UNDERSTANDING AND INTEGRATING PSYCHOSOCIAL FACTORS TO ENHANSE COMMUNICATION DURING A CRISIS

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UNDERSTANDING AND INTEGRATING PSYCHOSOCIAL
FACTORS TO ENHANSE COMMUNICATION DURING A CRISIS

• Emergency Public Information Subcommittee
• May 5, 2008
• Reston, VA
• RADM Brian W. Flynn, Ed.D.Assistant Surgeon
  General (USPHS, Ret.)Adjunct Professor Of
  PsychiatryAssociate Director Center for the
  Study of Traumatic Stress Dept of Psychiatry

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Psychosocial Consequences in Disasters

• In a disaster,
• the size of the
• psychological
• footprint
• greatly
• exceeds the
• size of the
• medical
• footprint.

psychological footprint
medical footprint
Source Shultz JM, et al., Behavioral Health
Awareness Training for Terrorism and Disasters,
Miami FL, DEEP Center, 2003
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Psychosocial Consequences in Disasters
Fear and Distress Response
Behavior Change
Psychiatric Illness
Impact of Disaster Event
Source Butler AS, Panzer AM, Goldfrank LR,
Institute of Medicine Committee on Responding to
the Psychological Consequences of Terrorism Board
of on Neuroscience and Behavioral Health.
Preparing for the psychological consequences of
terrorism A public health approach.
Washington, D.C. National Academies Press, 2003.
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Defining the Scope of Behavioral Health Factors

• Psychiatric disorders
• Substance abuse
• Fear driven behavior
• Fear driven decision making
• MUPS/MIPS
• Family/social function
• School behavior/ performance

• Workplace behavior/performance
• Risk taking
• Hypervigilance
• Distractibility
• Vulnerability/resiliency

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Quote I understand and empathize with your
concerns about mental health in an overwhelming
public health emergency. However, the issues I
have to deal with, and the decisions I have to
make, in the first twenty-four hours are life and
death issues. The mental health concerns,
while important, do not rise to that level of
importance. Source Public Health Official,
CDC conference, January 2004
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The behavioral choices people make to stay in
place, evacuate, seek/not seek medical care,
search forloved ones,etc. are veryreal life
anddeathdecisions.
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Todays Presentation

• Communication beyond the written and spoken word
• The role of confirmatory bias in communication
• Engaging consumers
• Focusing on what people want to know in addition
  to what we want them to know
• Prevention
• Optimizing the relationship
• between behavioral health
• and risk communication

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New Ideas?
Without a great deal of forethought, prolonged
training, and the development of systematic
performances, drills, and tests of all
participants, no community can prepare itself to
provide those additional health services that
will be essential for civilians subject to
disasters. When the average community prepares
itself for disasters, the effort of each citizen
and every profession must be fitted into a
coordinated system. Whoever guides each part of
the whole must have a clear concept of the
working of all the other parts.
Source William Wilson (Col. MC, USA) U.S. Armed
Forces Medical J., Vol 1, No.4 April 1950
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Better than any medication we know, information
treats anxiety in a crisis. Source
Saathoff, 2002
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IMPORTANCE OF COMMUNICATION IN RESPONSE TO THREAT
POSITIVE/ ADAPTIVE
THREAT OR PERCEPTION OF THREAT
FEAR AND DISTRESS
BEHAVIOR CHANGE
?
NEGATIVE/ MALADAPTIVE
COMMUNICATIONS!
COMMUNICATIONS!
COMMUNICATIONS!
COMMUNICATIONS!
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Linking Behavioral/Public Health Roles And
Expertise In Communicating Risk
Behavioral Health Perspectives
Enhance/ Inform Risk Communication
Consumer Oriented Approaches
Consumer/ Community Oriented Approaches

• Results
• 1. More effective individual/
• community intervention
• More efficient/effective
• organizational function
• Promote appreciation for
• respective skills/
• contributions

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Communication Takes Many Forms.Communication
Through

• Written and spoken word
• Behavior
• Symbols and rituals
• Images

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I.Communication Beyond The Written And Spoken
Word
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Communication Through Behavior
What does the behavior tell us about the risk of
the event?
What does the behavior tell us about the leader?
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For Example, What Behaviors Impact The Messages
In Pan Flu?

