disaster behavioral health

Disaster Behavioral HealthRandal Beaton, PhD, EMT

Tools and Resources for Idaho

Emergency Responders

HealthDistrict

7

What type of organization do you work for?

A. Hospital

B. EMS, pre-Hospital

C. Health District

D. Other

Participant Poll

Research Professor Schools of Nursing

and Public Health and Community Medicine

Randal Beaton, PhD, EMT

Faculty Northwest Center for

Public Health Practice University of Washington

Relevant Clinical Experience

• Volunteer EMT

• Counseled victims of 9/11 who lostco-workers

• “Psychological casualties” of Nisqually earthquake (2001)

• Stress management for First Responders – mostly firefighters and paramedics – in private practice

“You can observe a lot by watching”*

*Berra, 1998

Relevant teaching and research background

• Published studies on benefits of disaster training and drills

• NIOSH funded research into cause and effects of PTSD in firefighters

• Core faculty of HRSA funded BT Curriculum Development Grant(UW ’03 – present)

• Helped to write and drill UWSchool of Nursing Disaster Plan – 2002

NMDS drill (May 13, 2004)

Preamble/Assumptions

Disasters generally refer to natural or human caused events that cause property damage and large numbers of casualties.

Community wide disasters generally require outside assistance and/or assets.

Tsunami Disaster

Photo by Dr. Mark Oberle, Phuket, Thailand

Effects on Victims & Care Givers

Disasters can also affect the psychological, behavioral, emotional and cognitive functioning of the disaster victims (primary, secondary, tertiary, etc.) and rescue workers, first responders and first receivers.

Tsunami Disaster Victims

Photo by Dr. Mark Oberle in Phuket

Overarching Goal

Enhance the networking capacity and training of state of Idaho healthcare professionals to recognize, treat and coordinate care related to behavioral health consequences of bioterrorism and other public health emergencies.

HRSA critical benchmark #2-8

These training modules will address: behavioral health aspects of disasters

Disaster Cycle

There are a number of distinct conceptual stages in the disaster cycle:

DisasterCycle

Pre-event warning threat stage

Impact/Response

Recovery

Evaluation

Preparedness Planning

NMDS drill (May 13, 2004)

Disaster Behavioral Health

• Addressing incident-specific, stress reactions

• Providing outreach andcrisis counseling to victims

• Working hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors ofthe disaster

Source : http://www.disastermh.nebraska.edu/state_plan/Appendix%20D.pdf

Disaster behavioral health interventions differ from traditional behavioral health practice by:

Aims of Disaster Behavioral Health

• To prevent maladaptive psychological and behavioral reactions of disaster victims and rescue workers

and/or

• To minimize the counterproductive effects such maladaptive reactions might have on the disaster response and recovery

Questions

Disaster Behavioral HealthRandal Beaton, PhD, EMT

Modules 1-4Psychological phases of a disaster;

Temporal patterns of mental/behavioral response to disaster; Resilience;

Signs & symptoms of disaster victims

• Identify the psychosocial phases of a community-wide disaster and to describe the behavioral health tasks of disaster personnel during each phase

• Describe the various temporal patterns of behavioral health outcomes following a disaster, including resilience

• Identify the signs and symptoms of disaster victims, first responders and first receivers who may need a psychological evaluation

Learner Objectives: Modules 1 - 4

Module 1: Psychosocial Phases of a Disaster

* From Zunin & Myers (2000)

*

• Warning – e.g. weather forecast

• Educate

• Inform

• Instruct

• Evacuate or “stay put”

Implications/Tasks of each Phase for Disaster Personnel - Pre-disaster

• Threat, e.g., impending terrorist activity

• Risk communication: To reduce anxiety, must also tell people what they should do (without jargon)

Pre-Disaster

TopOff 2 – Seattle, May 2003

Impact

• Prepare for surge

• Advise/instruct/give directions

• Risk Communication update

• Leadership

Heroic

• Disaster survivors are true “First Responders”

Honeymoon (community cohesion)

• Survivors may be elated and happy just to be alive

• Realize this phase will not last

Disillusionment

• Reality of disaster “hits home”

• Provide assistance for the distressed

• Referrals to disaster mental health professionals

Inventory

•Psychological community needs assessment

– Short-term

– Mid-range

– Downstream needs

Working Through Grief (coming to terms)

• This is when disaster victims actually begin to need psychotherapy and/or medications (only a small fraction)

• Trigger events – reminders

• Anniversary reactions – set back

Reconstruction (“a new beginning”)

•Still, even following recovery, disaster victims may be less able to cope with next disaster

Behavioral Health Tasks, by Phase

Disaster Phase

Pre-event warning

Impact Heroic Honeymoon

Behavioral Health Tasks - Implications

Risk Comm., Educate, Inform, Forecast, Instruct, Evacuate

Advise, Risk Comm., Mitigate

First responders are often disaster survivors, citizens and rescue workers “rise to the occasion”

Realize it will not last

Available at: http://www.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc

Behavioral Health Tasks, by Phase, Continued

Available at: http://www.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc

Disillusionment Inventory Working through Grief

Reconstruction

“Assistance” for distressed

Psychosocial needs assessment, short-term, mid-range, and down-stream needs“

Psychotherapy and/or medicationsPsychoeducational Need to re-establish “sense of safety”Anniversaries – Triggers Reminders can rekindle dormant trauma/symptoms

Even when this is completed, survivors are still more susceptible to trauma from future disasters.

