Texas Department of State Health Services DSHS Disaster Mental Health Services DMHS Program

1. Texas Department of State Health Services (DSHS) Disaster Mental Health Services (DMHS) Program

2. Scenarios: A young woman with two young children is crying, her children appear scared� A middle aged man has liquor on his breath and appears a bit unruly�. An elderly hispanic couple refuses medication stating the curandero has not approved�. Several individuals in a shelter have come down with a debilitating illness of unknown origin� You have been assigned to staff the distribution point, ERT, shelter, etc�.. These are just a sampling of real life scenarios that will encounter in the field. Real life will probably be way more interesting. You have been assigned to staff the distribution point, ERT, shelter, etc�.. These are just a sampling of real life scenarios that will encounter in the field. Real life will probably be way more interesting.

3. GOAL The goal of this training is to provide an overview of Disaster Mental Health. Disaster mental health is the provision of stress management and/or crisis counseling following a critical incident or disaster. A disaster can be both natural or man-made. Give examplesDisaster mental health is the provision of stress management and/or crisis counseling following a critical incident or disaster. A disaster can be both natural or man-made. Give examples

4. Do you have days like this?Do you have days like this?

5. ObjectivesParticipates will be able to: Identify the phases of a disaster Identify six emotional concepts of a disaster Define traumatic stress Identify common stress reactions & ways to cope with these reactions Define Psychological First Aid (PFA) and Identify who can provide PFA Identify duties and responsibilities of DMHS) Differentiate between crisis counseling and traditional counseling

6. Phases of Disaster Individuals and communities go through these phases at different times, or may go back and forth, or may get stuck in one phase.Individuals and communities go through these phases at different times, or may go back and forth, or may get stuck in one phase.

7. Traumatic Stress �Traumatic stress refers to the emotional, cognitive, behavioral and physiological experiences of individuals who are exposed to, or who witness, events that overwhelm their coping and problem solving abilities� (Lerner & Shelton, 2001)

8. Emotional Concepts of a Disaster No one who sees a disaster is untouched by it Stress and grief are normal reactions to an abnormal situation Emotional reactions relate to the problems of living and recovery People do not seek out mental health services Services are practical rather than psychological Support systems are crucial to recovery Point 1: It does not matter if you experienced the event 1st hand or see it on TV, you will be impacted to some degree (example: 9/11, Most of us saw it on TV and still it felt like we were right there, it still impacts us 5 years later) Point 4: Because Negative Stigma is attached to Mental Health, people do not typically do not see the benefit of stress management believing that they will be treated as crazy, and will actively avoid seeking out these services Point 5: Practical assistance to help decrease stress may include: Ensuring immediate physical safety & helping meet basic needs, Providing information about disaster recovery activities and services, Promoting social engagement, Actively listening to children-many adults seeking housing and food do not have time to deal with family emotional issues, Where possible protect from additional traumatic experiences and trauma reminders, Helping survivors who have a missing family member, Helping survivors when a family member or close friend has been injured or died Point 6: Encouraging people to make time for family and friends is important. Encouraging families to devote time to purely recreational activities that maintain social contact with their support network is helpful. So, too, is encouraging active ties among neighbors and friends in post-disaster chores. For people with limited support systems, disaster support groups can be helpful. Groups help to counter isolation, challenge erroneous beliefs about uniqueness and pathology, provide emotional support, and allow survivors to share concrete information and recovery tips. Special considerations for children and adolescents are essential as they are less likely to be able to express their disconnect from support systems including their parents. Point 1: It does not matter if you experienced the event 1st hand or see it on TV, you will be impacted to some degree (example: 9/11, Most of us saw it on TV and still it felt like we were right there, it still impacts us 5 years later) Point 4: Because Negative Stigma is attached to Mental Health, people do not typically do not see the benefit of stress management believing that they will be treated as crazy, and will actively avoid seeking out these services Point 5: Practical assistance to help decrease stress may include: Ensuring immediate physical safety & helping meet basic needs, Providing information about disaster recovery activities and services, Promoting social engagement, Actively listening to children-many adults seeking housing and food do not have time to deal with family emotional issues, Where possible protect from additional traumatic experiences and trauma reminders, Helping survivors who have a missing family member, Helping survivors when a family member or close friend has been injured or died Point 6: Encouraging people to make time for family and friends is important. Encouraging families to devote time to purely recreational activities that maintain social contact with their support network is helpful. So, too, is encouraging active ties among neighbors and friends in post-disaster chores. For people with limited support systems, disaster support groups can be helpful. Groups help to counter isolation, challenge erroneous beliefs about uniqueness and pathology, provide emotional support, and allow survivors to share concrete information and recovery tips. Special considerations for children and adolescents are essential as they are less likely to be able to express their disconnect from support systems including their parents.

