Disaster Behavioral
Health
Randal Beaton, PhD, EMT
Tools and Resources
for Idaho
Emergency Responders
Southwest
District
3
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Randal Beaton, PhD, EMT
Research Professor
Schools of Nursing
and Public Health and
Community Medicine
Faculty
Northwest Center for
Public Health Practice
University of Washington
Relevant Clinical Experience
• Volunteer EMT
• Counseled victims of 9/11 who lost
co-workers
• “Psychological casualties” of Nisqually
earthquake (2001)
• Stress management for First Responders
– mostly firefighters and paramedics – in
private practice
“You can observe a lot by watching”*
*Berra, 1998
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 UW
School of Nursing Disaster Plan – 2002
NMDS drill (May 13, 2004)
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.
Tsunami Disaster
Photo by Dr. Mark Oberle, Phuket, Thailand
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.
Tsunami Disaster Victims
Photo by Dr. Mark Oberle in Phuket
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
Disaster Cycle
There are a number of distinct
conceptual stages in the disaster cycle:
Pre-event warning
threat stage
Preparedness
Planning
Disaster
Cycle
Evaluation
Recovery
Impact/Response
NMDS drill (May 13, 2004)
Disaster Behavioral Health
Disaster behavioral health interventions differ
from traditional behavioral health practice by:
• Addressing Incident-specific, stress reactions
• Providing outreach and
crisis counseling to victims,
both immediate and long-term
• Working hand-in-hand with paraprofessionals,
volunteers, community leaders, and survivors of
the disaster
Source : http://www.disastermh.nebraska.edu/state_plan/Appendix%20D.pdf
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
Questions
Disaster Behavioral Health
Randal Beaton, PhD, EMT
Modules 1-4
Learner Objectives: Modules 1 - 4
•
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
Module 1: Psychosocial Phases of a Disaster
*
* From Zunin & Myers (2000)
Implications/Tasks of each Phase for Disaster
Personnel - Pre-disaster
• Warning – e.g. weather forecast
• Educate
• Inform
• Instruct
• Evacuate or “stay put”
Pre-Disaster
• Threat, e.g., impending terrorist activity
• Risk communication: To reduce anxiety,
must also tell people what they should do
(without jargon)
TopOff 2 – Seattle, May 2003
Impact
• Prepare for surge
• Advise/instruct/give directions
• Risk Communication update
• Leadership
Heroic
Disaster survivors are true
“First Responders”
Honeymoon (community cohesion)
• Survivors may be elated and
happy just to be alive
• Realize this phase will not last
Disillusionment
• Reality of disaster “hits home”
• Provide assistance for the distressed
• Referrals to disaster mental health
professionals
Inventory
Psychological community needs
assessment
– Short-term
– Mid-range
– Downstream needs
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
Reconstruction (“a new beginning”)
Still, even following recovery, disaster
victims may be less able to cope with next
disaster
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.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc
Behavioral Health Tasks, by Phase, Continued
Disillusionment
Inventory
Working through
Grief
Reconstruction
“Assistance” for
distressed
Psychosocial
needs
assessment,
short-term,
mid-range, and
down-stream
needs“
Psychotherapy
and/or medications
Psychoeducational
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.
Available at:
http://www.son.washington.edu/portals/bioterror/Table%201%20ID%20Needs%20assessment.doc
Module 2: Temporal Patterns of
Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
100
90
80
Disruptions
70
60
Resilience
50
40
30
20
10
0
Event
2 Years
Resilience
• Differs from recovery
• Individuals “thrive”
• Relatively stable trajectory
Module 2: Temporal Patterns of
Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
100
90
80
Disruptions
70
60
Acute/Recovery
50
40
30
20
10
0
Event
2 Years
Acute Distress and Recovery
Post-disaster recovery usually occurs within:
– Days
– Weeks
– A few months
Module 2: Temporal Patterns of
Mental/Behavioral Responses to Disaster
Adapted From Bonanno (2004)
100
90
80
Disruptions
70
60
Acute/Chronic
50
40
30
20
10
0
Event
2 Years
Chronic Distress
Acute/Chronic Distress and/or Lasting
Maladaptive Health Behavior Outcomes
Module 2: Temporal Patterns of
Mental/Behavioral Responses to Disaster
Delayed Onset Distress
Adapted From Bonanno (2004)
100
90
80
Disruptions
70
60
Delayed
50
40
30
20
10
0
Event
2 Years
For more information:
Coping With a Traumatic Event
CDC Publication
Available at:
http://www.bt.cdc.gov/masstrauma/copingpub.asp
Module 3: Resilience
Definition:
The ability to maintain relatively stable
physical and psychological functioning
(not the same as recovery)
Module 3: Resilience (continued)
Risk Factors
Risk factors that deter resilience:
•
•
•
•
Job loss and economic hardship
Loss of sense of safety
Loss of sense of control
Loss of symbolic or community structure
Ways to Promote Community Resilience in
the Aftermath of Disaster
• Reunite family members
• Engage churches and pastoral community
• Ask teachers, community leaders and
authorities to “reach out”
Environmental Factors That Promote
Community Resilience
• Availability of social resources
• Community cohesion
• Sense of connectedness
Individual Characteristics Associated with
Resilience
• Positive temperament
• Ability to communicate
• Problem-solving and problem-focused vs.
emotion-based coping
• Positive self-concept
• Learned helpfulness vs. hopelessness
How Can First Responders and First
Receivers Cope?
Can emotional coping skills to deal with
emergent disasters be taught?
