Crisis Intervention

José A. Capriles Quirós, MD, MPH, MHSAProfessor,

UPR Center for Public Health Preparedness

A NEW AWARENESS

“Target Population”

• Prior to 9-11• Severe and persistent mental illness• Severe substance use disorders• Lack resources to access treatment • Hard to reach and difficult to engage• Various racial, ethnic cultural groups, women

• After 9-11• Disaster trauma survivors• Entire state population

Target Population Ecological Model

Victims

Vulnerable people

Emergency responders

Entire population

Children & parents Victims’ families

Vulnerable PopulationsPredictors of psychological distress post terrorist event:

Consequences are related to the quality and extent of exposure - being a victim, watching the attacks, talking on the phone with someone who was lost

Silver 2002; Schlenger 2002

Female gender is associated with worse short-term outcomes Silver 2002

Weak or deteriorating psychosocial resources Norris et al, 2002

Those with pre existing physical illness Shlev 2001 or mental Illness Yehuda 2002

Vulnerable Populations continuedPredictors of psychological distress post terrorist event:

Prior exposure to violence and trauma (Veterans) Hoven 2002

Hispanics and other immigrant populations, including refugees Galea et al. 2002

School aged children Pfefferbaum 2003

Middle aged and young adults are at greater risk than older adults (contrary to popular belief)

First responders - unique exposure & risk Beaton & Nemuth, J Traumatology 2004

Crisis Types• Greek Myth - Hercules dipped arrows in Hydra venom• Alexander the Great - combustible toxins sulphur• Acts of war (e.g., terrorism)• Violent deaths (e.g., fatal illness, homicide, suicide)• Criminal acts (e.g., robbery, child abuse, kidnapping)• Unexpected natural deaths (e.g., heart attack, cancer)• Industrial accidents/disasters (e.g., chemical spills)• Natural disasters (e.g., earthquake, tornado)• Severe illnesses (e.g., cancer)• Accidental injuries (e.g., car accident, burns)

Goals

• Crisis events are not a matter of “if” but “when”

• Planning must take place prior to a crisis• One size does not fit all• Crisis plans need to have consistent

structures and language • Crisis planning must be collaborative

Goals (continued)

• Crisis planning must include training and information

• The connection between crisis planning and response and academic performance

• Crisis planning is never done• Crisis planning/response is PART of a

larger process• Resources

Helping and healing communities

Terrorism: definition and examples

Illegal or threatened use of force or violence to coerce societies or governments by inducing fear in populations, involving ideological and political motives and justifications. National Research Council, 2002

Damaging mental well-being is the exact purpose of terrorism.

Examples in USA:2001 WTC and Pentagon AttacksFall 2001 Anthrax Attacks

1995 Oklahoma City Bombing

Crisis events are not a matter of “if” but “when”

• Where are safe places?• Definition of a crisis

– Extremely negative • Involves actual and/or threatened death and/or physical

and/or emotional injury.– Uncontrollable/Unpredictable

• Cannot be stopped, mitigated, or predicted.– Depersonalizing

• Is not sensitive to status, wealth, power, or position.– Sudden and unexpected

• Occurs without warning.

Variables impacting trauma potential

• Type of disaster• Natural disasters are typically less traumatic than are man-made

disasters or human caused crises.• Source of physical threat/injury

• Physical threat or injuries due to accidents/illness are less traumatic than are threats and/or injury due to assault violence.

• Presence of fatalities• Crises resulting in non-fatal trauma to significant others are less

traumatic than are events that result in sudden and unexpected death.

• In addition, events that involve sudden and unexpected death will be complicated by grief reactions.

Implications

• Need Outreach and Direct Care• Build Community Resiliency and Capacity• Rely on Existing Resources• Utilize A Phased Approach• Build in Diverse Strategies• Form new Collaborations and

Partnerships

Implications

• Opportunities for Community Education and New Relationships

• Paradigm Shift in Role of Mental Health Professionals (eg. Different interventions, settings, etc.)

• New Skills Needed for New Realties (eg Consultation re: “psychological warfare”)

Survey Results“Public Perspectives MH Effects of Terrorism” Poll

– 61% fear terrorism more than natural disaster

– 77% believe info on strategies to cope with fear and distress needed, equal importance to securing physical installations

– 57% do not think the PH system is meeting the MH needs resulting from the threat of terrorism

– Information received after a crisis significantly shapes reactions over the weeks and years following

NASMHPD, NMHA and Consortium for Risk and Crisis Communications, 2004

Madrid March 11, 2004

Madrid March 11, 2004

Disaster stages

BeforePreparednes

s

Disaster stages

BeforePreparednes

s

DuringAcute/

Intermediate

Immediate Reactions

• Disbelief

• Disorientation

• Fear

• Feeling time is slowed down

• Feeling numb or disconnected

• Feeling helpless or irrationally

failing to avoid danger

Disaster stages

BeforePreparednes

s

DuringAcute/

Intermediate

AfterRecovery

Plan for Intervention Assist With: Physical Needs

Establish safety, medical, food, water, shelter,

communication to public regarding event and future risks A good crisis management worker can:

