Disaster Mental Health Issues: Immediate and Over Time

1. Disaster Mental Health Issues:Immediate and Over Time Bill Martin, Ph D Disaster Response Network Coordinator MS Psychological Association

3. Presentation Objectives Understand impact of disaster trauma Understand roles in disaster response Understand disaster mental health interventions Understand long term disaster mental health needs

4. Characteristics of Disaster:Definition “A disaster is an occurrence such as a hurricane, tornado, flood, earthquake, explosion, hazardous materials accident, war, transportation accident, fire, famine, or epidemic that causes human suffering or creates collective human need that requires assistance to alleviate” (SAMHSA).

6. Nature of the Disaster influences impact Natural vs Human-Caused Personal Impact Size and Scope Visible Impact Probability of Recurrence

7. Who is impacted by a Disaster?

12. 1. The experience of a disaster can simply be overwhelming… that’s why we call it a disaster. The world around us changes and we therefore have to adapt and change as well.1. The experience of a disaster can simply be overwhelming… that’s why we call it a disaster. The world around us changes and we therefore have to adapt and change as well.

13. Everybody No one who sees a disaster is untouched by it.

14. Population Exposure Model Pop A Community victims killed and seriously injured Bereaved family members, close friends Pop B Community victims exposed to the incident but not injured Pop C Bereaved extended family/friends Residents in disaster zone whose homes were destroyed First Responders and recovery workers Medical Examiner’s office staff Service providers immediately involved with bereaved, body and death notification Pop D Mental Health and crime assistance providers Clergy Emergency health care providers Government officials Members of media Pop E Groups identifying with target-victim group Businesses with financial impact Community at large Pop A Community victims killed and seriously injured Bereaved family members, close friends Pop B Community victims exposed to the incident but not injured Pop C Bereaved extended family/friends Residents in disaster zone whose homes were destroyed First Responders and recovery workers Medical Examiner’s office staff Service providers immediately involved with bereaved, body and death notification Pop D Mental Health and crime assistance providers Clergy Emergency health care providers Government officials Members of media Pop E Groups identifying with target-victim group Businesses with financial impact Community at large

15. Seriously injured, families/friends of those seriously injured or killed. Community survivors exposed or experiencing significant damage. Responders dealing with casualties Health/Mental Health/Media dealing with survivors Community at large, businesses, those exposed via media

16. Epidemiology is unclear Keane, Terence. The Epidemiology of Post-Traumatic Stress Disorder: Some Comments and Concerns. PTSD Research Quarterly. Vol 1, No. 3, 1990. Wide variations in estimates within and across events (ranges 5% - 40%) Self report measures predominate Vietnam Vets: 15% PTSD current incidence, (Kulka et al (1990)).

17. Effects of Traumatic Stress in a Disaster Situation. NCPTSD Fact Sheet. 2000. Natural Disaster 4-5% Bombing 34% Plane Crash into Hotel 29% Mass Shooting 28%

18. Kessler, Ronald. Overview of Baseline Survey Results: Hurricane Katrina Community Advisory Group. Harvard Medical School. 2006. Survey 1000… follow up with 800 Loaded more toward N.O. population 2006: 16% w/Sx PTSD & 3% considered suicide 2007: 21% w/Sx PTSD & 6% considered suicide

19. Normal Reactions to Abnormal Events Resilience is probably the most common observation after all disasters. Hurricane Katrina: 26% said life was worse afterwards, 60% said about the same and 14% said better. The effects of traumatic events are not always negative. Learn they can “handle” crises effectively Communities can grow closer together Most “recover” on their own within 1-2 years

20. Disaster Response Phases Disaster Behavioral Reaction Phases: These phases reflect how impacted individuals experience or mentally process the event and the recovery process.   Handout PP “phases Heroic Phase. During this phase people are in a “fight-or-flight” mode, rushing to save themselves or others, protecting or rescuing possessions, finding a place of safety; or perhaps engaging in community activities such as sandbagging Honeymoon Phase.  During the honeymoon phase, people are relieved to have made it through the crisis, proud of how they handled it, feeling thankful and empowered, and feeling bonded with the community. They may dive whole-heartedly into cleaning and salvaging and begin working on their disaster recovery plan. Disillusionment: Over time, they begin to realize the true impact of the event and how much they really have to do to recover. They also discover the extensive processes they must go through to find help, and the limitations of what helping agencies and organizations can do while assisting them. As the disaster becomes old news, the media seem to forget about them, and they may feel abandoned. They may become angry or depressed and blame the agencies for not doing more. Reconstruction: During reconstruction they come to terms with their tasks at hand and pursue their recovery process, albeit with a heavier dose of reality and more viable expectations. Anniversary reactions are common. The timeline for these phases is very individualized, and different individuals experience them in different ways. For example, following the crisis some may move directly to disillusionment or despair, while others may move immediately into reconstruction, never losing their feelings of empowerment. QUESTION FOR DISCUSSION: Look again at the handout, “Symptoms of Stress.” Which reactions on the chart look as if they could be attributed to typical disaster behavioral reaction phases?Disaster Behavioral Reaction Phases: These phases reflect how impacted individuals experience or mentally process the event and the recovery process.   Handout PP “phases Heroic Phase. During this phase people are in a “fight-or-flight” mode, rushing to save themselves or others, protecting or rescuing possessions, finding a place of safety; or perhaps engaging in community activities such as sandbagging Honeymoon Phase.  During the honeymoon phase, people are relieved to have made it through the crisis, proud of how they handled it, feeling thankful and empowered, and feeling bonded with the community. They may dive whole-heartedly into cleaning and salvaging and begin working on their disaster recovery plan. Disillusionment: Over time, they begin to realize the true impact of the event and how much they really have to do to recover. They also discover the extensive processes they must go through to find help, and the limitations of what helping agencies and organizations can do while assisting them. As the disaster becomes old news, the media seem to forget about them, and they may feel abandoned. They may become angry or depressed and blame the agencies for not doing more. Reconstruction: During reconstruction they come to terms with their tasks at hand and pursue their recovery process, albeit with a heavier dose of reality and more viable expectations. Anniversary reactions are common. The timeline for these phases is very individualized, and different individuals experience them in different ways. For example, following the crisis some may move directly to disillusionment or despair, while others may move immediately into reconstruction, never losing their feelings of empowerment. QUESTION FOR DISCUSSION: Look again at the handout, “Symptoms of Stress.” Which reactions on the chart look as if they could be attributed to typical disaster behavioral reaction phases?

21. Disaster Mental Health:Who are your clients? Individuals and families of survivors Disaster responders Responding agencies and organizations Communities (especially over time)

22. Disaster Response Overview Responders work within some organization structure Little opportunity for individual effort Sustained effort is important Chaos and confusion reign

23. National Incident Management System Mandated comprehensive national approach to incident management Standard operational doctrines Applicable to all jurisdictions Flexible to scale Allows common vocabulary, titles and communications across situations and jurisdictions Promotes smooth transitions in personnel, resources, command and control

24. ICS Organization:Functional Structure

25. Operations Section

26. Planning Section

27. Logistics

28. Area Command Post

29. Volunteer and Faith-Based Groups American Red Cross Faith-Based Church of the Brethren Disaster Response Mennonite Disaster Service National Organization for Victim Assistance The Salvation Army Southern Baptist Convention United Methodist Committee on Relief Others

30. Community Based Agencies/Organizations Schools YMCA Boys and Girls Club Others

31. Normal Reactions to Abnormal Events:Acute and Chronic Behavioral Emotional Cognitive Physical interpersonal

32. Behavioral Getting Along with Others Sleep Changes Activity Level Changes Nightmares/Troubling Dreams Job Performance Changes Substance Abuse Avoidance More Accidents

33. Emotional Startle Easily Under-Controlled Anger Under-Controlled Crying Persistent Sadness Feelings Helplessness/Hopelessness Poor Frustration Tolerance Don’t Feel Pleasure like before

34. Cognitive Difficulty Concentrating Difficulty with Memory Difficulty with Learning Trouble Solving Problems Short Attention and Confusion Difficulty Making Decisions

35. Physical Immune system weakened More Diseases Problems Healing Injuries Changes in Eating Habits Weight Loss/Gains Changes in Sleeping Patterns Fatigue… less Endurance

36. Interpersonal Relationship Conflicts Parenting Problems Disruption of Support Systems Changes in Preferred Activities with Family and Friends Changes in Job, or Job Performance, or Job Satisfaction 1. Talk some about family and social networks and about work based support systems that are valuable “normally’ but are disrupted or no longer present after disaster.1. Talk some about family and social networks and about work based support systems that are valuable “normally’ but are disrupted or no longer present after disaster.

37. Disaster Vulnerabilities Severity of exposure, especially injury Living in disrupted community Female gender Age in middle years (40-60) Little previous disaster experience Ethnic minority group membership Poverty & Low SES Presence of children in the home Significantly distressed spouse Psychiatric history Secondary stress Weak or deteriorating psychosocial resources

38. Special Needs of Responders Reactions comparable to survivors, plus… They arrive with their own emotional baggage Unrealistic goals for their involvement Should be heroic, invulnerable, professional Belief that only other (cops, firemen, military, mental health folks, etc) can understand Unrealistic expectations from supervisors Failure to pace self… stay in emergency mode Underestimates impact of vicarious trauma

39. General Rule… Those most vulnerable before a disaster are most vulnerable after a disaster.

40. Needs following Disaster Maslow revisited Safety Food/Water/Shelter Re-establish social units Empowerment Recovery

41. Coping Continuums At Risk <---------> Safe Chaos <---------> Control Confused <---------> Informed Avoidant <---------> Engaged Helpless <---------> Empowered Grief <---------> Resolution

42. Disaster Mental Health Interventions General Issues: Best to conceptualize as “Normal reactions to abnormal circumstances” Most adapt and adjust over time Most will not see self as having mental health problems Most will not seek traditional mental health care And may be confused about what “mental health care” means

43. Traditional Mental Health Providers Psychiatrists Psychologists Social Workers (Licensed) Psychiatric Nurses Licensed Counselors Marriage/Family Counselors

44. But there are so many others now

45. But there are so many others now And the profusion of providers confuses the “product”

46. Contemporary Mental Health Providers “counselors”… for every problem peer counselors… for every peer “social workers” case workers case managers therapists “family” workers crisis managers crisis debriefers clinicians advocates life coaches mentors

47. Immediate Intervention:Psychological First Aid Contact & Engagement Safety & Comfort Stabilization Information Gathering & Assessment Practical Assistance Connection w/ Social Supports Information on Coping Linkage w/Collaborative Services Take care of yourself

48. DO Be polite, respectful and sensitive Be observant Be calm, patient and responsive Keep language simple and at appropriate developmental level Speak slowly Give only accurate information Stay in the here and now

49. Don’t Do not make assumptions Do not pathologize. Do not emphasize deficits… look for strengths Do not “debrief” but be sure to listen Do not speculate or pass on unconfirmed information

50. Contact and Engagement Introduce self… ask about immediate needs Be sensitive… intervention is intrusive Be calm... Remember the label on the pickle jar Ensure immediate safety & comfort Enhance predictability & self control Provide simple information Promote social engagement

51. Stabilization (if needed) Observe for signs of being overwhelmed Help “normalize” experience Consider alternative activities (breathing exercises, a walk, etc) Consider sources of social support Consider use of “grounding” or “thought substitution”

52. Information Gathering Nature and severity of disaster experience Exposure to death or serious injury Post disaster circumstances and ongoing threats Separation and loss issues Physical illness/Medication or Mental Health issues Available social support Thoughts about harm to self or others Substance use practices Prior successful coping experiences

53. Practical Assistance Most immediate needs Clarify the need Discuss their action plan or help develop an immediate action plan Provide instrumental support in taking action

54. Connection with Social Supports Enhance access to primary support systems Encourage use of immediately available support persons Discuss importance of support seeking and of helping others

55. Information on Coping Reality based information about situation Basic information about normal stress reactions Basic information on ways of coping (resiliency) Demonstrate simple relaxation techniques Assist with developmental issues Assist with anger management issues Address highly negative emotions (i.e. guilt and shame) Help with sleep problems Address substance abuse Lots of brochures and booklets available

56. Linkage with Collaborative Services Direction to additional needed services Promote continuity in helping relationships (and describe limitations in your intervention)

57. Long Term Recovery  Community resources significant Health and mental health resources Social services Basic infrastructure Economic Transportation Housing Cultural

58. Long-Term Stress Impact Anxiety and vigilance Anger, resentment and conflict Uncertainty about the future Prolonged mourning of losses Diminished problem solving Isolation and hopelessness Health problems Physical and mental exhaustion Lifestyle changes

59. Long Term Recovery Recall that most will not seek traditional mental health services May have already seen multiple “counselors” and still have problems So… what to do?

60. A Recommendation:Resiliency Training Let’s “package” some immediately useful psychological knowledge into a more easily digestible product for the public

61. Resiliency Training A “psychoeducational” model

62. Resiliency Training A “psychoeducational” model Delivered through existing and established organizations/agencies They already have credibility They already have a population

63. Resiliency Training A “psychoeducational” model Delivered through existing and established organizations/agencies Not likely to produce any fees

64. Resiliency Training A “psychoeducational” model Delivered through existing and established organizations/agencies Not likely to produce any fees Possible role for MPA… and for Professional Psychology Sponsoring these psychoeducational “classes” Public education about Psychology and what it has to offer

66. Resiliency Are hardy, resilient people just born that way?

67. Resiliency skills can be taught, are learned and, when practiced, increase our hardiness; our ability to withstand sudden and longer lasting stress.

68. Resilience (simply) is… an ability to endure more stress and respond more effectively, even in longer lasting crises.

69. Ways to Build Resiliency Take care of yourself Take control of what you can Avoid seeing crises as insurmountable Realistic expectations Make connections with others Take decisive action Move toward goals Accept that change is part of living Keep things in perspective Stay focused Keep at it

70. Take care of yourself Avoid unnecessary risks Build a nest Eat well Drink fluids Get active, maybe even exercise Have rest periods Have recreation periods Pace ourselves

71. Take control We think “moods” control our behavior. More often, “behavior” controls “moods”. Change your behavior and your mood will change. Make decisions about what you will do and when you will do it and then do it. Schedules and routine are our friends.

72. Avoid seeing crises as insurmountable We can’t change facts, change reality. Ultimately, we can only adapt to reality. But we can change how we think about, talk about events, and that will change how we feel and react.

73. Realistic Expectations We “judge” outcomes based on our “expectations”. If our expectations are unrealistic, then we are bound to be dissatisfied, disappointed. We can try to get more accurate, realistic information, so expectations are realistic. Focus on what can be done, not what can’t be done.

74. Make Connections Family Friends At work Civic groups Faith-based groups Assisting others

75. Take decisive action Avoidance and passivity are most predictive of worse adjustment. Accomplishment, even little steps, builds sense of control and confidence.

76. Move toward your goals Set goals… hourly, daily, weekly… Make a plan Start with a here and now focus Impose some structure, some routine What can I do now that will move me toward a goal

77. Change is part of living Accept that change is a necessary, unavoidable part of living Changes in life circumstances Changes in goals Changes in expectations Then adapt, make the changes that seem better for you… now

78. Keep things in perspective Watch how we describe things to ourselves Avoid those generalities… those “never” and “always” and “should” and “must”. Get those facts… things as they are and not things as we wish they were… or think they ought to be. Accurate information leads to more effective coping.

79. Stay focused Write that plan… day by day Write that journal… day by day Keeps us focused Allows us to see and measure progress

80. Keep at it Perseverance has much to do with successful coping A journey of a thousand miles is still one step at a time Focus on the steps… not just on the end of the journey

82. Disaster Mental Health Issues:Immediate and Over Time Bill Martin, Ph D Disaster Response Network Coordinator MS Psychological Association