Disaster Behavioral Health
Texas Department of State Health Services
Disaster Behavioral Health Services
Joy Counce
joy.counce@dshs.state.tx.us
1
What do you expect to learn from this
training?
2
Training Objectives
After this training you will be able to:
• Define Disaster Behavioral Health (DBH)
and list the 8 key concepts of DBH
• Identify 6 Psychological Phases of Disaster
• Identify 6 Stressors of Crisis Response
Workers
• Identify 10 ways to manage stress during
and after a disaster
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Definition of Disaster (1)
A disaster is a natural or human-caused
occurrence (e.g., hurricane, tornado, flood,
tsunami, earthquake, explosion, hazardous
materials accident, mass criminal victimization
incident, war, transportation accident, fire, terrorist
attack, famine, epidemic) that causes human
suffering.
A disaster creates a collective need that
overwhelms local resources and requires
additional assistance.
Adapted from the Center for Mental Health Services (CMHS) 2000.
4
Definition of Disaster (2)
A disaster is any natural catastrophe (e.g., tornado,
hurricane, storm, high water, wind-driven water, tidal
wave, tsunami, earthquake, volcanic eruption, landslide,
mudslide, snowstorm, drought) or, regardless of cause,
any fire, flood, or explosion in any part of the United
States that in the determination of the President causes
sufficient severity and magnitude to warrant major disaster
assistance under the Robert T. Stafford Disaster Relief
and Emergency Assistance Act of 1974 (Stafford Act).
Robert T. Stafford Disaster Relief and Emergency Assistance Act (1974).
5
Characteristics and Repercussions
of a
Disaster
Natural
Human
Caused
Natural
vs. Human
Caused
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Earthquakes, fires, hurricanes,
floods, tornadoes
Airplane crashes, chemical leaks,
mass violence, terrorism
No one to blame
People, governments, or
businesses to blame
Beyond human control
Seen as preventable and a
betrayal by fellow humans
Advance warning is possible
No advance warning
Post-disaster distress is high and
felt mainly by survivors
Post-disaster stress is often higher
than that of natural disasters and
felt by more people not directly
affected
In September 2008, Hurricane Ike, covering over half of
Cuba, makes its way west to Texas (NASA Satellite)
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Definition of Disaster Behavioral
Health (DBH)
http://www.phe.gov/Preparedness/planning/abc/Pages/behavioralhealth.aspx
• Disaster behavioral health is the provision
of mental health, substance abuse, and
stress management to disaster survivors
and responders.
• U.S. Department of Health and Human Services Office of the Assistant Secretary for
Preparedness and Response
8
What is DBH?
www.disastermh.nebraska.edu/files-Appendix-D.pdf
• Disaster behavioral health is a departure
from traditional behavioral health practice in
many ways.
• Disaster behavioral health interventions are
designed to address incident specific stress
reactions, rather than ongoing or
developmental behavioral health needs.
9
What is DBH? (cont.)
• Outreach and crisis counseling activities are
the core of disaster behavioral health
services.
• Behavioral health professionals work handin-hand with paraprofessionals, volunteers,
community leaders, and survivors of the
disaster in ways that may differ from their
formal clinical training.
10
What is DBH? (cont.)
• The primary goal is to decrease the stress of
an event and mitigate future problems
• Modalities may include Psychological First
Aid, Spiritual Care, Substance Abuse
services, Critical Incident Stress
Management (CISM), Crisis Counseling, or
other crisis intervention and disaster specific
support services
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What is DBH? (cont.)
•
•
•
•
•
Community based
Focus on strengths & coping skills
Restore functioning
Confirms reactions are common/normal
Focus is educational
12
Concepts of Disaster Behavioral
Health
Adapted from: DeWolfe, D. Field Manual for Mental Health and Human Service Workers in
Major Disasters. DHHS Publication No. ADM 90-537, Washington, D.C.: U.S. Government
Printing Office.
1. No one who sees a disaster is untouched by it
2. There are 2 types of disaster trauma – individual
and community
3. Most people pull together and function after a
disaster but their effectiveness is diminished
4. Stress and grief are common reactions to an
abnormal situation
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Concepts of Disaster Behavioral
Health
5. Reactions often relate to survival and recovery
issues
6. People do not seek out mental health services
7. Survivors may reject disaster assistance of all types
8. Mental health assistance is often more practical
than psychological in nature
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Preferred training/experience for disaster
behavioral health responders
15
Preferred training/experience
• ICS (100, 200, 700, 800) (Free on-line through
FEMA)
• Psychological First Aid, Crisis Intervention,
Pastoral Counseling, CISM, or some other Early
Psychological Intervention
• Ability to travel and work under adverse
conditions
• Experience working with survivors of disasters
and/or critical incidents or events
• Specialized training: children and adolescents,
cultural diversity, geriatric populations, victims of
crime, grief and loss, special needs populations,
death notifications, etc.
