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

3. North Central Health District 2

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

5. 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

6. 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

7. “You can observe a lot by watching”* *Berra, 1998

8. 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

9. NMDS drill (May 13, 2004)

10. 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.

11. Tsunami Disaster Photo by Dr. Mark Oberle, Phuket, Thailand

12. 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.

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

14. 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

15. 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

16. NMDS drill (May 13, 2004)

17. 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 : http://www.disastermh.nebraska.edu/state_plan/Appendix%20D.pdf Disaster behavioral health interventions differ from traditional behavioral health practice by:

18. 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

19. Questions

20. 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

21. 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

22. Module 1: Psychosocial Phases of a Disaster * From Zunin & Myers (2000) *

23. Warning – e.g. weather forecast Educate Inform Instruct Evacuate or “stay put” Implications/Tasks of each Phase for Disaster Personnel - Pre-disaster

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

25. TopOff 2 – Seattle, May 2003

26. Impact Prepare for surge Advise/instruct/give directions Risk Communication update Leadership

27. Heroic Disaster survivors are true “First Responders”

28. Honeymoon (community cohesion) Survivors may be elated and happy just to be alive Realize this phase will not last

29. Disillusionment Reality of disaster “hits home” Provide assistance for the distressed Referrals to disaster mental health professionals

30. Inventory Psychological community needs assessment –Short-term –Mid-range –Downstream needs

31. 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

32. Reconstruction (“a new beginning”) Still, even following recovery, disaster victims may be less able to cope with next disaster

33. 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: http://www.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc

34. Behavioral Health Tasks, by Phase, Continued Available at: http://www.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc 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.

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

36. Resilience Differs from recovery Individuals “thrive” Relatively stable trajectory

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

38. Acute Distress and Recovery Post-disaster recovery usually occurs within: –Days –Weeks –A few months

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

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

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

42. Delayed Onset Distress

43. For more information: Coping With a Traumatic Event CDC Publication Available at: http://www.bt.cdc.gov/masstrauma/copingpub.asp http://www.bt.cdc.gov/masstrauma/copingpub.asp

44. Module 3: Resilience Definition: The ability to maintain relatively stable physical and psychological functioning (not the same as recovery)

45. 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

46. 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”

47. Environmental Factors That Promote Community Resilience Availability of social resources Community cohesion Sense of connectedness

48. 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

49. 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

50. 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

51. Pathways to Resilience Denial/avoidance Useful illusions/distortions Disclosure – helpful for some

52. 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

53. 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

54. TopOff 2 – Seattle, May 2003

55. 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

56. 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

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

58. 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

59. Disaster Behavioral Health Module 5: Mental Health Risk of Disaster Workers Randal Beaton, PhD, EMT

60. Learner Objective: Module 5 To identify the behavioral health risks of disaster workers including First Responders

61. Module 5 Mental health risks of disaster workers including EMS and rescue personnel – secondary traumatization

62. Disaster Incident Scenes are Chaotic and Stressful

63. 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

64. 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.

65. 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

66. 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

67. Impact of Events Total Score Beaton et al, J. Traumatology, 2004

68. Prevalence of PTSD in Rescue Workers and Veteran Samples Corneil et al, 1999

69. 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

70. 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

71. 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

72. 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

73. For More Information: University of Washington Bioterrorism Curriculum Initiative Web Portal IES test and scoring instructions http://www.son.washington.edu/portals/bioterror/ LinkstoFacultyPub.asp

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

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

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

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

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

80. 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.

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

82. 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.

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

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

85. 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

86. 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!

87. Rural Health Concerns Resource Bridging the Health Divide: The Rural Public Health Research Agenda available at: http://www.upb.pitt.edu/crhp/Bridging%20the%20Health %20Divide.pdf http://www.upb.pitt.edu/crhp/Bridging%20the%20Health %20Divide.pdf University of Pittsburgh publication

88. Disaster Behavioral Health Module 17: Benefits of Training and Drills for First Responders and Disaster Personnel Randal Beaton, PhD, EMT

89. Learner Objective: Module 17 To describe documented benefits of disaster drills, training, and exercises Photo Credit: Erik Stuhaug

90. 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

91. DOD Preparedness Training for First Responders

92. Knowledge Gains in Trained First Responders Source: Beaton & Johnson (2002)

93. Enhancements in Perceived Confidence in Trained First Responders Source: Beaton & Johnson (2002)

94. Centers for Disease Control & Prevention Supplies –Strategic National Stockpile (SNS) –Local caches –PPE caches

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

96. TopOff 2 State-Local-Federal Coordination Law Enforcement vs. Human Services Response Risk/Benefit Analysis Photo Credit: Erik Stuhaug

97. TopOff 2

98. Benefits of Drills, Exercises and Trainings Improves interagency communication and/or highlights communication glitches Practices interagency collaboration and coordination Improves knowledge and skills of participants Enhances perceived competency of participants

99. 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