9. Okay, take a moment and think of a time when you were feeling a great deal of stress. Examples: Divorce, loss of a loved one, loss of your job, catastrophic illness, etc. Now look at this list, How many of you experienced 1 or more of these reactions? How did this affect your functioning? These are all normal, and usually very short term, reactions to an abnormal event. Most disaster survivors are normal people who function reasonably well in everyday life. Studies of human behavior in disaster indicate a heroic phase in which survivors demonstrate resiliency and strength in the aftermath. However, with the added stress of disaster, most individuals will usually show some signs of emotional and psychological strain. Post-disaster stress and grief reactions are normal reactions with the post-traumatic stress process. They are both natural and adaptive-a part of the recovery process , and should not be labeled pathological unless it interferes with regular functioning to a significant extent. Okay, take a moment and think of a time when you were feeling a great deal of stress. Examples: Divorce, loss of a loved one, loss of your job, catastrophic illness, etc. Now look at this list, How many of you experienced 1 or more of these reactions? How did this affect your functioning? These are all normal, and usually very short term, reactions to an abnormal event. Most disaster survivors are normal people who function reasonably well in everyday life. Studies of human behavior in disaster indicate a heroic phase in which survivors demonstrate resiliency and strength in the aftermath. However, with the added stress of disaster, most individuals will usually show some signs of emotional and psychological strain. Post-disaster stress and grief reactions are normal reactions with the post-traumatic stress process. They are both natural and adaptive-a part of the recovery process , and should not be labeled pathological unless it interferes with regular functioning to a significant extent.

10. Coping with Post-Disaster Stress Sharing experiences helps decrease anxiety and feelings of helplessness Get back into daily routines as soon as possible Maintain a healthy diet and get plenty of sleep Do some physical exercise every day Children are particularly vulnerable to emotional stress. Spend time each day giving your child your undivided attention and reassure them that they are safe. Here is a list of some healthy and practical stress management tools. Point 1-Talking to family, friends and neighbors can help decrease anxiety and feeling of helplessness It is always a good idea to develop a support system. If it is sharable; it is bearable. This works well for children as well. They are very vulnerable to emotional stress It is a good idea to spend some time with each child individually and just listen to what they have to say.Here is a list of some healthy and practical stress management tools. Point 1-Talking to family, friends and neighbors can help decrease anxiety and feeling of helplessness It is always a good idea to develop a support system. If it is sharable; it is bearable. This works well for children as well. They are very vulnerable to emotional stress It is a good idea to spend some time with each child individually and just listen to what they have to say.

11. Managing Stress & Fatigue Understand and set limits Seek social support; develop a buddy system Take breaks Eat well; sleep well Be active and exercise Drink plenty of fluids Read for pleasure Smile! Use humor Point 1: Know when enough is enough Point 2: It is a good idea to have a co-worker or friend that you can talk to when you are feeling overwhelm and need to vent Point 8: Because our job are stressful in itself, we recommend sharing some form of humor. It takes less muscles to Smile than to frown. And Smiling is contagious.Point 1: Know when enough is enough Point 2: It is a good idea to have a co-worker or friend that you can talk to when you are feeling overwhelm and need to vent Point 8: Because our job are stressful in itself, we recommend sharing some form of humor. It takes less muscles to Smile than to frown. And Smiling is contagious.