“Cook a meal, empty the garbage, make coffee, change a bed, file, type, sort papers, answer phones, drive a van, stock supplies, put up a tent, operate a radio, mark a trail, cut wood, baby-sit, and fold clothes, in addition to his/her professional role” Institute of Medicine 2002

During: Acute phase• Immediate response• Comfort, support, psychological first aid• Clinical screening• Attend to needs of directly affected and

vulnerable populations• Individual, family/group interventions across the

lifespan• Public messages• Support to caregivers

Early Responses to 9/11 AttacksNationwide – 1week

• 20% of Americans know someone who was missing, hurt or killed

• 64% had a shaken sense of safety & security

• 43% less willing to travel by airplane

Positive Adaptation – growth, altruism, activism, creativity, empathy

American Psychological Assn Feb 2002 Gallup 2001

After: Recovery phase• Expect most people will be OK• Identify those with delayed effects

• Risk populations: medically injured, prior history of SA or violence/trauma, families of deceased, etc.

• Major depression, substance abuse, trouble at work, domestic discord and violence, suicide

• Clinical work with people who have PTSD and lasting psychological effects

• Broad community outreach - information dissemination/education

• Lessons learned, evaluation, research

Before: Preparedness

• Debrief from previous events• Focus on prevention

• Strengthen community resilience, reduce risk factors, improve coping capacity

• Build response infrastructure• Coalitions, partnerships, networks• Model and role definition• Curriculum development, training• Communications/command structures

• Develop rapid response plan

Major Disaster Phases of Behavioral Health Response

Acutephase

Timeline

Days 1-2Rapid deployment teams provide immediate crisis intervention, State employees form core of response

Major Disaster Phases of Behavioral Health Response

Acutephase

Days 1-2Rapid deployment teams provide immediate crisis intervention, State employees form core of response

Days 3-14Teams expand to include volunteers from community-based behavioral health agencies

Timeline

Intermediatephase

Major Disaster Phases of Behavioral Health Response

Acutephase

Days 1-2Rapid deployment teams provide immediate crisis intervention, DMHAS and DCF employees form core of response

Days 3-14Teams expand to include volunteers from community-based behavioral health agencies

Day 14+FEMA declaration Services provided by contracted agencies, teams phase-out operations

Timeline

Intermediatephase

Recoveryphase

Traditional Role• Office-based treatment• Multiple treatment sessions• Therapeutic relationship • Client comes to you• Broad spectrum of disorders• Egalitarian environment• Collateral contact = provider

Adapting to new roles/situations

Traditional Role• Office-based treatment• Multiple treatment sessions• Therapeutic relationship • Client comes to you• Broad spectrum of disorders• Egalitarian environment• Collateral contact = provider

New Role• Street-based treatment• Psychological first aid• One shot intervention• You go to client • Focus on trauma• Hierarchical: top down• Collateral = fire chief, police

captain or faith leader

Adapting to new roles/situations

Crisis Response

Public Safety

Crisis Response

Public Safety

Public Health

Crisis Response

Public Safety

Behavioral HealthPublic Health

Crisis intervention (caring for people during the crisis)

Caring for people after the crisis (support long-term healing)

Crisis prevention (caring for people before the crisis)

Support short- to long-term copings, preventing secondary symptoms

Long term planning of prevention; optimizing crisis management

Short term relief in order to prevent collapsing of persons or systems

developed by A. Englbrecht & R. Storath, graphics: C. Enders

Crisis Management Model

Functions to Protect and Respond to Public Psychological Health

1. Basic resources – food, shelter, communication, transportation, and medical services

2. Interventions and programs to promote individual and community resilience

3. Surveillance for psychological consequences 4. Screening criteria for individuals5. Treatment for acute and long-term effects of

the trauma

Functions to Protect and Respond to Public Psychological Health

6. Human Services - contribute to psychological functioning, reuniting families, child care, housing, job assistance

7. Risk Communication, dissemination of information8. Training of service providers to respond. Prepare and

protect them against psychological trauma9. Capacity to handle large increase in demand for

services - “Surge Capacity”10. Case finding to locate individuals who need MH

services but are not utilizing conventional means; including the underserved, marginalized, and unrecognized groups of people

CRISIS PREPARATION PLAN:TASKS

• Establish policies and procedures• Incident Command Systems• Create assessment tool to evaluate plan• Organize and train• Conduct response exercises• Respond to the crisis• Evaluate crisis response

CRISIS PREPARATION PLAN:STEPS IN DEVELOPMENT

• Establish a multidisciplinary working group• Review existing plans/procedures• Determine essential elements of crisis plan• Conduct hazard analysis/capability assessment• Develop strategies

It’s All About RelationshipsInteragency Cooperation and Coordination

Integrate MH with other services

Systems issues reign supreme as barriers to

providing effective MH services

Evidence-based treatments will have little value if can not be delivered Norris 2002

Crisis Intervention and Terrorism Summary

Types of Intervention

Level of InterventionSOCIETAL

COMMUNITY

NEIGHBORHOOD

FAMILY

INDIVIDUAL

Public Safety

Public Education

Capacity Building

Family Self-Help Networks

Traditional Healing

Public Policy

Service Coordination

Training/Education

Family Education

Clinical Treatment

Green et al, in press

Public Health