resilience be changed? Measures that predict resilience in specific populations Interventions that support resilience in at-risk populations Research Directions

15. Resilience and Community definitions Funding studies Measurement Defining success/improvement Questions Complicating Research/Communication/ Understanding

16. Community Resilience and Policy

17. ASPR OPP Division of At-Risk, Behavioral Health, & Community Resilience (ABC) Mission: Provide subject matter expertise, education, and coordination to internal and external partners to promote community resilience and ensure that behavioral health issues and the needs of at-risk individuals are integrated in the public health and medical emergency preparedness, response, and recovery activities of the nation.

18. ABC Key Responsibilities: 1. Policy Coordination • Provide policy guidance on at-risk individuals, behavioral health, and community resilience and serve as subject matter experts to other ASPR programs 2. Response • During response, provide expertise and technical assistance to OPEO Emergency Management Group and coordination of ESF #8 partners to: • Address the functional needs of at-risk individuals, including children and people with special medical needs • Address behavioral health considerations of impacted members of the public, survivors, and, in particular, federal responders

19. ABC 3. Interagency Coordination • Represent HHS to White House Recovery Initiative on behalf of ASPR • Chair Emergency Preparedness Health Subcommittee of the DHS Interagency Coordinating Council on Emergency Preparedness and Individuals with Disabilities (ICC) • Coordination of Children’s HHS Interagency Leadership on Disasters Working Group; lead ASPR liaison with National Commission for Children and Disaster • ASPR Liaison to Human Services (ACF); ASPR Liaison to Intradepartmental Council on Native American Affairs (ICNAA) • Represent ASPR on Healthy People 2020, Federal Education and Training Interagency Group (FETIG)

20. What is an “At-Risk Individual”?

21. HHS Definition for At Risk Individuals In simple terms, at-risk individuals are those who, in addition to their event-related medical needs, have other needs that may interfere with their ability to access or receive medical care.

22. At-Risk: Example The health status of an individual receiving home dialysis treatment who relies on a local Para-transit system to attend medical appointments and food shopping could quickly become critical if 40% of the drivers are ill and transportation is suspended. In addition to treatment for influenza, his functional needs would be medical care (for dialysis) and transportation. Without addressing those functional needs, he cannot get healthcare services.

23. How Does Behavioral Health Fit in?

24. Disaster Behavioral Health Disaster behavioral health is the provision of mental health, substance abuse, and stress management to disaster survivors and responders. Behavioral Health Concerns of Survivors and Responders Distress is common - symptoms and reactions include: Emotional - irritability, excessive sadness Cognitive - decision making, following directions Physical - headache, stomach pain, difficulty breathing. Behavioral - alcohol/drug use, interpersonal conflict, non-compliance with medication needs. 24

25. Disaster Behavioral Health Strategies Assure Basic Needs Psychological First Aid Needs Assessment Monitor the Recovery Environment Outreach/Information Dissemination Fostering Resiliency/Recovery Consultation/Technical Assistance Triage Treatment 25

26. HHS ASPR ABC/Behavioral Health • Part of the nation’s public health response per ESF #8. • Behavioral health needs often emerge immediately following a disaster, but may also develop over time. • ABC works to address the behavioral health needs of disaster/emergency survivors as well as the needs of the response workforce (force protection) as these pertain to ESF #8. • ABC also works to forward behavioral health approaches to promote individual and community resilience.

27. Community Resilience and the NHSS

28. At-risk, BH, and Community Resilience in the NHSS • Public education to inform and prepare individuals and communities including information for and about at-risk individuals and the psychological aspects of preparedness • Build, connect, and engage local social networks for preparedness, response, recovery, and resilience • Integrated support from non-governmental organizations...including policies to develop neighborhood resources for at-risk individuals • Risk communication ...including messages in appropriate languages and in alternative, accessible formats with special attention to needs of at-risk individuals

29. At-risk, BH, and Community Resilience in the NHSS (cont.) • Case management support or individual assistance...utilize whole family approaches, including crisis counseling... follow up regarding the physical and behavioral health • Reconstitution of the public health, medical, and behavioral health infrastructure • Access to health care and social services—for all community members, including at-risk individuals/special medical needs patients • Evidence-based prevention and treatment services; assess behavioral health needs among incident victims and response workers, monitor physical and behavioral health outcomes

30. At-risk, BH, and Community Resilience in the NHSS (cont.) • Fatality management ... support families with factual information and compassion • Develop “bystander response” until emergency responders arrive, (including the need for psychological support addressing the needs of at-risk individuals) • Recovery planning should address behavioral health services for affected communities and responders • Resilient communities have robust social networks and health systems that support recovery after adversity...including social and psychological resources

31. Pandemic and All Hazards Preparedness Act (PAHPA) • Passed in Dec 2006 “to improve the Nation’s public heath and medical preparedness and response capabilities for emergencies, whether deliberate, accidental, or natural” • Established: • Assistant Secretary for Preparedness and Response (ASPR) • Every four years prepare the National Health Security Strategy

32. National Health Security Strategy (NHSS) • National health security • “…a state in which the Nation and its people are prepared for, protected from, and resilient in the face of health threats or incidents with potentially negative health consequences.” • Establishes a national, NOT federal only, set of goal and strategic objectives for national health security.

