disaster behavioral health randal beaton, phd, emt tools and resources for idaho emergency...
TRANSCRIPT
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Disaster Behavioral HealthRandal Beaton, PhD, EMT
Tools and Resources for Idaho
Emergency Responders
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CentralHealthDistrict
4
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What type of organization do you work for?
A. Hospital
B. EMS, pre-Hospital
C. Health District
D. Other
Participant Poll
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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
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Relevant Clinical Experience
• Volunteer EMT
• Counseled victims of 9/11 who lostco-workers
• “Psychological casualties” of Nisqually earthquake (2001)
• Stress management for First Responders – mostly firefighters and paramedics – in private practice
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“You can observe a lot by watching”*
*Berra, 1998
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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 UWSchool of Nursing Disaster Plan – 2002
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NMDS drill (May 13, 2004)
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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.
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Tsunami Disaster
Photo by Dr. Mark Oberle, Phuket, Thailand
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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.
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Tsunami Disaster Victims
Photo by Dr. Mark Oberle in Phuket
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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
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Disaster Cycle
There are a number of distinct conceptual stages in the disaster cycle:
DisasterCycle
Pre-event warning threat stage
Impact/Response
Recovery
Evaluation
Preparedness Planning
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NMDS drill (May 13, 2004)
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Disaster Behavioral Health
• Addressing Incident-specific, stress reactions
• Providing outreach andcrisis counseling to victims
• Working hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors ofthe disaster
Source : http://www.disastermh.nebraska.edu/state_plan/Appendix%20D.pdf
Disaster behavioral health interventions differ from traditional behavioral health practice by:
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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
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Questions
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Modules 1,2 & 4Psychological phases of a disaster;
Temporal patterns of mental/behavioral response to disaster; (Resilience briefly);
Signs & symptoms of disaster victims
Disaster Behavioral HealthRandal Beaton, PhD, EMT
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• 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
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Module 1: Psychosocial Phases of a Disaster
* From Zunin & Myers (2000)
*
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• Warning – e.g. weather forecast
• Educate
• Inform
• Instruct
• Evacuate or “stay put”
Implications/Tasks of each Phase for Disaster Personnel - Pre-disaster
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• Threat, e.g., impending terrorist activity
• Risk communication: To reduce anxiety, must also tell people what they should do (without jargon)
Pre-Disaster
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TopOff 2 – Seattle, May 2003
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Impact
• Prepare for surge
• Advise/instruct/give directions
• Risk Communication update
• Leadership
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Heroic
•Disaster survivors are true “First Responders”
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Honeymoon (community cohesion)
• Survivors may be elated and happy just to be alive
• Realize this phase will not last
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Disillusionment
• Reality of disaster “hits home”
• Provide assistance for the distressed
• Referrals to disaster mental health professionals
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Inventory
•Psychological community needs assessment
– Short-term
– Mid-range
– Downstream needs
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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
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Reconstruction (“a new beginning”)
•Still, even following recovery, disaster victims may be less able to cope with next disaster
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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: http://www.nwcphp.org/edu/dbh/DisasterPhases.doc
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Behavioral Health Tasks, by Phase, Continued
Available at: http://www.nwcphp.org/edu/dbh/DisasterPhases.doc
Disillusionment Inventory Working through Grief
Reconstruction
“Assistance” for distressed
Psychosocial needs assessment, short-term, mid-range, and down-stream needs“
Psychotherapy and/or medicationsPsychoeducational 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.
