Disaster Behavioral Health Randal Beaton, PhD, EMT Tools and Resources for Idaho Emergency Responders

South Central Health District 5

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 lost co-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 UW School 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: Disaster Cycle 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 and crisis counseling to victims Working hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors of the disaster Source : 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 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

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 ImpactHeroicHoneymoon 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:

Behavioral Health Tasks, by Phase, Continued DisillusionmentInventoryWorking 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:

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

Resilience Differs from recovery Individuals “thrive” Relatively stable trajectory

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

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

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

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

Delayed Onset Distress

For more information: Coping With a Traumatic Event CDC Publication Available at:

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:

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: allpubs/ADM90-537/default.asp

Disaster Behavioral Health Module 5 Mental 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 Centers for 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 Beaton et al, J. Traumatology, 2004

Prevalence of PTSD in Rescue Workers and Veteran Samples 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 LinkstoFacultyPub.asp

Disaster Behavioral Health Module 7 CISM and CISD Randal Beaton, PhD, EMT

Learner Objective: 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

Module 7: What are CISM and CISD? – Critical Incident Stress Management – Critical Incident Stress Debriefing What are the risks and benefits?

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 CISM’s 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

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

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

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.

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.

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.

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

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

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

For More Information: Critical Incident Stress Management Stephen A Pulley, DO

Disaster Behavioral Health Module 18 Multiple Unexplained Physical Symptoms (MUPS) Randal Beaton, PhD, EMT

Learner Objective: Module 18 To identify some of the unexplained physical symptoms (MUPS) observed in disaster survivors and their implications for disaster response/recovery

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

The “Worried Well” May develop physical symptoms such as rashes, fatigue, etc. May pursue treatment May compete for scarce resources with other disaster victims

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)

“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