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

2. Southeastern
Health
District 6

3. What type of organization do you work for?
Participant Poll
What type of organization do you work for?
A. Hospital
B. EMS, pre-Hospital
C. Health District
D. Other

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

5. 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

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

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 1,2 & 4
Psychological phases of a disaster; Temporal patterns of mental/behavioral response to disaster; (Resilience briefly); 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:

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:

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
Delayed Onset Distress

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

42. 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

43. TopOff 2 – Seattle, May 2003

44. 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

45. 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

46. Signs and Symptoms, continued
Domestic violence, child or elder abuse
Family members feel their loved ones are acting in uncharacteristic ways

47. For more information:
Field Manual for Mental Health and Human Service Workers in Major Disasters
Available at:
allpubs/ADM90-537/default.asp

48. Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 10
Post-Disaster Assessment

49. Learner Objective: Module 10
To identify and describe some basic principles of a post-disaster assessment of community psychosocial needs.

50. Principles of Psychological Needs Assessment Post-disaster
Type of Disaster
Vulnerable populations
Scope of the disaster
Downstream factors

51. TopOff 2: Dirty Bomb Scenario

52. Man-made Technological
Disaster Typology
Natural
Man-made Technological
Biological
Unintentional
Floods, Hurricanes, Earthquakes, etc.
e.g., Bhopal, Haz-Mat, Nuclear Power plant accident
Epidemic e.g., 1918 Influenza Pandemic
Intentional
“Act of God”
Chemical, Nuclear, Radiological, Explosion, Acts of Terrorism
Bioterrorism

53. “It is not the event but the effect
that makes the disaster.”

54. Vulnerable Populations (Community Composition)
Psychiatric populations
Children/infants – Schonfeld Hot Topic Archive
Elderly
Pregnant Women
Women with young children
Native American Tribes

55. Population Exposure Model
DeWolfe, see SAMHSA publication

56. Population Exposure Model (DeWolfe)
Seriously injured victims • bereaved family members
Victims with high exposure to trauma • victims evacuated from the disaster zone
Bereaved extended family members and friends • rescue and recovery workers with prolonged exposure • medical examiner’s office staff • service providers directly involved with death notification and bereaved families

57. Population Exposure Model (DeWolfe) (continued)
People who lost homes, jobs, pets, valued possessions • mental health providers • clergy, chaplains, spiritual leaders • emergency health care providers •school personnel involved with survivors, families, of victims • media personnel
Government officials • groups that identify with target victims group • businesses with financial impacts
Community-at-large

58. Downstream Factors Economic impact on community Job loss Housing needs
Community Disruption
Loss of “symbols”

59. Red Cross Role (in needs assessment)
Can “assist” disaster victims
Make appropriate referrals

60. Disaster Response and Recovery
Disaster Response and Recovery: A Handbook for Mental Health Professionals available at:

61. Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 13
Providing Post-Disaster Behavioral Health Assistance

62. Learner Objective: Module 13
To describe some basic approaches to (early) post-disaster behavioral health assistance for disaster victims

63. TopOff 2

64. Key Principles of Post Disaster Behavioral Health Approaches
No one who experiences a disaster first hand is unfazed
Disaster stress and grief reactions are normal and expected – “normalize” these reactions

65. Key Principles of Post Disaster Behavioral Health Approaches (continued)
Many emotional reactions of disaster survivors stem from problems of living brought about by the disaster
Most disaster survivors do not see themselves as needing behavioral health services following a disaster

66. Key Principles of Post Disaster Behavioral Health Approaches (continued)
Disaster survivors may reject all forms of disaster assistance
Disaster behavioral health assistance is more practical than psychological
Disaster behavioral health services need to be uniquely tailored to the communities they serve

67. “Therapy by just walking around”
Things to Remember
“Therapy by just walking around”

68. Highest priority for counseling efforts: Disaster workers
Things to Remember
Disaster counselors assume a variety of roles: “carry water”, pitch tents, serve meals and “listen”.
Highest priority for counseling efforts: Disaster workers

69. Helping Survivors in the Wake of Disaster Resource
A National Center for PTSD Fact Sheet Available at:

70. Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 16: Rural Issues

71. Learner Objective: Module 16
To identify some special considerations for rural settings in terms of disaster behavioral health preparedness, response and recovery

72. Module 16:
Rural Mental Health Preparedness versus Urban Settings

73. Rural America 65 million Americans Frontier/Small towns
Transportation/highway systems
Rural “attitude”

75. Rural America Sites of Farms (food supply)
Sites of power facilities (including nuclear)
Sites of headwaters and reservoirs (water supply)

76. 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.

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

78. 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.

79. Rural Preparedness: Barriers
The main barrier to rural preparedness is lack of funding.

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

81. 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

82. 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!

83. Rural Health Concerns Resource
Bridging the Health Divide: The Rural Public Health Research Agenda available at:
University of Pittsburgh publication