Mental Health Response Team Early Interventions to Disaster Nancy Pierce, MSW, LCSW Mental Health Crisis Consultants MHR

1. Mental Health Response TeamEarly Interventions to DisasterNancy Pierce, MSW, LCSWMental Health Crisis ConsultantsMHRT Project Coordinator

2. Traumatic Stress • Threat, horror, loss • Exceeds coping resources • Breaks protective defenses • Severity related to event being unexpected, inescapable, uncontrollable, without meaning • Incongruous, intrusive, distressful, unremitting memories + cognitive/behavioral responses • May result in development of stress disorders: • ASD = Acute Stress Disorder • PTSD = Post traumatic Stress Disorder

3. Traumatic Stress Theory • PTSD is not a normal stress response • Trauma event may not be the sole cause of post-traumatic stress symptoms • ‘Stress response’ is not a sufficient cause of traumatic stress disorders therefore… • Efforts to reduce stress alone are not sufficient to prevent stress disorders (ASD, PTSD)

4. Prevalence/Prevention of PTSD • Prevention of PTSD focuses on • Traumatic experience and/or • Cognitive/behavioral response to trauma • Not the level of stress experienced • Majority require no treatment • Focus on resilience vs. reactions • ID risk and protective/resilience factors • Prevalence of PTSD is much lower than prevalence of trauma

5. Current Best Practices • Support rather than supplant established internal and external resources • Build resilience and protective factors • “Watchful waiting” • Careful, conservative referrals • Many tools, no prescriptions

6. Post-Trauma Distress • Immediate reactions to traumatic events can look like stress disorder • Most reactions fade away over time, less frequent, less intense • Humans beings are equipped to have negative experiences, can learn and grow from them and not be debilitated

7. Common Reactions to Trauma • Re-experiencing trauma (cues and triggers) • Flashbacks • Unwanted thoughts • Nightmares • Avoidance • Reminders of event • Talking or having feelings, memories • Increased arousal • Hyper-vigilance, ↑ startle response • Impatience, irritability/anger

8. Common Reactions to Trauma • Fear and anxiety • Guilt and shame • Grief and depression • ↓ Intimacy and trust • ↑ Use of alcohol and other substances • Self-image/world view can become negative • Symptoms of trauma = adaptations to traumatic event in effort to protect self, our beliefs and how we find meaning

9. Risk Factors for Stress Disorders • Already suffering from anxiety and mood disorders, mental illness, substance abuse • Proneness to experience irritability, depression, anxiety • Cognitive style/ability or disability • Prior trauma/abuse or neglect • Family instability • Poor/unstable social supports • Not engaged with community

10. Protective Factors • Resilience, psychological hardiness • Cognitive and emotional stability/ability • Positive competent social supports • Functional family/home life/role models • Involved in community and/or school • Self-control, mood management, effective coping, problem solving • Spirituality or religion • Ability to ask, accept and use help

11. What is Normal? • Changes after trauma are normal • Major trauma may produce severe problems in immediate aftermath • Many feel better within 3 months after event • Others recover more slowly/some don’t recover without help • Becoming more aware of changes since trauma may be the first step toward recovery

12. Many Traumatized Victims… • Don’t believe they need help • Won’t seek out services despite emotional distress • Report “better off” than others less affected • Believe help = sign of weakness • Prefer to seek informal support from friends and family • More likely to accept help with “problems in living” than accept mental health counseling

13. Crisis Response to Communities • Practical field application of crisis intervention to help persons learn to cope with extreme stresses they may face in aftermath • Objectives to “prevent PTSD,” or “return to pre-disaster functioning” have been modified since there is no clear evidence as to what early interventions help or work • Still victims of disasters hope they will return to their pre-disaster functioning

14. Trauma Recovery/Resilience

15. Processing Trauma Experience • Integration of trauma recollections takes time, repetition and support • Allow time for the natural recovery process to occur intermittently and in small doses • Use avoidant behaviors as natural way to tolerate trauma • Educate family/friends how to be empathic, patient listeners • ID and accept help/support from family, friends, community structures like neighbors, churches, schools, support groups

16. Resilience • Different from recovery or adjustment • Capacity to maintain normal functioning despite adversity • Successful operation of “basic human adaptational systems” • Ability to bounce back from crisis • Persevere through difficult times

17. Resilience Factors/Examples • Psychological hardiness: • Confidence, commitment to find meaning in life • Belief in benefits from good and bad experiences • Shift locus of control from external to internal • Cognitive flexibility and acceptance • Able to flexibly shift expectations and priorities • Active coping style problem solving and managing emotions • Engage in physical exercise for mood & health • Meaning in religion, spirituality, benevolence • Positive social support/resilient role models

18. Promoting Resiliency • Resiliency more common than we think with uncommon ways to promote it • Over-optimism about oneself • Repressing/avoiding unpleasant thoughts emotions • Moving forward as a necessary life task • Use of humor and positive emotions • Flexible problem-solving, learning to face fears • Resilience is about people reaching out and helping each other (altruism)

