Objectives:

1. Healing in the Midst of Chaos:A Medical-Behavioral Health Approach to Disaster MedicineJeanne M. LeBlanc, Ph.D., ABPP(Rp), R. Psych.jeannemleblanc@hotmail.com

2. Objectives: • To provide an overview of a disaster and the potential situational challenges faced by medical providers. • To increase awareness of common psychological responses when providing medical care in disaster settings. • To detail a model of a holistic medical care at time of disaster. • Increase awareness of signs of burnout/compassion fatigue and approaches to self-care.

3. Definition of Disaster: Disasters, irrespective of cause, share several features: • Sudden and unexpected occurrence, demanding prompt action; • Material or natural damage making access to the survivors difficult and/or dangerous; • Adverse effects on health due to potential injury, pollution, and the risks of epidemics, and emotional and psychological factors; • A context of insecurity requiring police or military measures to maintain order; • Media coverage. They can be natural or man-made, or both.

4. Disaster Behavioral Health Disaster behavioral health intervention: • Is directed towards normal stress responses to an abnormal event. • Outreach, crisis counseling, and provider support activities are the core of disaster behavioral health activities. • Behavioral health professionals work hand in hand with paraprofessionals, volunteers, providers, community leaders, and survivors of the disaster in ways that likely differ from their formal clinical training.

5. Challenges for Disaster Medicine and Behavioral Health

6. Environmental Issues

7. Transportation may be challenging

8. Practice Zones: Katrina

9. Safety and Security

10. Safe and Clean Food and Water

11. Disaster Behavioral Health in the Field: Myths and Facts Myth: Psychologists and other mental health professionals are too “touchy-feely” and out of touch with the here-and-now needs of the medical team.

12. Disaster Behavioral Health Fact: Experienced Disaster Behavioral Health Providers can be a key member of the medical response team – assisting with management of medical needs such as pain management, sleep hygiene, stress management. (Behavioral Health: Holding hands…and holding hammer….)

13. Disaster Behavioral Health: • Myth: Disaster Behavioral Health should practice away from the medical team – have a table set up somewhere…we’ll just send the people who seem unstable that direction, so they don’t interfere with our medical care.

14. Disaster Behavioral Health • Fact: This approach is often ineffective. • Stigma….no one wants to be seen at an area set aside and labeled “mental health”. Most will walk away after you refer them. • Inefficient – many psychological symptoms are shown somatically, and behavioral health does not know what the physician has ruled in or out – so people are sent back and forth, wasting time. (Behavioral Health team in Haiti comforts each other because no one else wants to be seen there beneath the label….)

15. New ApproachDisaster Behavioral Health -Integration with the Team • Acute stage: Meeting needs of patient, family, and/or providers • Pain management: deep breathing, relaxation • Stress management/provider Support: • Being aware of when mental health status is at a crisis level • Post-op emotional care

16. Behavioral Heath: The “New Normal”… Moving Forward. • Survivor and Provider Education • It helps people to have their stress-related experiences “normalized”, so that they do not misunderstand their normal feelings as being a sign of medical or psychological illness. “A normal reaction to an abnormal event…..”

17. A word about asking people to tell their story • You must ask yourself, what is your need to know? • Your question can lead to increased traumatization and stress…..even suicidality for some. • Case Example: The woman who learned to hate disaster medical workers

18. Who is Carrying Who ?

19. Key Concepts: Disaster Behavioral Health • No one who sees a disaster or works with challenging patients is untouched by it (and yes, that includes you!) • Stress and Grief reactions are very commons(PTSD is not very common). • Most people do not see themselves as needing behavioral health, and will not ask for it – but they do often respond to when assistance is provided in the context of other services. 4. Thus Disaster Behavioral Health assistance is often more “Practical” than “Psychological”” Source http://www.disastermh.nebraska.edu/state_plan/Appendix%20D.pdf

20. What IS Normal for Anyone Impacted?Behavioral and Emotional Responses/Symptoms • Anxiety, fear • Grief, guilt, self-doubt, sadness • Irritability, anger, resentment, increased conflicts with friends/family • Feeling overwhelmed, hopeless, despair, depressed • Anticipation of harm to self or others; isolation or social withdrawal

21. What IS Normal?Behavioral and Emotional Responses & Symptoms

22. What IS Normal?Cognitive Responses/Symptoms • Memory loss, Anomia • Calculation difficulties; Decision making difficulties • Confusion in general and/or confusing trivial with major issues • The latter issue can be very common amongst providers, particularly in acute situations. • Concentration problems/distractibility • Reduced attention span and/or preoccupation with disaster • Recurring dreams or nightmares

