Consequences of Disaster

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12Managing Mental He..

THE CHALLENGE

• It is generally believed that mass

disasters, but especially terrorism, will

create more psychological casualties

than physical casualties

• (Holloway, et al., 1997, JAMA; DiGiovanni,

1999, Am. J. Psychiatry)


THE NEED

• Goiania, Brazil 1987

• Radiological incident

• 250 exposed, 20 hospitalized, 4 died

• 5,000 psychosomatic symptoms, 0

exposed (20:1 psychological to physical)

• 125,800 requested screening

Peterson, 1988


Fatal Cancer Risk

Baseline (Non-Radiogenic) Fatal Cancer Risk = 25%

Dose

Risk

1 mrem .01 mSv* 5 x 10 -7 .00005%

10 mrem .1 mSv 5 x 10 -6 .0005%

100 mrem 1 mSv 5 x 10 -5 .005%

1 rem 10 mSv 5 x 10 -4 .05%

10 rem .1 Sv 5 x 10 -3 .5%

100 rem 1 Sv 5 x 10 -2 5%

1000 rem 10 Sv 5 x 10 -1 50%

*1 mSv=100 mrem


Disaster Psychology

Overview


The majority of persons exposed to disaster

experience fear and distress at the time of

impact.

Impact of

Disaster

Event

Fear and Distress

Response

Most will not

come to hospitals.


A subset will be distressed to the point

of significant behavior change.

Fear and Distress

Response

Impact of

Disaster

Event

Behavior

Change

Many will seek care

at hospitals.


Only a small subset progress to

psychiatric illness.

Fear and Distress

Response

Impact of

Disaster

Event

Behavior

Change

Psychiatric

Illness

Many will need

care later.


HEROIC PHASE

• Fear, anger, confusion

• Psychological numbing

• Altruistic concerns

• Survival based concerns

• May include disregard for personal safety


HONEYMOON PHASE

• Characterized by outpourings of community

and professional support and assistance

• Symptomatic reactions may begin to be

evident

• May include feeling relieved or euphoric

about surviving


DISILLUSIONMENT PHASE

• Initial sources of support begin to withdraw

(as agencies complete their missions)

• Less media focus

• Loss of sense of shared experience in the

community

• Normal routines re-established

• More pervasive anger, disappointment,

resentment, loss, grief, abandonment


RECONSTRUCTION

• Rebuilding

• Mourning

• Re-establishing relationships

• Non disaster focused lifestyle


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

• No one who sees a disaster is

untouched by it

Myers, 1994

• Most people pull together and function

during and after a disaster, but their

effectiveness is diminished


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

Disaster stress and grief reactions are

normal responses to an abnormal situation

• Many emotional reactions of disaster

survivors stem from problems of living

caused by the disaster


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

Disaster relief procedures have been called

"the second disaster"

• Most people do not see themselves as

needing mental health services following

disaster, and will not seek out such services


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

• Survivors may reject disaster assistance of

all types

Disaster mental health assistance is often

more "practical" than "psychological" in

nature


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

• Mental health / healthcare staff need to set

aside traditional methods, avoid the use of

mental health labels, and use an active

outreach approach to intervene successfully

in disaster


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

• Survivors respond to active interest and

concern

• Interventions must be appropriate to the

phase of disaster

• Support systems are crucial to recovery


KEY CONCEPTS OF DISASTER

PSYCHOLOGY

Myers, 1994

Disaster mental health services must be

uniquely tailored to the communities they

serve


PSYCHOLOGICAL CRISIS

An acute RESPONSE to a trauma, disaster, or

other critical incident wherein:

1. Psychological balance is disrupted

(increased stress)

2. One’s usual coping mechanisms have failed

3. Evidence of significant distress,

impairment, dysfunction


WHAT IS TRAUMATIC

STRESS?

• Stress resulting from an incident powerful

enough to overwhelm the usual coping

abilities of the persons involved


Psychological Triage in Disasters

General Principles

• There is a wide range of expected stress

reactions

• Expect normal recovery for most

individuals

• Know the warning / danger signs that

require referral to mental health workers

• Know referral resources before the disaster


Signs and Symptoms of Distress

Cognitive

Emotional

Behavioral

Physical

Spiritual


Risk Communication

• The ability to deliver messages to those you

interact with that will help:

– Inform

– Calm

– Empower

– Focus


When it is Done

• We deliver risk based messages every day

• In crisis situations, these messages must be

even clearer

• The message must address what the risk

perception of the audience is, and offer

solutions to the crisis at hand


Understanding Risk

Perception

• The goal of Risk Communication is to bring

perceived risk in line with actual risk.