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Possible DBH Outreach Locations
•
•
•
•
•
•
•
Disaster Recovery Center (DRC)
Incident Command Post (ICP)
Points of Distribution (POD)
Mass Care Shelter
Joint Field Office (JFO)
Disaster District Committee (DDC)
Regional Medical Operations Center
(RMOC)
• Family Assistance Center (FAC)
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Phases of Disaster
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Phases of Disaster
Honeymoon
Emotional Highs
(Community Cohesion)
Reconstruction
“Heroic”
A New
Beginning
Pre-disaster
Disillusionment
Warning
Threat
Impact
Inventory
Trigger Events and Anniversary
Reactions
1 to 3 Days -------------------TIME-------------------------------1 to 3 Years
Zunin/Meyers
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6 Psychological Phases of Disaster
•
•
•
•
•
•
Pre-disaster Phase
Impact Phase
Heroic Phase
Honeymoon Phase
Disillusionment Phase
Reconstruction Phase
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Pre-Disaster Phase
Disasters with no warning
• Feelings of vulnerability
• Lack of security
• Fears about the future
• Loss of control
• Inability to protect self and family
Disasters with warning
• Guilt and self-blame for failure to heed warning
21
22
Impact Phase
Usually the shortest phase
Reactions vary dependent on length and type of disaster
• Range of intense emotional reactions from
shock to overt panic
• Fear and isolation
• Anxiety
• Stunned and disorganized
• Confusion and disbelief
• Self preservation
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Impact Phase Needs
• Explanation of incident
• Safety/security
• Basic physical needs (Maslow’s
Hierarchy of Need)
• Support/caring
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25
Inventory
•
•
•
•
•
•
Immediate assessment of damage
Overwhelmed by disaster
Attempt to locate and assist survivors
Initial discovery of non-survivors
Inability to locate loved ones
High need for information
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Heroic Phase
• Evacuation and relocation has
psychological significance
• Family separation
• High level of activity with low level of
productivity
• Adrenaline-induced rescue behavior
• Risk assessment may be impaired
27
28
Honeymoon Phase
Usually only lasts a few weeks
•
•
•
•
Disaster assistance readily available
Community bonding occurs
Optimism exists
Opportunity to build rapport and
relationships between providers,
resources, affected people, and
stakeholders
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Disillusionment Phase
• Stress and fatigue take a toll
• Optimism turns to discouragement
• May have an increased need for substance
abuse services
• Larger community returns to business as
usual
• Reality of losses sets in
• Diminishing assistance leads to feelings of
abandonment
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Reconstruction Phase
• Long-term process of rebuilding (1-3 years)
•
•
•
•
Ongoing struggles with agencies
Stress of temporary housing/finances
Requires committed community support
Adjustment to new circumstances/the new normal
while possibly still grieving
• Good news: most people rebuild and discover new
meaning
31
Psychological Consequences of a
Disaster
For Example:
 Change in travel
patterns
 Smoking
 Alcohol
consumption
For Example:
 Insomnia
 Sense of vulnerability
Distress
Responses
Behavioral
Changes
Psychiatric
Illness
For Example:
 PTSD
 Major depression
From IOM publication “Preparing for the Psychological Consequences of Terrorism”
www.nap.edu
NOTE: Indicative only; not to scale
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Typical Individual Outcome of
Disaster
• Most will return to normal function with no
significant problems
• Some will have severe reactions
• Few will develop diagnosable conditions
• Most do not seek help or treatment
• Survivors often reject help
33
Common Reactions to a Disaster
•
•
•
•
•
•
•
•
Trouble concentrating
Difficulty making decisions
Preoccupation with the disaster
Frequent dreams or nightmares
Increased alcohol/drug use
Feeling depressed, sad, irritable or angry
Tiredness or low energy for no reason
Increase or decrease in appetite
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Disorders that may result from
severe reactions
•
•
•
•
•
•
•
Depressive disorders
Social isolation
Anxiety disorders
Substance Abuse
Posttraumatic Stress Disorder (PTSD)
Suicidal ideation and behavior
Paranoia
35
It is likely that early psychological
intervention (i.e., response
oriented crisis and disaster mental
health intervention) is best thought
of as a means of enhancing
resiliency.
[Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In
Everly & Parker, Mental Health Aspects of Disaster: Public Health
Preparedness and Response. Balto: Johns Hopkins Center for Public Health
Preparedness.
36
ALL Crisis Intervention should be
based upon the Assessment of
NEED…and the further
ASSESSMENT of the most
appropriate intervention.
37
Helpful guidelines…
• Never presume to know what the person is
experiencing.
• Do NOT assume that everyone is
traumatized.
• Do NOT label/diagnose or patronize.
• Do NOT “debrief”.
• DO refer to professional help if out of your
comfort zone or beyond your skill level.
38
Goals of DBH and early
psychological interventions
• To help survivors:
•
•
•
•
•
•
•
•
Understand their situations and reactions
Regain a sense of mastery and control
Identify, label, and express emotions
Adjust to the disaster and losses
Manage stress
Make decisions and take action
Develop coping strategies
Use community resources
39
Characteristics of Early
Psychological Interventions
40
Crisis Counseling
•
•
•
•
•
•
•
•
Engage
Identify immediate needs
Gather information
Prioritize needs
Provide practical assistance
Educate
Provide emotional support
Determine next steps and follow up
41
Psychological First Aid
Core Actions
•
•
•
•
•
•
•
•
Contact and engagement
Safety and comfort
Stabilization
Information gathering: currents needs and
concerns
Practical assistance
Connection with social supports
Information for coping
Linkage with collaborative services
42
Critical Incident Stress Management
(CISM) icisf.org
• A comprehensive, integrative, multicomponent
crisis intervention system that functionally spans
the entire temporal spectrum of a crisis…precrisis, into acute crisis, and into the post-crisis
phase.