19. What Does Help? • Focus on practical issues and needs • Give accurate, simple info about plans/events • Help without intruding or forcing interventions when victims aren’t ready or able to use them • Recognize the need for passage of time after survival is ensured when people have emotional stability/strength to face what was lost • Explore risk and protective factors • Discuss self-care and strategies to reduce anxiety like grounding and relaxation techniques

20. What Can We Do? • Provide active yet calming presence to ID signs of distress and immediate needs • Bear witness/be present to provide “emotional ballast”/balance and provide advocacy • Actively listen, empathize, normalize/reassure to help make sense and find meaning • Assist in “resiliency building” by modeling positive coping skills & effective problem solving

21. ID Vulnerable Persons • Needs may be more complex or intense • May exceed traditional services provided • Increased susceptibility due to needs & disability • Can’t access and use standard support resources in relief/recovery • Higher risk during traumatic chaos, needing assistance and services tailored to their needs • ID persons with special needs: current or past trauma, behavioral or emotional disorders, impulsive risk behaviors

22. Children • Dependent on adults for security • Lack authority/ability to control environment • Underreport due to difficulty verbalizing trauma experience or downplay feelings • Nonverbal signs of distress are mistaken for other disorders • Traumatic effects more damaging to still-developing/malleable minds and alter path of child’s development • Developmental stage in which trauma occurs may help predict impact on child

23. Children and Trauma • Children and adolescents are affected by how adults closest to them conduct themselves • Children thrive on consistency, routines and rituals so restore familiar childhood activities • Encourage expression of thoughts and feelings by talking/explaining what happened • Protect children from overexposure to graphic/disturbing images, but provide factual info in simple and direct language • Parents should be encouraged to provide social support and keep families united

24. What Children Need • If disoriented/shock, needs 1:1 support with protective adult, parent/family • Physical comforts • Cuddle toys • Blankets for warmth and “nesting” • Snacks for nurturance • Repeated concrete explanations about what happened, what is going to happen • Repeated assurances they are safe/secure • Access to materials to play, draw, familiar play activities • Opportunities to talk

25. Help Children Grieve • Advice on loss and death depends on culture, religious faith and beliefs of survivors • Children often mirror parents’ responses • Depends on age and maturity of child • Keep it short, simple and accurate • Use patient listening, don’t force talking • It helps to make it safe for child to grieve losses, to know they are not alone in their grief • Include children in recovery efforts preparing and planning for future

26. Educate Parents to Help Children • Parents most concerned about children who are vulnerable • Parents usually best helpers for children • Parents feel helped when they are taught how to help their children • Parents feel empowered when workers consult and advise parents on how to help

27. How Parents Can Help • Model calmness and control • Reassure child they are safe • Reassure trustworthy people in charge • Let child know okay to feel upset/angry • Observe child’s behaviors • Changes in sleep, appetite, etc • Tell the truth • Stick to the facts • Keep explanations age-appropriate • Keep explanations brief and simple for young • Separate fact from fantasy for older • Be a empathic, patient listener

28. What Parents Can Do • Focus child on next day or two • Make time to talk with child • Stay close to child to reassure and monitor • Limit TV time watching disaster • Maintain normal routine but be flexible • Spend extra time before bedtime • Make sure child is eating, sleeping, being active to ↓ stress • Offer prayers, thinking hopeful thoughts, going to community gatherings, religious services instills sense family being supportive • Find out what school counseling is in place

29. Elderly • Reluctant to ask for help • Need to provide verbal assurance and attention • Loss of independence, not enough time in their lives to rebuild or recreate • Recovery of possessions, make home visits, arrange for companions, provide transportation • Relocation to familiar surroundings • Re-establish family and social contacts • Reduce barriers to accessing resources • Assist in obtaining medical, financial assistance • Re-establish medication regimens

30. People with Serious Mental Illness • Disruption of medications, treatment, routine • May not adapt well to unfamiliar and over-stimulating environment of shelters • Need monitoring of case management teams • Involve family/friends to help with treatment • Don’t typically experience long-term problems

31. People with Physical Disabilities • Feel vulnerable because of ongoing physical problems • Perceptions of lost control and autonomy • Disruption in normal patterns of care or assistance leading to anxiety/stress • Vulnerable to marginalization, isolation

32. Culture Counts! • Cross-cultural differences related to ethnic, religious identity or place of origin: • Variations in meaning • Expression of thoughts, feelings, behaviors • Cross-cultural differences may influence: • Validity of assessment • Response to treatment • Ways of interacting with survivor • Response sensitive to local customs & culture • Use culturally competent assessments and interventions

33. Cultural Competence Checklist • Meanings associated with current disaster and emergency response • Beliefs and practices regarding death, burial, mourning, trauma and healing • Trauma and violence in country of origin/USA • Views about mental health and responders • Cultural courtesy (who to talk to first, who is considered family)

34. Who is at Risk and Why?

35. Disasters & Communities • Disasters and major critical events test functioning of communities • Affect those directly/indirectly impacted and those who come to help • Lives, culture, beliefs may be altered and new coping skills required • Multiple losses related to incident • Think of concentric circles to see broad range of persons involved in disasters