33. Community Resilience at the National Level “The vision for health security described in the NHSS is built on a foundation of foundation of community resilience—healthy individuals, families, and communities with access to health care and with the knowledge and resources to know what to do to care for themselves and others in both routine and emergency situations.”

34. Community Resilience at the National Level “Communities help build resilience by implementing policies and practices to ensure the conditions under which people can be healthy, but assuring access to medical care, building social cohesion, supporting healthy behaviors, and creating a culture of preparedness in which bystander response to emergencies is not the exception but the norm.”

35. Framework for the NHSS

36. Key Elements of the NHSS • Build, connect, and engage local social networks for preparedness, response, recovery, and resilience • Integrated support from non-governmental organizations • Risk communication • Case management support or individual assistance • Access to health care and social services—including behavioral health— for all community members, including at-risk individuals/special medical needs patients • Resilient communities have robust social networks and health systems that support recovery after adversity...including social and psychological resources

37. Resources NHSS Web page: http://www.phe.gov/Preparedness/planning/authority/nhss/Pages/default.aspx HHS ASPR Web site: http://www.phe.gov/ HHS ASPR Division for At-Risk Individuals, Behavioral Health, and Community Resilience (ABC) Web page: http://publichealthemergency.hhs.gov/preparedness/planning/abc/Pages/default.aspx 37

38. Department of Defense Disaster Mental Health Policy

39. What We’ll Cover • Force Health Protection and Readiness • Policy Development • Military Health System Quadruple Aim • Disaster Mental Health Background • DoD Disaster Mental Health Policy • Summary UNCLASSIFIED

40. Force Health Protection and Readiness (FHP&R) Psychological Health Strategic Operations develops policies and programs: - To build psychological health and resilience - To mitigate operational stress across the deployment cycle - To ensure a fit and ready fighting force Currently four mental health policies in coordination UNCLASSIFIED

41. Policy Development • Mental health policies are shared between Force Health Protection and Readiness (FHP&R) and Clinical and Program Policy (C&PP) • FHP&R has deployment related psychological health policies • C&PP has garrison-focused clinical care policies • Mental health subject matter experts (SMEs) • Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury • C&PP/Office of the Chief Medical Officer (OCMO) • FHP&R/PHSO • Policy development requires close collaboration among these offices, along with Service proponents/leads UNCLASSIFIED

42. Policy Development U.S. Air Force photo by Airman 1st Class James Bell/Released UNCLASSIFIED

43. Policy Initiatives Support the MHS Quadruple Aim Disaster Mental Health Policy • Ensure Access to Care • Enhance Psychological Health and Resiliency • Ensure Individual and Family Medical Readiness UNCLASSIFIED 43

44. Disaster Mental Health Background National Health Security Strategy 2009 Report of the DoD Independent Review 2010-Protecting the Force: Lessons from Fort Hood *U.S. Air Force photo by Senior Airman Nicole Mickle, 5/27/10, Port San Antonio UNCLASSIFIED

45. DoD’s Disaster Mental Health Policy Remember this? UNCLASSIFIED

46. Where’s the Beef? DoD Instruction 6055.17 “DoD Installation Emergency Management (IEM) Program” DoD Instruction 6200.03 “Public Health Emergency Management Within the DoD” Disaster Mental Health Policy UNCLASSIFIED

47. What’s in DoDI 6055.17?All-hazards All-hazards. Any incident, natural or man-made, including those defined in DoDI 6055.07, that warrant action to protect the life, property, health, and safety of military members, dependents, and civilians at risk, and minimize any disruptions of installation operations. UNCLASSIFIED

48. What’s in DoDI 6055.17?Installation Emergency Management • Disaster mental health representative now included on the Installation Emergency Management Working Group (IEMWG) • Installation Emergency Management (IEM) plan now will include disaster mental health, will be coordinated with other protection-related program plans, and will be updated annually UNCLASSIFIED

49. What’s in DoDI 6200.03?Definitions • Disaster mental health (DMH). Provision of prevention, outreach, screening, psychological first aid, education, and referral services to individuals and groups who may have or who have had exposure to an all-hazards incident. • Disaster mental health response team (DMHR). Designated team that provides command consultation, prevention, outreach, screening, psychological first aid, education, and referral services following an all-hazards incident. UNCLASSIFIED

50. What’s in DoDI 6200.03?DMHR Teams Comprised of a multidisciplinary team, to include, at a minimum, individuals in each of the following areas: mental health spiritual support family support Can include non-MH providers trained in acute mental health intervention Identify and train primary and alternate team members Commander enters into agreements, as needed, to ensure access to a DMHR team UNCLASSIFIED