12. Psychological First Aid (PFA) An evidence based approach designed to reduce the initial stress caused by traumatic events and to foster short and long term adaptive functioning. Psych 1st aid seeks to acknowledge that disaster stress may interfere in the short term and/or the long term with normal daily functioning and that assistance in dealing with stressors results in quicker recovery. The lack of psychological assistance for those who need it in the long term amy result in health problems such as heart disease and/or social problems such as inability to hold a job.Psych 1st aid seeks to acknowledge that disaster stress may interfere in the short term and/or the long term with normal daily functioning and that assistance in dealing with stressors results in quicker recovery. The lack of psychological assistance for those who need it in the long term amy result in health problems such as heart disease and/or social problems such as inability to hold a job.

13. Psychological First AidWho? When? Where? May be used for everyone PFA is a useful tool for non-clinicians Used during and immediately after trauma/disaster May be used anywhere PFA may be used with anyone. Responders, children, adolescents, parents/caretakers, families and adults. It may be used on a broader scale in the community to help healing occur. PFA is a stress management approach for clinicians that has been developed by the VA National Center for Post-Traumatic Stress. It is fast becoming the new standard in providing relief to victims and survivors of trauma. Studies show that the effects of trauma may be mitigated by regaining normalcy, even a �new� normalcy and through peer support which includes emotional, informational, companionship, validation and instrumental support such as services, money, transportation. Literally� Support may be a bottle of water, a shoulder to cry on, information. Because it does not require much structure it can be provided nearly everywhere.PFA may be used with anyone. Responders, children, adolescents, parents/caretakers, families and adults. It may be used on a broader scale in the community to help healing occur. PFA is a stress management approach for clinicians that has been developed by the VA National Center for Post-Traumatic Stress. It is fast becoming the new standard in providing relief to victims and survivors of trauma. Studies show that the effects of trauma may be mitigated by regaining normalcy, even a �new� normalcy and through peer support which includes emotional, informational, companionship, validation and instrumental support such as services, money, transportation. Literally� Support may be a bottle of water, a shoulder to cry on, information. Because it does not require much structure it can be provided nearly everywhere.

14. Psychological First AidBasic Objectives Contact and Engagement Safety and comfort Help survivors discuss needs and concerns Calm distraught survivors Offer practical assistance and information Connect to social supports Provide information on stress and coping Establish a human connection in a non-intrusive, compassionate manner. Be prepared to listen and speak in calm, concrete terms. During and after disaster individuals will be in an unfamiliar enviornment, reassure that they are safe and ensure that their immediate basic needs are being met. In an unfamiliar enviornment, survivors may not be aware of what assistance is available or how to access. If needed, find out what is causing distress and if you or your organization/group is in a position to assist or directly refer to someone who can. Assisting the survivor with current or anticipated problems is central to PFA. Work with the individual to identify and clarify the most immediate needs and to discuss an action plan-sometimes people just need a sounding board to verify they are doing the right thing. Whenever possible, give the survivor the tools for recovery (Phone number, address, stress management handout) and encourage to pursue the assistance rather than doing for them. This helps to regain a measure of control over their lives and recovery. If necessary (Due to disability, culture) assist in linkage to collaborative services. If disconnected from primary social supports (Family, friends, church), encourage to make use of available resources (Yourself, other relief workers, other affected persons). Children and adolescents especially benefit from being plugged into �normal� group support activities such as drawing, game playing and skits. Information on what is known about the event, what is being done to assist them and available services help orientation to the situation and significantly decrease stress levels. Handouts, websites, group education on the potential effects of stress and how to cope with or decrease stress should be readily available.Establish a human connection in a non-intrusive, compassionate manner. Be prepared to listen and speak in calm, concrete terms. During and after disaster individuals will be in an unfamiliar enviornment, reassure that they are safe and ensure that their immediate basic needs are being met. In an unfamiliar enviornment, survivors may not be aware of what assistance is available or how to access. If needed, find out what is causing distress and if you or your organization/group is in a position to assist or directly refer to someone who can. Assisting the survivor with current or anticipated problems is central to PFA. Work with the individual to identify and clarify the most immediate needs and to discuss an action plan-sometimes people just need a sounding board to verify they are doing the right thing. Whenever possible, give the survivor the tools for recovery (Phone number, address, stress management handout) and encourage to pursue the assistance rather than doing for them. This helps to regain a measure of control over their lives and recovery. If necessary (Due to disability, culture) assist in linkage to collaborative services. If disconnected from primary social supports (Family, friends, church), encourage to make use of available resources (Yourself, other relief workers, other affected persons). Children and adolescents especially benefit from being plugged into �normal� group support activities such as drawing, game playing and skits. Information on what is known about the event, what is being done to assist them and available services help orientation to the situation and significantly decrease stress levels. Handouts, websites, group education on the potential effects of stress and how to cope with or decrease stress should be readily available.