Doubtful, but some hints:
– Stay focused on duties – out focused
– Stay professional; maintain “professional
boundaries”
– Sort out family/roles/conflicts ahead of time
How can First Responders and First
Receivers cope? (continued)
– Drill, drill, drill – automatic, over-learned
responses can be recalled under stress, also
instills confidence
– Self-talk – I will survive versus
catastrophizing
– Importance of social support – especially in
aftermath
Pathways to Resilience
• Denial/avoidance
• Useful illusions/distortions
• Disclosure – helpful for some
For more information:
APA Fact Sheets on Resilience to Help
People Cope With Terrorism and Other
Disasters
Available at:
http://www.apa.org/psychologists/resilience.html
accessed 01/24/05
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
TopOff 2 – Seattle, May 2003
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
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
Signs and Symptoms, continued
• Domestic violence, child or elder abuse
• Family members feel their loved ones are
acting in uncharacteristic ways
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
Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 5
Learning Objective: Module 5
•To identify the behavioral health risks of
disaster workers including First Responders
Module 5
Mental health risks of disaster workers
including EMS and rescue personnel –
secondary traumatization
Disaster Incident Scenes are
Chaotic and Stressful
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-18OHO3559 from the National Institute for
Occupational Safety and Health of the Centers
for Disease Control
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.
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
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
Impact of Events Total Score
.6
.5
.4
.3
.2
.1
0.0
-.1
N=
24
52
Day Before
93
21
1wk Af ter
1-2days After
1 mth Af ter
2wk Af ter
Time w/ reference to 9/11/01
Beaton et al, J. Traumatology, 2004
54
Prevalence of PTSD in Rescue Workers and
Veteran Samples
Community Male (Canada, 1990's)
Crime Victims (US 1980's)
Vietnam Era Vets Overall
Iraq Combat Veterans (2004)
Canadian Fire Fighters
Wounded Combat Vietnam Vets
9/11 Rescue Workers
British Ambulance Drivers
US Urban Fire Fighters and Paramedics
0%
Corneil et al, 1999
5%
10%
15%
20%
25%
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
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
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
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
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
Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 7
Learner Objectives: Module 7
To describe Critical Incident Stress
Management (CISM) and the Critical
Incident Stress Debriefing (CISD) process
and to evaluate the associated benefits
and risks
Module 7:
• What are CISM and CISD?
– Critical Incident Stress Management
– Critical Incident Stress Debriefing
• What are the risks and benefits?
Module 7: Critical Incident Stress
Management (CISM)
• A multipart program that works to
decrease the effects of Critical Incident
Stress such as that stemming from a
disaster
• CISM’s strength is attributable to its
emergency service peer-driven process
that is monitored by mental health
professionals: Peers and mental health
professionals are cross-trained
Module 7: Critical Incident Stress
Management (CISM) (continued)
• Goals in CISM are to restore the health
and environment of the individuals
• To deter traumatic stress effects
• To speed recovery and productivity
• An important feature is helping the
individual recognize that the danger has
passed and that the need to react also
has passed
Module 7: CISM Teams
• More than 350 CISM teams exist in the
US
• More than 400 exist worldwide
• Teams have many functions within the
CISM process
Module 7: CISM Functions (continued)
Scene support and staff advisement
– The team functions within the incident
command structure, and its members are
present in a primarily supportive and advisory
role. Their activity is emotional first aid,
allowing for venting of feelings.
Module 7: CISM Functions (continued)
Demobilization
– Demobilization occurs rarely and is reserved
for only very large disaster events. An
arranged site allows all units to rotate through
before they return to their stations for postoperation procedures.
Module 7: CISM Functions (continued)
Defusing
– Next to education, the most commonly
employed CISM technique is defusing.
Defusing usually is a 1-on-1 interaction
between a team member and a concerned
individual
– During defusing, the emergency worker
receives education about recognition of stress
reactions and management strategies for
dealing with stress.
Module 7: CISM Functions (continued)
Debriefing
– Debriefing is a complex process led by
specially trained personnel and typically
occurs 2-14 days after the event
– Debriefing takes approximately 2-3 hours
– This peer-driven process focuses on
psychological and emotional aspects of the
event
Module 7: CISM Functions (continued)
Benefits
– Individuals are made to feel their organization
cares about them
– Helps some individuals to vent
– May help to screen for psychological
problems
Module 7: CISM Functions (continued)
Risks
– Some individuals may be overwhelmed and
“sensitized” by debriefing
– May be presented as something that will
prevent PTSD – evidence is lacking
For More Information:
Critical Incident Stress Management
Stephen A Pulley, DO
http://www.emedicine.com/emerg/topic826.htm
Disaster Behavioral Health
Randal Beaton, PhD, EMT
Module 18
Learner Objectives: Module 18
To identify some of the unexplained physical
symptoms (MUPS) observed in disaster
survivors and their implications for disaster
response/recovery
MUPS
Multiple Unexplained Physical Symptoms
(MUPS) in the Aftermath of Trauma and
Disaster
The “Worried Well”
• May develop physical symptoms such as
rashes, fatigue, etc.
• May pursue treatment
• May compete for scarce resources with
other disaster victims
Planning for “Worried Well”
• Hospitals and health departments need to
plan for “worried well” who :
– Are actually “not well”
– May develop signs of actual exposure later
(either chemical, bio- and/or radiologic
– Need guidance and understanding (at the
very least)
“Masked PTSD”
Disaster Survivors may develop “masked
PTSD” in which physical stress symptoms
predominate
Source: Beaton, et al, (2005) in press – Sarin
gas 10 years later
http://www.son.washington.edu/portals/bioterror/LinkstoFacultyPub.asp