Disaster Behavioral Health

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Tools and Resources for Idaho Emergency
  Responders

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Southwest District 3
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What type of organization do you work for?
Participant Poll

• A. Hospital
• B. EMS, pre-Hospital
• C. Health District
• D. Other

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Research Professor Schools of Nursing and
Public Health and Community Medicine
Randal Beaton, PhD, EMT
Faculty Northwest Center forPublic Health
Practice University of Washington

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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

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You can observe a lot by watching
Berra, 1998
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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

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NMDS drill (May 13, 2004)
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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.
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Tsunami Disaster
Photo by Dr. Mark Oberle, Phuket, Thailand
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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.

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Tsunami Disaster Victims
Photo by Dr. Mark Oberle in Phuket
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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

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Disaster Cycle
There are a number of distinct conceptual stages
in the disaster cycle
Pre-event warning threat stage
Preparedness Planning
Disaster Cycle
Impact/Response
Evaluation
Recovery
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NMDS drill (May 13, 2004)
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Disaster Behavioral Health
Disaster behavioral health interventions differ
from traditional behavioral health practice by

• Addressing Incident-specific, stress reactions
• Providing outreach andcrisis counseling to
  victims,both immediate and long-term
• Working hand-in-hand with paraprofessionals,
  volunteers, community leaders, and survivors
  ofthe disaster

Source http//www.disastermh.nebraska.edu/state_
plan/Appendix20D.pdf
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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

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Questions
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Disaster Behavioral Health

Randal Beaton, PhD, EMT

• Modules 1-4

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Learner Objectives Modules 1 - 4

• 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

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Module 1 Psychosocial Phases of a Disaster

From Zunin Myers (2000)
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Implications/Tasks of each Phase for Disaster
Personnel - Pre-disaster

• Warning e.g. weather forecast
• Educate
• Inform
• Instruct
• Evacuate or stay put

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Pre-Disaster

• Threat, e.g., impending terrorist activity
• Risk communication To reduce anxiety, must also
  tell people what they should do (without jargon)

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TopOff 2 Seattle, May 2003
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Impact

• Prepare for surge
• Advise/instruct/give directions
• Risk Communication update
• Leadership

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Heroic

• Disaster survivors are true First Responders

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Honeymoon (community cohesion)

• Survivors may be elated and happy just to be
  alive
• Realize this phase will not last

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Disillusionment

• Reality of disaster hits home
• Provide assistance for the distressed
• Referrals to disaster mental health professionals

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Inventory

• Psychological community needs assessment
• Short-term
• Mid-range
• Downstream needs

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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

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Reconstruction (a new beginning)

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

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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/port
als/bioterror/Table20120ID20Needs20assessment.
doc
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Behavioral Health Tasks, by Phase, Continued
Disillusionment Inventory Working through Grief Reconstruction
Assistance for distressed Psychosocial needs assessment, short-term, mid-range, and down-stream needs Psychotherapy and/or medications Psychoeducational 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.
Available at http//www.son.washington.edu/port
als/bioterror/Table20120ID20Needs20assessment.
doc
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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Resilience

• Differs from recovery
• Individuals thrive
• Relatively stable trajectory

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Acute Distress and Recovery

• Post-disaster recovery usually occurs within
• Days
• Weeks
• A few months

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
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Chronic Distress

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

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Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
Delayed Onset Distress
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For more information

• Coping With a Traumatic Event
• CDC Publication
• Available at http//www.bt.cdc.gov/masstrauma/co
  pingpub.asp

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Module 3 Resilience

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

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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

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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

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Environmental Factors That Promote Community
Resilience

• Availability of social resources
• Community cohesion
• Sense of connectedness

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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

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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

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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

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Pathways to Resilience

• Denial/avoidance
• Useful illusions/distortions
• Disclosure helpful for some

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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
• accessed 01/24/05

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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

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TopOff 2 Seattle, May 2003
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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

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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

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Signs and Symptoms, continued

• Domestic violence, child or elder abuse
• Family members feel their loved ones are acting
  in uncharacteristic ways

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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

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 5

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Learning Objective Module 5

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

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Module 5

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

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Disaster Incident Scenes are Chaotic and
Stressful
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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

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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.