• What behaviors reinforce the message?
• What behaviors undermine the message?
• Whose behavior impacts the message?
• Leadership
• Provider
• Consumer

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Communication Through Symbols Rituals
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Understanding Symbols And Rituals

• Symbols and rituals help when the written and
  spoken word fails us
• They have both idiosyncratic and shared meaning

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Understanding Symbols And Rituals

• They promote a shared experience
• They can help unite occupational, cultural,
  religious, and generational groups
• They can help heal divisions

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Understanding Symbols Rituals

• We can learn much from
• The faith community
• The military

More important linkages For both BH PH
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The Purpose Of Remembrance Events And Sites

• Provide comfort to survivors and families of the
  dead
• Recall and honor the suffering and recovery of
  those who survived

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The Purpose Of Remembrance Events And Sites

• Provide a time and/or place specific to event to
  focus/honor/reflect

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Important Balances/Tensions

• Emphasize those who helped
• Local
• Distant

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Oklahoma City Bombing-- A Case Example
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Communication Through Images

• Images Are Like Projective Tests
• Behavioral Health Professionals Can Help Public
  Health Risk Communicators Appreciate The
  Projective Nature/Power Of Images

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What Do The Communicators Communicate Through
Their Behavior?
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I never want to see this image published again!
You have no idea what this does to the family of
this child every time they see it. It
re-traumatizes them! -Oklahoma City Psychologist
This picture has probably been more responsible
for bringing donated funds into this community to
help the survivors than any other single
image. -AP reporter
Rumor Control This firefighter did not commit
suicide. Rumor Message Responders are at huge
psychological risk
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In Pan FluWho Are The Responder/Rescuers?
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What assumptions are made about the event by the
image?
What assumptions are made about the people by the
image?
How do our existing beliefs effect how we
interpret the image?
Could there be a helpful risk communication
message here about use of PPE and self-care?
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What assumptions are made about the event by the
image?
What assumptions are made about the person by the
image?
How do our existing beliefs effect how we
interpret the image?
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What Will Be The Defining Images During Pan Flu
Recovery?
How Do Images/Messages Interact?
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What Will Happen To Our Cherished Symbols When
Avian Flu Strikes?
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II.The Role Of Confirmatory Bias In
Communication

• An example of where behavioral health/science
  expertise can be helpful

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Definition
We tend to perceive and accept input that is
consistent with and reinforces our biases. We
tend to ignore input that is not consistent with
or challenges our biases. We tend to interpret
input in ways that confirm our biases.
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Understanding the Power Of Confirmatory Bias
Bias
Bias Confirmed
Experience Observation Message
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Modifying Bias
Bias Modified/ Reduced/Replaced
Bias
Bias Refuted
Experience Observation Message
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Potential biases Negative racial
stereotypes? Class stereotypes? Gender
stereotypes?
What is the message/observation? Looting? Survivin
g? Evacuation? Situation out of control?
Biases confirmed? Refuted?
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Potential biases Racial stereotypes? Beliefs
about police? Gender stereotypes?
What is the message/observation? Image of
police? Situation in control?
Biases confirmed? Refuted?
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III.Engaging Consumers
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Community Involvement

• Remember Redefining Readiness

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Why Including Consumers Is Important

• Failure to include the public in planning.
  Results in
• Inaccurate assumption about human behavior
• Reduced compliance, trust, confidence
• Lacking understanding of factors influencing
  comfort with and confidence in planning
  (Redefining Readiness, NY Academy of Medicine)
• We can learn from MH consumers/advocates With
  us not for us.

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the American public has had little or no role
in helping government and private organizations
develop terrorism plans(Redefining Readiness,
NY Academy of Medicine, p.59)
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Working Group on Civic Engagement in Health
Emergency Planning Overview

• Problem Does volunteerism plus stockpiled
  basements equal public preparedness?
• Process What scholarly research and practical
  experience suggest
• Principal Findings
• Extreme events compel citizen action judgment
  cant boil down the publics role in disasters to
  a simple checklist
• Civic infrastructure yields remedies at all
  stages of disasters, and it ought to be involved
  in planning execution
• Effective leaders engage community partners in
  advance of an event, not just hone their mass
  media skills

Source Monica Shoch-Spana, Ph.D., Center for
Biosecurity, UPMC. Presented at IOM December
19-20, 2007
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Think About Organizations As Message Recipients
Also
This quote implies a certain type of
organizational culture. Perhaps one not best
ready to survive a pandemic. Perhaps
organizations where leadership communicates
with employees and overtly recognizes that
employees can also educate leaders stand a better
chance of weathering a pandemic. Do we in
behavioral health have something to contribute to
this discussion?