23. What IS Normal?Physiological Responses/Symptoms • Fatigue • Nausea • Fine motor tremors • Tics • Paresthesia • Profuse Sweating • Dizziness • GI Upset • Heart Palpitations • Choking or smothering sensation

24. Mis-Attribution of Normal Arousal:

25. Behavioral Health: Why Should You Care? During work in a highly stressed setting after disaster, you might see or experience…. • Patients who just don’t seem to want to believe you when you tell them that nothing (or very little) is wrong physically – and they keep on wanting to take up your time? • Constantly being interrupted by loved ones of patients who keep asking the same questions, again and again? • Arguments and/or “unreasonable” behavior between members of your team? • Episodes of pronounced irritability? • A strong desire to drink heavily and/or curl up in your tent/sleeping area and not come out for a while? • A decision to divorce your spouse, leave your practice and turn your life over to volunteering/working at a NGO – just as soon as you get home? Then someone likely would be able to benefit from consultation with Behavioral Health.

26. Compassion Fatigue and Burnout: Stress Response in Daily Practice In essence, Compassion Fatigue is “…a gradual lessening of compassion over time, brought on by an exposure to trauma on a regular basis.” --Boyle (2011) as cited by Markaki, 2014. Burnout: Similar to compassion fatigue, but more related to work-place stressors. • Often associated with more anger and frustration, negativity; cynicism.

27. Compassion Fatigue and Burnout • Often studied in physicians working in ER, ICU, oncology, for example. • But also found across medical practice: • Residents working primarily night shifts and those working more than 80 hours per week appear to be at high risk of developing compassion fatigue. Residents with children are more likely to experience secondary traumatic stress. (Bellolio et al., 2014)

28. Compassion Fatigue & Burnout • Can contribute to: • Decreased productivity + avoidance of challenging pts. • Poor focus • Increased likelihood of medical and documentation errors • Feelings of incompetency and self-doubt • Increased negativity towards patients/colleagues

29. Warning Signs of a Need to Seek Help Persistent (Sustained) Stress Reactions: • Abuse of alcohol/drugs • Med-seeking • Vague somatic complaints with no apparent physical basis • Suicidal thoughts • Phobic avoidance of reminders, • Out of the ordinary level of grief, • Frequent episodes of intense anger, • Severe sleep disruption or frequent nightmares, • Severe and ongoing anxiety, clinical depression, • Severe distressing intrusive thoughts. • Inability to leave work at work

30. How to minimize your crisis!From CDC: Disaster Mental Health for Responders: Key Principles, Issues and Questions Things you can do to help maintain your own mental, emotional, physical, spiritual balance. • Management of workload • Set task priority levels and create a realistic work plan • Delegate existing workload when needed • Balanced Lifestyle • Exercise and stretch muscles when possible • Eat nutritionally, avoid junk food, caffeine, alcohol, tobacco • Obtain adequate sleep and rest • Maintain contact and connection with primary social supports

31. Minimizing your crisis! • Stress Reduction Strategies • Reduce physical tension by deep breathing, meditating, prayer, walking • Use time off for exercise, reading, listening to music, taking a bath • Talk about emotions & reactions with coworkers at appropriate times • Self-Awareness • Recognize and heed early warning signs for stress reactions • Accept that one may not be able to self-assess problematic reactions –use a buddy • Be careful not to identify too much with survivors/victims’ grief and trauma • Avoid making life-changing decisions for at least 4-6 weeks post-disaster (longer if stress is ongoing.) • Be vigilant not to develop vicarious traumatization or compassion fatigue • Recognize when own disaster experience interferes with effectiveness

32. Don’t forget – even the strongest provider can use a warm heart…

33. References • Providing Compassionate Healthcare: Challenges in Policy and Practice. Ed. By S. Shea, R. Wynyard, and C. Lionis., Routledge, (2014) • Bragard, I., Dupuis, G., & Fleet, R. (2014). Quality of work life, burnout, and stress in emergency department physicians: a qualitative review. European Journal of Emergency Medicine. • Markaki, A. (2014). 15 Understanding and protecting against compassion fatigue. Providing Compassionate Healthcare: Challenges in Policy and Practice, 214. • Bellolio, M. Fernanda; Cabrera, Daniel; Sadosty, Annie T; Hess, Erik P; Campbell, Ronna L; Lohse, Christine M; et al.(2014). Compassion Fatigue is Similar in Emergency Medicine Residents Compared to other Medical and Surgical Specialties. Western Journal of Emergency Medicine