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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

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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

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Impact of Events Total Score
Beaton et al, J. Traumatology, 2004
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Prevalence of PTSD in Rescue Workers and Veteran
Samples
Corneil et al, 1999
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Excerpts from the Impact of Event Scale
(Intrusion Items)

• I thought about it when I didnt mean to
• I had trouble falling asleep or staying asleep,
  because of pictures or thoughts about it that
  came to my mind
• I had waves of strong feelings about it

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

1. I had dreams about it
2. Pictures about it popped into my mind
3. Other things kept making me think about it
4. Any reminder brought back feelings about it

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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 hadnt happened, or it wasnt
   real

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

• I tried not to talk about it
• I was aware that I still had a lot of feelings
  about it, but I didnt deal with them
• I tried not to think about it
• My feelings about it were kind of numb

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For More Information

• University of Washington Bioterrorism Curriculum
  Initiative Web Portal
• IES test and scoring instructions
• http//www.son.washington.edu/portals/bioterror/L
  inkstoFacultyPub.asp

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 7

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Learner Objectives Module 7

• To describe Critical Incident Stress Management
  (CISM) and the Critical Incident Stress
  Debriefing (CISD) process and to evaluate the
  associated benefits and risks

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Module 7

• What are CISM and CISD?
• Critical Incident Stress Management
• Critical Incident Stress Debriefing
• What are the risks and benefits?

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Module 7 Critical Incident Stress Management
(CISM)

• A multipart program that works to decrease the
  effects of Critical Incident Stress such as that
  stemming from a disaster
• CISMs strength is attributable to its emergency
  service peer-driven process that is monitored by
  mental health professionals Peers and mental
  health professionals are cross-trained

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Module 7 Critical Incident Stress Management
(CISM) (continued)

• Goals in CISM are to restore the health and
  environment of the individuals
• To deter traumatic stress effects
• To speed recovery and productivity
• An important feature is helping the individual
  recognize that the danger has passed and that the
  need to react also has passed

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Module 7 CISM Teams

• More than 350 CISM teams exist in the US
• More than 400 exist worldwide
• Teams have many functions within the CISM process

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Module 7 CISM Functions (continued)

• Scene support and staff advisement
• The team functions within the incident command
  structure, and its members are present in a
  primarily supportive and advisory role. Their
  activity is emotional first aid, allowing for
  venting of feelings.

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Module 7 CISM Functions (continued)

• Demobilization
• Demobilization occurs rarely and is reserved for
  only very large disaster events. An arranged
  site allows all units to rotate through before
  they return to their stations for post-operation
  procedures.

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Module 7 CISM Functions (continued)

• Defusing
• Next to education, the most commonly employed
  CISM technique is defusing. Defusing usually is
  a 1-on-1 interaction between a team member and a
  concerned individual
• During defusing, the emergency worker receives
  education about recognition of stress reactions
  and management strategies for dealing with stress.

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Module 7 CISM Functions (continued)

• Debriefing
• Debriefing is a complex process led by specially
  trained personnel and typically occurs 2-14 days
  after the event
• Debriefing takes approximately 2-3 hours
• This peer-driven process focuses on psychological
  and emotional aspects of the event

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Module 7 CISM Functions (continued)

• Benefits
• Individuals are made to feel their organization
  cares about them
• Helps some individuals to vent
• May help to screen for psychological problems

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Module 7 CISM Functions (continued)

• Risks
• Some individuals may be overwhelmed and
  sensitized by debriefing
• May be presented as something that will prevent
  PTSD evidence is lacking

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For More Information

• Critical Incident Stress Management
• Stephen A Pulley, DO
• http//www.emedicine.com/emerg/topic826.htm

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Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 18

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Learner Objectives Module 18

• To identify some of the unexplained physical
  symptoms (MUPS) observed in disaster survivors
  and their implications for disaster
  response/recovery

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MUPS

• Multiple Unexplained Physical Symptoms (MUPS) in
  the Aftermath of Trauma and Disaster

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The Worried Well

• May develop physical symptoms such as rashes,
  fatigue, etc.
• May pursue treatment
• May compete for scarce resources with other
  disaster victims

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Planning for Worried Well

• Hospitals and health departments need to plan for
  worried well who
• Are actually not well
• May develop signs of actual exposure later
  (either chemical, bio- and/or radiologic
• Need guidance and understanding (at the very
  least)

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Masked PTSD

• Disaster Survivors may develop masked PTSD in
  which physical stress symptoms predominate
• Source Beaton, et al, (2005) in press Sarin
  gas 10 years later
• http//www.son.washington.edu/portals/bioterror/Li
  nkstoFacultyPub.asp