• Look at our messages through the lens of their
  connotative meaning/group behavior, etc.

Example CDC Pandemic Flu Website Business
Pandemic Influenza Planning Checklist 1.5
Communicate to and educate your
employees --http//www.pandemicflu.gov/plan/wo
rkplaceplanning/businesschecklist.html
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IV.Focusing On What People Want To Know In
Addition To What We Want Them To Know
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Those We Love
Child at School
Elderly Parent- Home/ Assisted Living
Parent at Work
Social Supports
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The Basic Questions
AM I OK? WHAT ABOUT THOSE I LOVE? WHAT SHOULD I
DO?
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IMPORTANT FACTORS/PROCESSES DURING THE IMMEDIATE
ONSET PERIOD
OUTCOMES
Personal Characteristics
CONCERNS
Messages

• Personal
• Characteristics
• Perceived risk
• vulnerability
• Resilience
• Impairment
• Experience
• Med/Psych risk
• factors

• Concerns
• Am I OK?
• What about
• those I love?
• What should
• I do?

• Outcomes
• /- Distress
• Pos/neg behavioral
• adaptation

• Messages
• Credibility of
• message
• Credibility of
• messenger
• Cultural
• appropriateness
• of message
• Delivery
• mechanisms
• Behavioral
• connectedness

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IMPORTANT FACTORS/PROCESSES DURING THE PRIMARY
IMPACT PERIOD
OUTCOMES
Personal Characteristics
CONCERNS
Messages

• Concerns
• Health risk
• Availability of
• health services
• Guilt
• Anger
• Soc. justice
• Fear of future
• Grief
• Bereavement
• Soc./community
• change
• Economic loss
• Crisis of faith
• What should I do?

• Personal
• Characteristics
• Hlth. status
• Resilience
• Impairment
• Experience
• Soc. support
• Med/Psy risk
• factors
• Remaining
• resources
• Spiritual/faith
• context

• Outcomes
• /- Pos/neg behavioral
• adaptation
• /- Trust
• /- Social change

• Messages
• Credibility of
• message
• Credibility of
• messenger
• Cultural
• appropriateness
• of message
• Delivery
• mechanisms
• Behavioral
• connectedness

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IMPORTANT FACTORS/PROCESSES DURING THE RECOVERY
PERIOD
OUTCOMES
Personal Characteristics
CONCERNS
Messages

• Concerns
• Hlth. status
• Guilt
• Survivor guilt
• Anger
• Soc. justice
• Fear of future
• Grief
• Bereavement
• Soc./community
• Change
• Economic loss
• Crisis of faith
• What Should I do?

• Personal
• Characteristics
• Hlth. status
• Resilience
• Impairment
• Experience
• Soc. support
• Med/Psy risk
• factors
• Remaining
• resources
• Spiritual/faith
• context

• Outcomes
• /- Understanding
• /- Trust
• Social change
• /- Anger/revenge
• /- Litigation
• Pos/neg behavioral
• adaptation

• Messages
• Credibility of
• message
• Credibility of
• messenger
• Cultural
• appropriateness
• of message
• Delivery
• mechanisms
• Behavioral
• connectedness

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Guide For Interventions
A major new article is about to come out Five
Essential Elements of Immediate and Mid-Term
Mass Trauma Intervention Empirical
Evidence (Psychiatry, in press) Authors Steven
Hobfoll plus 19 others Very diverse/credible
authors
The Five Elements Provide a sense of
safety Calming Sense of self- and community
efficacy Connectedness Hope
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Suggested Matrix For Considering Messaging
Strategies


