Crisis Intervention

1. Crisis Intervention José A. Capriles Quirós, MD, MPH, MHSA Professor, UPR Center for Public Health Preparedness

2. A NEW AWARENESS

3. “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

4. Victims Children & parents Victims’ families Emergency responders Vulnerable people Entire population Target Population Ecological Model

5. Vulnerable Populations Predictors 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 IllnessYehuda 2002

6. Vulnerable Populations continued Predictors of psychological distress post terrorist event: Prior exposure to violence and trauma (Veterans) Hoven 2002 Hispanics and other immigrant populations, including refugeesGalea 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

8. 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)

9. 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 • Crisisplanning must be collaborative

10. 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

11. Helping and healing communities

12. 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 Attacks Fall 2001 Anthrax Attacks 1995 Oklahoma City Bombing

13. 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.

14. 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.

15. 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

16. 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”)

17. 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

18. Madrid March 11, 2004

19. Madrid March 11, 2004

20. Disaster stages Before Preparedness

21. Disaster stages Before Preparedness During Acute/ Intermediate

22. Immediate Reactions • Disbelief • Disorientation • Fear • Feeling time is slowed down • Feeling numb or disconnected • Feeling helpless or irrationally failing to avoid danger

23. Disaster stages Before Preparedness During Acute/ Intermediate After Recovery

24. 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

25. 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

26. 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

27. 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

28. 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

29. Major DisasterPhases of Behavioral Health Response Timeline Acute phase Days 1-2 Rapid deployment teams provide immediate crisis intervention, State employees form core of response

30. Major DisasterPhases of Behavioral Health Response Timeline Acute phase Intermediate phase Days 1-2 Rapid deployment teams provide immediate crisis intervention, State employees form core of response Days 3-14 Teams expand to include volunteers from community-based behavioral health agencies

31. Major DisasterPhases of Behavioral Health Response Timeline Acute phase Recovery phase Intermediate phase Days 1-2 Rapid deployment teams provide immediate crisis intervention, DMHAS and DCF employees form core of response Days 3-14 Teams expand to include volunteers from community-based behavioral health agencies Day 14+ FEMA declaration Services provided by contracted agencies, teams phase-out operations

32. 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

33. 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

34. Crisis Response Public Safety

35. Crisis Response Public Safety Public Health

36. Crisis Response Public Safety Public Health Behavioral Health

37. Crisis Management Model Crisis intervention (caring for people during the crisis) Short term relief in order to prevent collapsing of persons or systems Crisis prevention (caring for people before the crisis) Caring for people after the crisis (support long-term healing) Long term planning of prevention; optimizing crisis management Support short- to long-term copings, preventing secondary symptoms developed by A. Englbrecht & R. Storath, graphics: C. Enders

38. Functions to Protect and Respond to Public Psychological Health • Basic resources – food, shelter, communication, transportation, and medical services • Interventions and programs to promote individual and community resilience • Surveillance for psychological consequences • Screening criteria for individuals • Treatment for acute and long-term effects of the trauma

39. Functions to Protect and Respond to Public Psychological Health • Human Services - contribute to psychological functioning, reuniting families, child care, housing, job assistance • Risk Communication, dissemination of information • Training of service providers to respond. Prepare and protect them against psychological trauma • Capacity to handle large increase in demand for services - “Surge Capacity” • Case finding to locate individuals who need MH services but are not utilizing conventional means; including the underserved, marginalized, and unrecognized groups of people

40. 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

41. 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

42. It’s All About Relationships Interagency 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

43. Crisis Intervention and Terrorism Summary Public Health Level of Intervention SOCIETAL COMMUNITY NEIGHBORHOOD FAMILY INDIVIDUAL Public Policy Public Safety Public Education Service Coordination Capacity Building Training/Education Family Self-Help Networks Family Education Clinical Treatment Traditional Healing Types of Intervention Green et al, in press