Disaster Mental Health Issues: Immediate and Over Time

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Disaster Mental Health IssuesImmediate and Over
Time

• Bill Martin, Ph D
• Disaster Response Network Coordinator
• MS Psychological Association

10/23/2007
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Presentation Objectives

• Understand impact of disaster trauma
• Understand roles in disaster response
• Understand disaster mental health interventions
• Understand long term disaster mental health needs

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Characteristics of DisasterDefinition

• 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).

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Nature of the Disaster influences impact

• Natural vs Human-Caused
• Personal Impact
• Size and Scope
• Visible Impact
• Probability of Recurrence

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Who is impacted by a Disaster?
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Everybody

• No one who sees a disaster is untouched by it.

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Population Exposure Model
(DeWolfe, 2000)
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• 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

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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)).

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• 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

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• 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

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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

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Disaster Response Phases
(Adapted from Zunin/Meyers)
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Disaster Mental HealthWho are your clients?

• Individuals and families of survivors
• Disaster responders
• Responding agencies and organizations
• Communities (especially over time)

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Disaster Response Overview

• Responders work within some organization
  structure
• Little opportunity for individual effort
• Sustained effort is important
• Chaos and confusion reign

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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

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ICS OrganizationFunctional Structure
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Operations Section
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Planning Section
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Logistics
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Area Command Post
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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

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Community Based Agencies/Organizations

• Schools
• YMCA
• Boys and Girls Club
• Others

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Normal Reactions to Abnormal EventsAcute and
Chronic

• Behavioral
• Emotional
• Cognitive
• Physical
• interpersonal

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Behavioral

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

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Emotional

• Startle Easily
• Under-Controlled Anger
• Under-Controlled Crying
• Persistent Sadness
• Feelings Helplessness/Hopelessness
• Poor Frustration Tolerance
• Dont Feel Pleasure like before

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Cognitive

• Difficulty Concentrating
• Difficulty with Memory
• Difficulty with Learning
• Trouble Solving Problems
• Short Attention and Confusion
• Difficulty Making Decisions

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Physical

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

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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

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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

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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

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General Rule

• Those most vulnerable before a disaster are most
  vulnerable after a disaster.

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Needs following Disaster

• Maslow revisited
• Safety
• Food/Water/Shelter
• Re-establish social units
• Empowerment
• Recovery

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Coping Continuums

• At Risk lt---------gt Safe
• Chaos lt---------gt Control
• Confused lt---------gt Informed
• Avoidant lt---------gt Engaged
• Helpless lt---------gt Empowered
• Grief lt---------gt Resolution

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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

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Traditional Mental Health Providers

• Psychiatrists
• Psychologists
• Social Workers (Licensed)
• Psychiatric Nurses
• Licensed Counselors
• Marriage/Family Counselors

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• But there are so many others now

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• But there are so many others now
• And the profusion of providers confuses the
  product

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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

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Immediate InterventionPsychological 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

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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

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Dont

• 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

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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

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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

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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

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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

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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

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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

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Linkage with Collaborative Services

• Direction to additional needed services
• Promote continuity in helping relationships (and
  describe limitations in your intervention)

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Long Term Recovery

• Community resources significant
• Health and mental health resources
• Social services
• Basic infrastructure
• Economic
• Transportation
• Housing
• Cultural

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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

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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?

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A RecommendationResiliency Training

• Lets package some immediately useful
  psychological knowledge into a more easily
  digestible product for the public

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Resiliency Training

• A psychoeducational model

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Resiliency Training

• A psychoeducational model
• Delivered through existing and established
  organizations/agencies
• They already have credibility
• They already have a population

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Resiliency Training

• A psychoeducational model
• Delivered through existing and established
  organizations/agencies
• Not likely to produce any fees

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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

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Resiliency

• Are hardy, resilient people just born that way?

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

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Resilience (simply) is

• an ability to endure more stress and respond more
  effectively, even in longer lasting crises.

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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

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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

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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.

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Avoid seeing crises as insurmountable

• We cant 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.

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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 cant be
  done.

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Make Connections

• Family
• Friends
• At work
• Civic groups
• Faith-based groups
• Assisting others

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Take decisive action

• Avoidance and passivity are most predictive of
  worse adjustment.
• Accomplishment, even little steps, builds sense
  of control and confidence.

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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

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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

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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.

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Stay focused

• Write that plan day by day
• Write that journal day by day
• Keeps us focused
• Allows us to see and measure progress

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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

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Disaster Mental Health IssuesImmediate and Over
Time

• Bill Martin, Ph D
• Disaster Response Network Coordinator
• MS Psychological Association

10/23/2007