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

n

Resilience

Resilience

• Differs from recovery

• Individuals “thrive”

• Relatively stable trajectory

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

n

Acute/Recovery

Acute Distress and Recovery

Post-disaster recovery usually occurs within:

– Days

– Weeks

– A few months

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

n

Acute/Chronic

Chronic Distress

Acute/Chronic Distress and/or Lasting Maladaptive Health Behavior Outcomes

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

n

Delayed

Delayed Onset Distress

Delayed Onset Distress

For more information:

Coping With a Traumatic Event

CDC PublicationAvailable at: http://

www.bt.cdc.gov/masstrauma/copingpub.asp

Module 3: Resilience

Definition:

The ability to maintain relatively stable physical and psychological functioning(not the same as recovery)

Module 3: Resilience (continued)Risk Factors

Risk factors that deter resilience:

• Job loss and economic hardship

• Loss of sense of safety

• Loss of sense of control

• Loss of symbolic or community structure

Ways to Promote Community Resilience in the Aftermath of Disaster

• Reunite family members

• Engage churches and pastoral community

• Ask teachers, community leaders and authorities to “reach out”

Environmental Factors That Promote Community Resilience

• Availability of social resources

• Community cohesion

• Sense of connectedness

Individual Characteristics Associated with Resilience

• Positive temperament

• Ability to communicate

• Problem-solving and problem-focused vs. emotion-based coping

• Positive self-concept

• Learned helpfulness vs. hopelessness

How Can First Responders and First Receivers Cope?

Can emotional coping skills to deal with emergent disasters be taught?

Doubtful, but some hints:

– Stay focused on duties – out focused

– Stay professional; maintain “professional boundaries”

– Sort out family/roles/conflicts ahead of time

How can First Responders and First Receivers cope? (continued)

– Drill, drill, drill – automatic, over-learned responses can be recalled under stress, also instills confidence

– Self-talk – I will survive versus catastrophizing

– Importance of social support – especially in aftermath

Pathways to Resilience

• Denial/avoidance

• Useful illusions/distortions

• Disclosure – helpful for some

For more information:

APA Fact Sheets on Resilience to Help People Cope With Terrorism and Other

Disasters

Available at:

http://www.apa.org/psychologists/resilience.html

Module 4: Signs & Symptoms Suggesting Need for Psychological Evaluation

• Suicidal or homicidal thoughts or plan(s)

• Inability to care for self

• Signs of psychotic mental illness – hearing voices, delusional thinking, extreme agitation

TopOff 2 – Seattle, May 2003

Signs and Symptoms, continued

• Disoriented, dazed – not oriented x 3; recall of events impaired (R/O TBI)

• Clinical depression – profound hopelessness and despair, withdrawal and inability to engage in productive activities

Signs and Symptoms, continued

• Severe anxiety – restless, agitated, inability to sleep for days, nightmares, overwhelming intrusive thoughts of the disaster

• Problematic use of alcohol or drugs

Signs and Symptoms, continued

• Domestic violence, child or elder abuse

• Family members feel their loved ones are acting in uncharacteristic ways

For more information:

Field Manual for Mental Health and Human Service Workers in Major Disasters

Available at:

http://www.mentalhealth.org/publications/

allpubs/ADM90-537/default.asp

Disaster Behavioral Health

Module 5Mental Health Risk of

Disaster Workers

Randal Beaton, PhD, EMT

Learner Objective: Module 5

To identify the behavioral health risks of disaster workers including First Responders

Module 5

Mental health risks of disaster workers including EMS and rescue personnel – secondary traumatization

Disaster Incident Scenes are Chaotic and Stressful

Firefighters’ Secondary Post-trauma Symptoms Following 9/11

•Randal D. Beaton, L. Clark Johnson, Shirley A. Murphy, and Marcus Nemuth (2004)

•This project was supported by Grant R-18-OHO3559 from the National Institute for Occupational Safety and Health of the Centersfor Disease Control

Assumption

• Terrorist attacks on the World Trade Center in NYC on Sept. 11, 2001 left 343 NYC firefighters dead

• The assumption is that the “fire service family” is very close-knit

• The rationale for the current study is based on the hypothesis that secondary trauma was a potential outcome for firefighters across the U.S.

