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

2. Panhandle Health District 1

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

4. 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

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 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

15. NMDS drill (May 13, 2004)

16. Disaster Behavioral Health Addressing Incident-specific, stress reactions Providing outreach and crisis counseling to victims, both immediate and long-term 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:

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. Modules 1-4 Disaster Behavioral Health Randal Beaton, PhD, EMT

20. 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

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

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

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

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 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

33. 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.

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. Delayed Onset Distress Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

41. 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

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

43. 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

44. 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”

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

46. 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

47. 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

48. 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

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

50. 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

51. 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

52. TopOff 2 – Seattle, May 2003

53. 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

54. 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

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

56. 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

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

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

59. Principles of Psychological Needs Assessment Post-disaster Type of Disaster Vulnerable populations Scope of the disaster Down stream factors

60. TopOff 2: Dirty Bomb Scenario

61. Disaster Typology Natural Man-made TechnologicalBiological Unintentional Floods, Hurricanes, Earthquake s, 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

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

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

64. DeWolfe, see SAMHSA publication Population Exposure Model

65. A.Seriously injured victims bereaved family members B.Victims with high exposure to trauma victims evacuated from the disaster zone C.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 Population Exposure Model (DeWolfe)

66. E.Government officials groups that identify with target victims group businesses with financial impacts F.Community-at-large Population Exposure Model (DeWolfe) (continued) D.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

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

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

69. Disaster Response and Recovery Disaster Response and Recovery: A Handbook for Mental Health Professionals available at: http://www.empowermentzone.com/disaster.txt accessed 01/24/05 http://www.empowermentzone.com/disaster.txt

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

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

72. TopOff 2

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

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

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

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

77. 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”.

78. Helping Survivors in the Wake of Disaster Resource A National Center for PTSD Fact Sheet. Available at: http://www.ncptsd.org/facts/disasters/fs_helping_ survivors.html http://www.ncptsd.org/facts/disasters/fs_helping_ survivors.html

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

80. Learner Objectives: Module 16 1.To identify some special considerations for rural settings in terms of disaster behavioral health preparedness, response and recovery

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

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

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

85. 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.

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

87. 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.

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

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

90. 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

91. 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!

92. 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 accessed 01/24/05. University of Pittsburgh publication. http://www.upb.pitt.edu/crhp/Bridging%20the%20Health %20Divide.pdf