15. Psychological First Aid Delivery Operate within the Response frame work Be calm, courteous, organized and helpful Be visible and available Maintain confidentiality Operate within expertise and designated role Be sensitive to cultural, ethnic and community concerns The goal of PFA is to reduce distress, assist with current needs and promote adaptive functioning. Not to have the survivor relive details of the traumatic experience and losses. Although you may not be tasked to provide PFA, it is helpful to know the concepts so that if the opportunity presents itself, you can make a survivor feel better. The goal of PFA is to reduce distress, assist with current needs and promote adaptive functioning. Not to have the survivor relive details of the traumatic experience and losses. Although you may not be tasked to provide PFA, it is helpful to know the concepts so that if the opportunity presents itself, you can make a survivor feel better.

16. Psychological First AidBehaviors To Avoid Do not presume to know what the person is experiencing Do not assume that everyone is traumatized Do not label/diagnose or patronize Do not �debrief� Acknowledge feelings or thoughts, but unless you are a survivor as well, it is impossible to understand the events impact. It will be unique for everyone. The majority of folks, depending on the event, including kids are pretty resiliant. While they may go through very brief periods of shock and stress, the majority of people will reorient and recover on their own fairly quickly. Much of what the survivor is going through is going to be a normal and transitory stress reaction. Focus instead on what the survivor has done that is effective. While encouraging and allowing the survivor to discuss what occurred, do not ask for details on what happened to the individual and what they are feeling. Discussions that focus on getting someone to open up emotionally should be done by a counselor skilled in emotional debriefing without causing further possibly debilitating distress. Acknowledge feelings or thoughts, but unless you are a survivor as well, it is impossible to understand the events impact. It will be unique for everyone. The majority of folks, depending on the event, including kids are pretty resiliant. While they may go through very brief periods of shock and stress, the majority of people will reorient and recover on their own fairly quickly. Much of what the survivor is going through is going to be a normal and transitory stress reaction. Focus instead on what the survivor has done that is effective. While encouraging and allowing the survivor to discuss what occurred, do not ask for details on what happened to the individual and what they are feeling. Discussions that focus on getting someone to open up emotionally should be done by a counselor skilled in emotional debriefing without causing further possibly debilitating distress.

17. Psychological First AidIndividuals Who May Need Services Those showing signs of acute distress Disoriented Confused Frantic Panicky Extremely withdrawn Extremely irritable While these are some of the behaviors that indicate that you should see if you or a counselor can help, often someone will get a tremendous emotional boost by just having someone listen and care. Taking 5 minutes to listen to someone can mean the difference between sadness and optimism. While these are some of the behaviors that indicate that you should see if you or a counselor can help, often someone will get a tremendous emotional boost by just having someone listen and care. Taking 5 minutes to listen to someone can mean the difference between sadness and optimism.