Information Is An Intervention
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V.Prevention
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Preventing The Disaster
Death Physical Trauma
Psychological Trauma (4-5001 Larger Than
Medical)
DISASTER
Social/Community Disruption
Public Health Effects
Adverse Economic Impact
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Levee Design/Community Planning
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Mine Safety
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Liquid Natural Gas (LNG) Tankers Close To People
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East Africa Embassy Bombings Same Time/Same Bomb

• Nairobi
• Many deaths
• Many injuries
• Many psychological
• casualties

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East Africa Embassy Bombings Same Time/Same Bomb

• Dar Es Salaam
• Few deaths
• Few injuries
• Minimal psychological casualties

The Difference? Architecture!
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Preventing/Reducing Exposure
We Must Learn More About How To Get People Out
Of Harms Way
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Do We Know Enough About Why People Do Not
Evacuate? Dont receive warnings? Physically
unable? Logistics?
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Do We Know Enough About Why People Do Not
Evacuate? Historical distrust of
authorities? Commitment (possessions, animals,
family)? Denial?
Different Reasons Call For Different Strategies!
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VI.Optimizing The Relationship Between
Behavioral Health AndRisk Communication
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Who Are We Talking About?

• Behavioral health agency risk communicators,
  disaster specialists, special populations
  specialists
• Risk communicators in
• 1. Other government administration agencies
• 2. Government operations organizations
• 3. Private/private not for profit organizations
• 4. Others

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Understanding Each OtherDo Your Homework

• Professional culture
• Organizational culture
• Organizational scope and boundaries
• View as a cross cultural opportunity/ challenge

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Initiating The Relationship

• After doing homework, take the initiative.
  Before event is best, during is good, after is
  just OK
• Choose timing (events, successes, failures, etc.)
• Be clear on both your contribution and limits
• Build on personal relationships
• Use trusted/respected broker
• Send the best first
• Come with something specific to offer

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Anticipate Challenges/Barriers

• Funding
• Work load
• Historyorganizational
• Political influences
• Stigma about behavioral health
• Inaccurate understanding of behavioral health

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Prepare To Highlight Benefits

• Help RCs do their jobs faster, better
• Prevent/reduce problems/errors
• Promote consistent messaging
• Enhance message/communication effectiveness
• Pre-event education/orientation to BH factors and
  value added

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Think About What Risk Communication Can Add to
Behavioral Health

• Many of the same as on prior slide
• New/better mechanisms to deliver BH interventions
• Opportunity to reduce stigma
• Opportunity to develop organizational allies
• Apply skills in a different context
• Promote community mental health
• Learn skills (e.g., communication, clarity of
  message, presentation skills, etc.)

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Building Trust/Confidence

• Be competent
• Dont over-promise
• Follow customer service principles
• Be flexible
• Respect boundaries
• Build relationships based on utility, not funding
• Trust builds personally before organizationally

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General Behavioral Health Contributions

• Content
• Context
• Human resources
• Stress identification and intervention

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Options For Specific BH Roles

• Joint planning/preparedness
• Pre-event training/education
• Review/preparation of talking points
• Review/preparation of releases
• Ready experts
• Coaching of risk communicators
• Identification and help with stress related
  issues for RC personnel
• Recipient of RC consultation

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Special Communications Issues

• How people absorb information?
• Developmental stage
• Trauma history
• Cognitive abilities
• Stress level
• Cultural context
• Through what pathways do people receive
  information?
• How do people gauge the credibility of the source
  and legitimacy of the content?
• What do they do on the basis of the information?

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Why Is Integrating Behavioral Health And Risk
Communication So Critical?
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Combining Behavioral Health and Risk
Communication

• Enhances understanding of how people receive and
  process information and how this translates into
  behavior
• Promotes trust and credibility
• Optimizes desired behavior and reduces undesired
  behavior
• Helps assure that resources are preserved and
  appropriately used
• Reduces the size of the footprint of adverse
  psychological consequenses

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The Bottom Line Message

• Understanding and Integrating Risk Communication
  And Behavioral Health Are Central To Sound
  Preparedness And Response

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Contact Information

• BRIAN W. FLYNN, ED.D.
• P.O. Box 1205
• Severna Park, MD 21146
• Phone [phone]
• Email Brianwflynn_at_aol.com