• May be applied to individuals, small groups, large
groups, families, organizations, and even
communities.
• Founded in the emergency services professions in
the late 1970s
43
Spiritual Care
source: Nebraska Disaster Chaplain Network
Disaster Spiritual Care: Devoting presence,
attention, and respectful assistance to
helping people discern what is the meaning
in their lives now, in this new environment of
destruction and pain; and how they will seek
to live out that meaning as the recovery
unfolds.
• Foster McCurley, 2003
44
Ethics
(FEMA Crisis Counseling Assistance and Training Program Participant
Workbook: Module 1: Core Content Training, SAMHSA DTAC)
• Maintain confidentiality
• Get a release of information before sharing any
information
• Follow the state and local regulations on
mandatory reporting for child and elder abuse
and neglect
• Follow state and local reporting regulations in
cases of suicidal or homicidal intent
• Safeguard the interests and rights of
individuals who lack decision making abilities
45
Ethics (cont.)
• Ethical Guidelines
• Do no harm
• Participation is voluntary
• Consider reactions in relation to the disaster
phase and context
• Individual coping styles should be respected
• Immediate interventions are supportive
46
Ethics (cont.)
• Talking with a person in crisis does not
always mean talking about the crisis
• Be aware of the situational and cultural
contexts of the survivor and the intervention
itself
47
Typical Stressors for Crisis
Counselors Working a Disaster
• Repeated exposure to traumatic stories
• Exposure to survivors’ reactions to disaster
• Approaching survivors who may reject their
help
• Feeling overwhelmed by the sadness of
others
• Feeling helpless to alleviate the pain of
others
48
Typical Stressors for Crisis
Counselors Working a Disaster
• Staff shortages
• Working long hours
• Away from family and friends for extended
periods of time
• Personal experience with the disaster
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Signs That You May Need Stress
Management Assistance
• Disorientation or confusion and difficulty
communicating thoughts
• Difficulty remembering instructions
• Difficulty maintaining balance
• Becoming easily frustrated and being
uncharacteristically argumentative
• Inability to engage in problem-solving and difficulty
making decisions
50
Signs That You May Need Stress
Management Assistance
• Limited attention span and difficulty
concentrating
• Colds or flu-like symptoms
• Headaches/tremors/nausea
• Loss of objectivity
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Ways to Manage Your Stress
• Drink plenty of water, and eat healthy snacks like
fresh fruit, whole grain breads, and other energy
foods.
• Stay in touch with your family and friends.
• Pair up with another responder so that you may
monitor one another’s stress.
• Take frequent breaks as is practical.
• Do not over identify with survivors.
52
Ways to Manage Your Stress
• Talk out your stress- process your thoughts and
reactions with someone else (coworker, therapist,
clergy, friend, family, supervisor).
• Learn about Compassion Fatigue.
• Build a positive support system that supports you,
not fuels your stress
• Participate in memorials, rituals, and use of
symbols as a way to express feelings.
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Ways to Manage Your Stress
• Take care of yourself: Exercise, Meditate, Get
enough sleep, nutrition.
• Do things outside of work that bring you joy and
fuel your passion(s).
• Find some alone time for yourself, nurture your
spirit.
• Humor…it can help to keep problems in
perspective.
• Use time off to decompress and recharge your
batteries (music, exercise, read, relaxing meal,
movie)
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Top 10…
Things To Do
In Coping with Stress
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#10
Exercise
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#9
Spend Time With Others
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#8
Reach Out To Others
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#7
Stay Calm
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#6
Eat a Healthy Diet
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#5
Do Things That Make You Feel
Good
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#4
Use the Power of Prayer
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#3
Get Plenty of Rest
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#2
Remember, You’re Not
Crazy!
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#1
Talk To Friends
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Resources
• National Child Traumatic Stress Network (free PFA
course)
– http://learn.nctsn.org/
• FEMA (free ICS courses)
– http://training.fema.gov/is/nims.asp
• SAMHSA
– http://www.samhsa.gov/dtac/
• International Critical Incident Stress Foundation
– http://www.icisf.org/
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Resources
• DSHS acronym list
– http://online.dshs.state.tx.us/library/acronym.htm
• TDEM website
– http://www.txdps.state.tx.us/dem/index.htm
• FEMA acronym list
– http://www.fema.gov/plan/prepare/faat.shtm
• Centers for Disease Control
– http://www.bt.cdc.gov/mentalhealth/
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Contact Information
Disaster Behavioral Health Services
909 West 45th Street
Austin, TX 78751-2008
(512) 206-5555
DBHS@dshs.state.tx.us
http://www.dshs.state.tx.us/mhsa-disaster