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Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
0
10
20
30
40
50
60
70
80
90
100
Event 2 Years
Dis
rup
tio
ns
Resilience
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Resilience
• Differs from recovery
• Individuals “thrive”
• Relatively stable trajectory
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Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
0
10
20
30
40
50
60
70
80
90
100
Event 2 Years
Dis
rup
tio
ns
Acute/Recovery
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Acute Distress and Recovery
• Post-disaster recovery usually occurs within:
– Days
– Weeks
– A few months
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Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
0
10
20
30
40
50
60
70
80
90
100
Event 2 Years
Dis
rup
tio
ns
Acute/Chronic
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Chronic Distress
Acute/Chronic Distress and/or Lasting Maladaptive Health Behavior Outcomes
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Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
0
10
20
30
40
50
60
70
80
90
100
Event 2 Years
Dis
rup
tio
ns
Delayed
Delayed Onset Distress
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For more information:
Coping With a Traumatic Event
CDC PublicationAvailable at: http://
www.bt.cdc.gov/masstrauma/copingpub.asp
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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
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TopOff 2 – Seattle, May 2003
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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
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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
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Signs and Symptoms, continued
• Domestic violence, child or elder abuse
• Family members feel their loved ones are acting in uncharacteristic ways
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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
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Disaster Behavioral Health
Module 5
Randal Beaton, PhD, EMT
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Learning Objective: Module 5
To identify the behavioral health risks of disaster workers including First Responders
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Module 5
Mental health risks of disaster workers including EMS and rescue personnel – secondary traumatization
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Disaster Incident Scenes are Chaotic and Stressful
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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 Centersfor Disease Control
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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.
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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
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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
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Impact of Events Total Score
5421935224N =
Time w/ reference to 9/11/01
1 mth After
2wk After
1wk After
1-2days After
Day Before
95
% C
I P
TS
D C
ase
Pre
va
len
ce
.6
.5
.4
.3
.2
.1
0.0
-.1
Beaton et al, J. Traumatology, 2004
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Prevalence of PTSD in Rescue Workers and Veteran Samples
0% 5% 10% 15% 20% 25%
US Urban Fire Fighters and ParamedicsBritish Ambulance Drivers
9/11 Rescue WorkersWounded Combat Vietnam Vets
Canadian Fire FightersIraq Combat Veterans (2004)
Vietnam Era Vets OverallCrime Victims (US 1980's)
Community Male (Canada, 1990's)
Corneil et al, 1999
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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
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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
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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
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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
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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
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Disaster Behavioral Health
Modules 15
Randal Beaton, PhD, EMT
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Learner Objective: Module 15
To identify some basic principles of psychological “first aid” for disaster workers and victims
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Psychological First Aid
• Support and presence
• Reduce psychological arousal—take a breath—you’re going to be OK.
• “Screen” and mobilize support for those most distressed.
• Keep families together or facilitate reunions.
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Disaster Behavioral Health Priorities
Optimal efforts to conduct assessments or early treatment of mental health problems should be conducted within a hierarchy of needs:
Survival Food
Safety Shelter
Security Crisis Counseling
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Psychological “First Aid”
Traumatic Incident Stress: Information for Emergency Workers:
NIOSH Guidelines
http://www.cdc.gov/niosh/unp-trinstrs.html
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Disaster Behavioral Health
Modules 17
Randal Beaton, PhD, EMT
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Learner Objective: Module 17
To describe documented benefits of disaster drills, training, and exercises
Photo Credit: Erik Stuhaug
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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
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DOD Preparedness Trainingfor First Responders
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Knowledge Gains in Trained First Responders
Source: Beaton & Johnson (2002)
DP Trained?
YesNo
DP
Q T
ota
l Sco
re
18
17
16
15
14
13
12
11
10
Pre-training
4mo. Post-training
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Enhancements in Perceived Confidence in Trained First Responders
Source: Beaton & Johnson (2002)
DP Trained?
YesNo
Pe
rce
ive
d c
om
pe
ten
cy "
Bio
log
ica
l"
30
20
10
0
Pre-training
4mo. Post-training
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Centers for Disease Control & Prevention
Supplies
– Strategic National Stockpile (SNS)
– Local caches
– PPE caches
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SNS Exercise
Source: Beaton et al. (2004)
Much Less Much More
How much did drill affect your confidence?
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TopOff 2
• State-Local-Federal Coordination
• Law Enforcement vs. Human Services Response
• Risk/Benefit Analysis
Photo Credit: Erik Stuhaug
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TopOff 2
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Benefits of Drills, Exercises and Trainings
• Improves interagency communication and/or highlights communication glitches
• Practices interagency collaborationand coordination
• Improves knowledgeand skills of participants
• Enhances perceivedcompetency of participants
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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