• Often we must do this in times of crisis


Negative Dominance

• Negative messages tend to have greater

influence than positive

• Negative impact of our words or actions

will stay longer than positive

• Overcome negative messages with more

positive (at least 4:1)!

• Focus on what is being done, rather than

what is not

• Allow people to see the solution


Basic Principles

• Provide information that is:

– Simple

– Timely

– Accurate

– Relevant

– Credible

– Consistent


Crisis Intervention

Overview


CRISIS INTERVENTION

• Psychological first aid (not therapy)

designed to:

– Stabilize

– Mitigate distress, meet basic needs

– Assist in problem-solving

– Assist in regaining sense of control

– Facilitating access to other resources if desired,

or if necessary


Psychological First Aid

• Mobilizes the strengths of survivors

• Strives to relieve emotional suffering

• Improves a person’s immediate ability to

function under stress

• Strives to reduce the likelihood of longerterm

negative effects

IRC, 2003


Psychological First Aid

• Uses communication skills to engage those

in crisis in an active and empowering

manner

• Emphasizes the strengths and abilities of

disaster survivors

• Emphasizes connection to the community as

a source of resilience

IRC, 2003


Essential skills for offering

Psychological First Aid

• Active listening skills

• Caring attitude

• Empathy

• Non-judgmental approach

• Commitment

• Patience

• Self care


Psychological First Aid

SAFETY

FUNCTION

ACTION

Source: Shultz and Flynn, 2005


Psychological First Aid

SAFETY: Optimize physical safety and health

Protect

Sustain

Inform

FUNCTION: Optimize psychological health

Comfort

Reunite

Psycho-educate

Assess

ACTION: Facilitate behavioral health

Activate

Source: Shultz and Flynn, 2005


Psychological First Aid

SAFETY

Protect

• Provide safety and security

• Provide shelter and “personal space”

• Remove survivor from traumatic scene

• Reduce stressors and reminders

• Protect survivors from onlookers and media

Source: Shultz and Flynn, 2005


Psychological First Aid

SAFETY

Sustain

Provide basic needs:

• Food, water, ice

• Clothing

• Electricity, light, heat, air conditioning

• Sanitation

• Medical care

Source: Shultz and Flynn, 2005


Psychological First Aid

SAFETY

Inform

• Provide credible event information

• Clarify what happened

• Orient and provide reality testing

• Inform about risks and resources

• Present options for constructive action

Source: Shultz and Flynn, 2005


Psychological First Aid

FUNCTION

Comfort

• Establish compassionate “presence”

• Comfort, console, soothe

• Reassure

• Listen actively as survivors tell their story

• Apply and teach stress management

Source: Shultz and Flynn, 2005


Psychological First Aid

FUNCTION

Reunite

• Reunite family members

• Reunite children with parents

• Reunite close friends

• Keep family members together

Source: Shultz and Flynn, 2005


Psychological First Aid

FUNCTION

Psychoeducate

• Educate about normal reactions

• Tell survivors what to expect

• Educate about adaptive behaviors

• Educate about strategies to reduce anxiety

• Emphasize resiliency

Source: Shultz and Flynn, 2005


Psychological First Aid

FUNCTION

Assess

• Identify vulnerable, high-risk individuals

• Identify persons unable to function

• Assess support systems

• Refer for psychological support, as needed

Source: Shultz and Flynn, 2005


Psychological First Aid

ACTION

Activate

• Set realistic goals

• Problem-solve to meet goals

• Define simple, concrete tasks

• Redirect to constructive, helping tasks

• Encourage survivors to assist others

Source: Shultz and Flynn, 2005


Psychological First Aid

Protect

SAFETY

Sustain

Inform

Reunite

Comfort

FUNCTION

Psychoeducate

Assess

Activate

ACTION

Source: Shultz and Flynn, 2005


Cautions

1. The majority of individuals exposed to a traumatic event

will not need formal psychological intervention, beyond

being provided relevant information.