The Current Study

• Study participants were 261 urban firefighters employed in a Pacific Northwest state

• Fortuitously, the respondents were participating in a NIOSH-funded longitudinal study and provided pre-9/11 and post-9/11 self-report data on PTSD, physiologic symptoms and coping

Data Collection

Data were obtained from five “temporal groups”:

– The day before 9/11, n = 24– 1 or 2 days after 9/11, n = 52– One week after 9/11, n = 93– Two weeks after 9/11, n = 21– One month after 9/11, n = 54

Impact of Events Total Score

5421935224N =

Time w/ reference to 9/11/01

1 mth After

2wk After

1wk After

1-2days After

Day Before

95

% C

I P

TS

D C

ase

Pre

va

len

ce

.6

.5

.4

.3

.2

.1

0.0

-.1

Beaton et al, J. Traumatology, 2004

Prevalence of PTSD in Rescue Workers and Veteran Samples

0% 5% 10% 15% 20% 25%

US Urban Fire Fighters and ParamedicsBritish Ambulance Drivers

9/11 Rescue WorkersWounded Combat Vietnam Vets

Canadian Fire FightersIraq Combat Veterans (2004)

Vietnam Era Vets OverallCrime Victims (US 1980's)

Community Male (Canada, 1990's)

Corneil et al, 1999

Excerpts from the Impact of Event Scale (Intrusion Items)

1. I thought about it when I didn’t mean to

2. I had trouble falling asleep or staying asleep, because of pictures or thoughts about it that came to my mind

3. I had waves of strong feelings about it

Excerpts from the Impact of Event Scale (Intrusion Items), Continued

4. I had dreams about it

5. Pictures about it popped into my mind

6. Other things kept making me think about it

7. Any reminder brought back feelings about it

Excerpts from the Impact of Event Scale (Avoidance Items)

1. I avoided letting myself get upset when I thought about it or was reminded of it

2. I tried to remove it from memory

3. I stayed away from reminders of it

4. I felt as if it hadn’t happened, or it wasn’t real

Excerpts from the Impact of Event Scale (Avoidance Items), Continued

5. I tried not to talk about it

6. I was aware that I still had a lot of feelings about it, but I didn’t deal with them

7. I tried not to think about it

8. My feelings about it were kind of numb

For More Information:

University of Washington Bioterrorism Curriculum Initiative Web Portal

IES test and scoring instructions

http://www.son.washington.edu/portals/bioterror/

LinkstoFacultyPub.asp

Disaster Behavioral Health

Module 15:Psychological “First Aid”

Randal Beaton, PhD, EMT

Learner Objective: Module 15

To identify some basic principles of psychological “first aid” for disaster workers and victims

Psychological First Aid

• Support and presence

• Reduce psychological arousal—take a breath—you’re going to be OK.

• “Screen” and mobilize support for those most distressed.

• Keep families together or facilitate reunions.

Disaster Behavioral Health Priorities

Optimal efforts to conduct assessments or early treatment of mental health problems should be conducted within a hierarchy of needs:

Survival Food

Safety Shelter

Security Crisis Counseling

Psychological “First Aid”

Traumatic Incident Stress: Information for Emergency Workers:

NIOSH Guidelines

http://www.cdc.gov/niosh/unp-trinstrs.html

Disaster Behavioral HealthRandal Beaton, PhD, EMT

Module 16: Rural Issues

Learner Objective: Module 16

To identify some special considerations for rural settings in terms of disaster behavioral health preparedness, response and recovery

Module 16:Module 16:

Rural Mental Health Preparedness versus Urban Settings

Rural America

• 65 million Americans

• Frontier/Small towns

• Transportation/highway systems

• Rural “attitude”

Rural America

• Sites of Farms (food supply)

• Sites of power facilities (including nuclear)

• Sites of headwaters and reservoirs (water supply)

Rural Emergency Preparedness

• Rural health departments have less capacity/resources/range of personnel.

• Downsizing of rural hospitals has decreased/eliminated infrastructure.

• EMS systems rely on volunteers.

• General lack of funding and equipment.

Rural Preparedness

• Several preparedness planning challenges are relatively unique to rural areas (e.g. coordination between state bioterrorism staff and Tribal nations).

Rural Preparedness

• Rural areas are affected by weather, tourism, a fragile financial and economic based and are geographically isolated, making it difficult to support medical systems.

Rural Preparedness: Barriers

• The main barrier to rural preparedness is lack of funding.

Rural Preparedness

• The Federal Government and the States must be financial partners but implementation must occur at a local level.

Rural Mental Health Preparedness

• Not much good research

• Perceived risks – terror vectors– Agri-terrorism; water sources

• Paucity of resources – personnel and PPE

• Evacuation issues– Communication

• Pathogens will not spare rural communities:– Native Alaskan Flu of 1918

Rural Risk Communication

• Local news broadcasters viewed as more credible

• Perception is that terrorists will target urban population centers

• Terrorists might target rural settings – so no one feels safe!

Rural Health Concerns Resource

Bridging the Health Divide: The Rural Public Health Research Agenda available at: http://www.upb.pitt.edu/crhp/Bridging%20the%20Health%20Divide.pdf

University of Pittsburgh publication.