18. Psychological First AidAt Risk Populations Responders/volunteers who participated in response efforts Children, especially whose parent(s) are missing or have died Those with multiple displacements The medically frail The elderly Those with serious mental illness Adolescent and adult substance abusers Mothers with babies/small children Very-low income Responders typically have a high stress threshold, however after several days of response they will need to be encouraged to care for self. These other groups are at higher risk for emotional and physical effects of stress and, are usually harder to engage or fall through the cracks because they cannot express their needs.Responders typically have a high stress threshold, however after several days of response they will need to be encouraged to care for self. These other groups are at higher risk for emotional and physical effects of stress and, are usually harder to engage or fall through the cracks because they cannot express their needs.

19. Disaster Mental Health Services Mission Statement The mission of DMHS is to decrease the adverse mental health effects of trauma for victims, survivors and responders of traumatic events. DMHS provides immediate response capability.

20. Disaster Mental Health ServicesResponsibilities During a Disaster Provide situational awareness for Service Providers Coordinate emergency response stress management and crisis counseling services in Texas Coordinate with DSHS response components as well as State and Federal partners May provide staffing at the State Operations Center (SOC), DSHS Multi Agency Coordination Center (MACC), or FEMA Joint Field Office (JFO) During a disaster our office performs some important program functions. We serve as the liaison to the state hospitals, local mental health authorities, substance abuse providers, Department of State Health Services, Substance Abuse and Mental Health Services Administration, and the Federal Emergency Management Agency (to name a few) I will go into more details about the next 3 points a little later During a disaster our office performs some important program functions. We serve as the liaison to the state hospitals, local mental health authorities, substance abuse providers, Department of State Health Services, Substance Abuse and Mental Health Services Administration, and the Federal Emergency Management Agency (to name a few) I will go into more details about the next 3 points a little later

21. The Purpose of Crisis Counseling Normalize and validate feelings and reactions Help define and prioritize needs Help design strategies for addressing needs Help to adapt/reestablish coping skills Offer practical assistance and referral(s) Prevent future emotional and psychological problems

22. Crisis Counseling Strategies Provide opportunities to share experiences, reactions, problems and solutions Provide information addressing common physical and psychological reactions to crisis Reestablish coping skills that worked in the past Provide education about substance use as coping tool Restore the individual�s sense of control Discuss the impact that the disaster has on children and the family Encourage networking with support groups, providers, and the clergy

23. Crisis Counseling Program Services Outreach-Primarily in the home or business Screening and Assessment for referral to formal mental health, public health, physician, etc Counseling-Individual and Group Information and Referral to disaster assistance organizations Public Education about the effects and means to manage stress As previously mentioned, our services are community based. Once a disaster is federally declared, we hire staff to go out and assess the mental health needs of individuals in the impacted area. As previously mentioned, our services are community based. Once a disaster is federally declared, we hire staff to go out and assess the mental health needs of individuals in the impacted area.

24. Crisis Counseling vs. �Traditional� Counseling Office Based Focus: Diagnosis & Treatment Attempts to impact functioning Examines content Psychotherapeutic focus Home & community based Assesses strengths, adaptation & coping skills Seeks to restore pre-disaster functioning Accepts content at face value Validates appropriateness of reactions and normalizes the experience Psycho-educational focus One of the most significant differences between Cc and Traditional Counseling is that we reach out to the community. We do not wait for individuals to come to us. Through CC, we help individuals return to their normal day to day functions prior to the disaster Psycho-educational focus---providing the knowledge needed to cope and/or manage stressOne of the most significant differences between Cc and Traditional Counseling is that we reach out to the community. We do not wait for individuals to come to us. Through CC, we help individuals return to their normal day to day functions prior to the disaster Psycho-educational focus---providing the knowledge needed to cope and/or manage stress

25. Contact Information Community Preparedness Section Community & Regional Coordination Branch Disaster Mental Health Services Ed Maldonado - Ext. 6936 Melva Richardson - Ext. 3093 1100 W. 49th Street, T306 Austin, TX 78756 Office (512) 458-7111, extension� Fax: (512) 458-7231 For more complete information and printable brochures, forms, etc�� http://www.dshs.state.tx.us/comprep/dmh/default.shtm