2. The focus should be upon the individual more so than

the event; assessment is essential.

3. Unless the magnitude of impairment is such that the

individual represents a threat to self or others, crisis

intervention should be voluntary.

4. The interventionist must be careful not to interfere with

natural recovery or adaptive compensatory mechanisms.

5. Individuals should not be encouraged to talk about or

relive the event, unless they are comfortable doing so.


Meeting the Needs of

Special Populations


CHILDREN—Reactions

Helpful Interventions

• First priority is to re-unite children with their

primary caretakers if possible, or create adult

presence to provide safety, comfort, and

reassurance.

• Create separate safe area for children --

minimize their exposure to ongoing traumatic

experience, including witnessing traumatic

reactions in adults

• Provide for basic needs – food, water, medical

first aid, warmth, dry shelter


CHILDREN—Reactions

Helpful Interventions

• Provide age-appropriate activities for children

(have play materials ready)

• Triage for severe reactions

• Identify healthy coping strategies already

being used, reinforce them, and educate others

about them

• Educate primary caregivers about what to

expect, signs and symptoms of distress, and

what to say to children


ELDERLY/ DISABLED

Helpful Interventions

• Provide strong and ongoing verbal reassurance

• Assist with recovery of physical possessions, if

possible

• Give special attention to suitable relocation

options

• Help re-establish familial and social contacts

• Assist in filling out forms, obtaining medical and

financial assistance

• Help re-establish medication regimens


CHRONIC

MENTAL ILLNESS

Special Strengths

• Mental illness does not preclude mentally

healthy responses and adaptive coping skills

• Function fairly well if regular essential

services have not been disrupted

• Many demonstrate an increased ability to

handle disaster stress without decompensating

from primary illness


CHRONIC

MENTAL ILLNESS

Helpful Suggestions

• Challenge is to determine how outreach can

successfully engage them

• Do not automatically attribute stress reactions

to exacerbation of mental illness

• Recognize how aspects of particular mental

illness may make individual reluctant to

seek/accept help


CHRONIC

MENTAL ILLNESS

Helpful Suggestions

• Provide training to staff (re: how to work with

individuals with mental illness)

• Screen for suicidal ideation and attempts, problem

drinking, drug abuse and violence

• Emphasize developing and maintaining

relationships – foster interdependence

• Focus on individual strengths

• Support individual’s attempts at growth


Disaster Worker Stress

and Self Care


WORKER STRESS DURING

DISASTERS

• Sources of Stress

– Long hours

– Time pressures

– Uncertain Duration

– Unfamiliar Settings/Procedures

– New Challenges

Source: Flynn, 2002


WORKER STRESS DURING

DISASTERS

• Sources of Stress

– Identification with victims

– Role ambivalence

– Extreme fear or distress

– Demand for services

– Concern for safety and welfare of family

Source: Flynn, 2002


SIGNS OF DISTRESS

• Intrusive memory experiences

• Avoidance of reminders of the event

• Hypervigilance

• Disturbed sleep

• Demoralization

• Anger

• Fear

• Physiological reactivity


CHRONIC SYMPTOMS

• Sense of alienation

• Isolation and withdrawal

• Delayed loss of confidence

• Guilt

• Numbing

• Feelings of loss of control

• Suicidal thoughts


SELF-CARE

• Why is this important?

– Responding to people in crisis can be frustrating

due to competing needs of supervisors,

clients/victims and caregivers.

– Adrenaline and desire to help can lead to

regrettable decisions and practices.

– Normal mechanisms of self-care can be more

difficult to access if crisis is large scale or

prolonged.

– Self-care often gets overlooked by disaster

personnel


Disaster Worker Stress Survival: Before

the Incident

Training / Drills

Mentorship

Physical Fitness/ Exercise

Nutrition

Self care

Family Plan


Disaster Worker Stress Survival: During

the Incident

Don’t fight expected reactions/Self monitor

Try to be flexible!

Talking/writing, when you can

Eat/Hydrate/Take breaks

Buddy system

Relaxation techniques

Rotating out of intensity

Spiritual support

Delegate non-essential tasks


During the Incident

• Connect to others

• