Disaster Behavioral Health

1
Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Tools and Resources for Idaho Emergency
  Responders

2
North Central Health District 2
3
What type of organization do you work for?
Participant Poll

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

4
Research Professor Schools of Nursing and
Public Health and Community Medicine
Randal Beaton, PhD, EMT
Faculty Northwest Center forPublic Health
Practice University of Washington

5
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

6
You can observe a lot by watching
Berra, 1998
7
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

8
NMDS drill (May 13, 2004)
9
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.
10
Tsunami Disaster
Photo by Dr. Mark Oberle, Phuket, Thailand
11
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.

12
Tsunami Disaster Victims
Photo by Dr. Mark Oberle in Phuket
13
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

14
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
15
NMDS drill (May 13, 2004)
16
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
• Working hand-in-hand with paraprofessionals,
  volunteers, community leaders, and survivors
  ofthe disaster

Source http//www.disastermh.nebraska.edu/state_
plan/Appendix20D.pdf
17
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

18
Questions
19
Disaster Behavioral Health

Randal Beaton, PhD, EMT

• Modules 1-4
• Psychological phases of a disaster Temporal
  patterns of mental/behavioral response to
  disaster Resilience Signs symptoms of
  disaster victims

20
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

21
Module 1 Psychosocial Phases of a Disaster

From Zunin Myers (2000)
22
Implications/Tasks of each Phase for Disaster
Personnel - Pre-disaster

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

23
Pre-Disaster

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

24
TopOff 2 Seattle, May 2003
25
Impact

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

26
Heroic

• Disaster survivors are true First Responders

27
Honeymoon (community cohesion)

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

28
Disillusionment

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

29
Inventory

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

30
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

31
Reconstruction (a new beginning)

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

32
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
33
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
34
Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
35
Resilience

• Differs from recovery
• Individuals thrive
• Relatively stable trajectory

36
Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
37
Acute Distress and Recovery

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

38
Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
39
Chronic Distress

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

40
Module 2 Temporal Patterns of Mental/Behavioral
Responses to Disaster
41
Delayed Onset Distress

• Delayed Onset Distress

42
For more information

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

43
Module 3 Resilience

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

44
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

45
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

46
Environmental Factors That Promote Community
Resilience

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

47
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

48
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

49
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

50
Pathways to Resilience

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

51
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

52
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

53
TopOff 2 Seattle, May 2003
54
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

55
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

56
Signs and Symptoms, continued

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

57
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

58
Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 5
• Mental Health Risk of Disaster Workers

59
Learner Objective Module 5

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

60
Module 5

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

61
Disaster Incident Scenes are Chaotic and
Stressful
62
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

63
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.

64
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

65
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

66
Impact of Events Total Score
Beaton et al, J. Traumatology, 2004
67
Prevalence of PTSD in Rescue Workers and Veteran
Samples
Corneil et al, 1999
68
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

69
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

70
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

71
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

72
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

73
Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 16 Rural Issues

74
Learner Objective Module 16

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

75
Module 16

• Rural Mental Health Preparedness versus Urban
  Settings

76
Rural America

• 65 million Americans
• Frontier/Small towns
• Transportation/highway systems
• Rural attitude

77
(No Transcript)
78
Rural America

• Sites of Farms (food supply)
• Sites of power facilities (including nuclear)
• Sites of headwaters and reservoirs (water supply)

79
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.

80
Rural Preparedness

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

81
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.

82
Rural Preparedness Barriers

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

83
Rural Preparedness

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

84
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

85
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!

86
Rural Health Concerns Resource

• Bridging the Health Divide The Rural Public
  Health Research Agenda available at
  http//www.upb.pitt.edu/crhp/Bridging20the20Heal
  th20Divide.pdf
• University of Pittsburgh publication

87
Disaster Behavioral Health
Randal Beaton, PhD, EMT

• Module 17
• Benefits of Training and Drills for First
  Responders and Disaster Personnel

88
Learner Objective Module 17

• To describe documented benefits of disaster
  drills, training, and exercises

Photo Credit Erik Stuhaug
89
Options

• Training and Drills for First Responders and
  Disaster Personnel
• Options
• Meet endlessly to discuss
• Wait for a disaster and then react
• Conduct exercises and training and update plan
  based on outcomes

90
DOD Preparedness Trainingfor First Responders
91
Knowledge Gains in Trained First Responders
Source Beaton Johnson (2002)
92
Enhancements in Perceived Confidence in Trained
First Responders
Source Beaton Johnson (2002)
93
Centers for Disease Control Prevention

• Supplies
• Strategic National Stockpile (SNS)
• Local caches
• PPE caches

94
SNS Exercise
How much did drill affect your confidence?
Much Less Much More
Source Beaton et al. (2004)
95
TopOff 2

• State-Local-Federal Coordination
• Law Enforcement vs. Human Services Response
• Risk/Benefit Analysis

Photo Credit Erik Stuhaug
96
TopOff 2
97
Benefits of Drills, Exercises and Trainings

• Improves interagency communication and/or
  highlights communication glitches
• Practices interagency collaborationand
  coordination
• Improves knowledgeand skills of participants
• Enhances perceivedcompetency of participants

98
Resource

• Beaton, et al. (2003) Evaluation of the
  Washington State National Pharmaceutical
  Stockpile Dispensing Exercise. Part II
  Dispensary Site Worker Findings
• document linked from
• http//www.son.washington.edu/portals/bioterror/
• LinkstoFacultyPub.asp