36. Continuities of Life Disrupted • Conducting normal life disrupted by disaster • Functional continuity • How to maintain usual routines, roles • Historical continuity • Lost home, community, place of work, personal objects/memorabilia = loss of ID, sense of history • Interpersonal continuity/social network • Relocation, loss of home/neighborhood • Spiritual continuity • Loss of faith, feeling vulnerably, unable to deal with a world no longer good, safe or predictable

37. ↑ Risk of Mental Health Problems • Severe exposure to disaster • Injury, threat to life, extreme loss • Living in highly disrupted/traumatized community • Female gender, middle years 40-60 • Presence of spouse who is highly distressed • Membership of ethnic minority group • Poverty, low socio-economic status • Presence of children in home • Psychiatric history • Secondary stressors • Weak or diminishing psycho-social resources

38. Pre-Trauma Event • Recognize both capacity for vulnerability and resiliency • ID vulnerable populations with inherent or pre-existing characteristics: • Fragile/prone to anxiety/depressions • Elderly, disabled, refugees, severe mentally ill • AODA, socially/economically disadvantaged, • Family instability, prior history for trauma, parent pathology, middle-age women, children

39. During Trauma Event • Disaster experience: greatest exposure leads to greatest suffering = dose-response relationship • Bereavement/loss, injury may predict more negative outcome • Dissociation/panic may predict worse outcome • Relocation, displacement, separation are especially difficult for youth and elderly

40. Post-Trauma Event • Positive social support = protective factor • Belief they are cared for by others • Negative or losing social support = risk factor • Criticism, blame, impatience, second guessing • Additional or secondary life stressors • Coping: belief in one’s ability to cope more important than specific coping mechanism • Avoidance, extreme denial, blaming are detrimental ways of coping

41. Early InterventionsPsychological First AidPsycho-educationCoping Skills

42. Psychological First Aid (PFA) • Used during earliest stage post-event when survivors need help taking in information or seeing beyond immediate needs • Non-intrusive way of being present for victims • Meets basic needs first, restoring sense of safety, providing comfort and support • Targets any acute stress reactions and immediate needs to help recovery take place • PFA is not about having victims speak about traumatic experience, but willingness to listen to those who choose to share

43. PFA Approach • Empower survivors by acknowledging and supporting strength, competence and courage • Let survivors determine kind of assistance they receive and the pace of self-disclosure • Listen to shared stories which help create order, management and meaning, without leaving them with unmanageable feelings • Help survivors recognize own strengths by asking about past coping, skills they have used successfully in past • Encourage survivors to support and assist others • Give children active role caring for self/sibs

44. PFA Practice Points • Be calm and grounded • Know your limits • Physically available and emotionally present • Normalize by providing acknowledgment and recognition of suffering and strength • Express empathy = enter into their world, bear witness, communicate understanding/respect • Support choice not to self-disclose • Don’t assume all people need or want more help/interventions in the immediate aftermath • PFA is based on belief that most people will recover naturally on their own

45. Create Sense of Safety & Security • Physical security • Give directions of “what to do, where to go” • Food, clothing, shelter • Emotional safety from media, onlookers • Establish “personal space” to preserve privacy • Provide human contact and support • Provide safe place to express emotions • Assist in contacting & reuniting with supports • Help children understand what has happened • Facilitate problem solving by starting small • Provide sense of future and hope

46. Ventilation and Validation • Survivors may want to: • Tell their disaster story • Ventilate feelings and reactions • Be heard and feel validated • MHRT can help with storytelling process • Ask questions to facilitate flow of story telling • Echo key words or phrases to acknowledge • Support and honor silence by waiting for survivor to decide if wants to continue story • Listen and summarize to help survivors develop narrative for event and to find words to describe their reactions • Reassure reactions are acceptable and not uncommon

47. Prediction and Preparation • Help in predicting and preparing for post-disaster possibilities/challenges • Set small, doable goals • Focus on daily planning using simple problem solving techniques • Talk or write about event to bring order to chaotic feelings • Plan time for memories and memorials • Find someone in community to support them • Educate survivors about stress reactions that might occur for them or children

48. Is PFA Effective? • Continues to be a lack of evidence regarding effective early interventions • Appears promising and probably is effective • Less specific intervention geared to be broader, flexible, which uses empathy and collaboration • Allows mental health to be visible and helpful during early phase after disaster • Helps to establish rapport without intruding by supporting the natural recovery process • May lay groundwork for more intensive interventions during recovery phase

49. PFA as Pre-Screening Tool • May serve as a prescreening tool by: • Knowing who and where are vulnerable populations • Targeting resources for them • May help to determine best time for intervention so not too soon or too late • May help survivors accept possible referral for follow up treatment if needed

50. Psycho-Education • Least controversial/most accepted, recommended • Info on: typical reactions/symptoms experienced by survivors; resilience; effective/ineffective coping strategies; loss/grief; ways for parents to help children; treatment resources • Doing outreach, using media, flyers, websites, established community structures like churches, schools, community centers • Goal to let survivors know what they might experience without alarming them or causing them to anticipate future distress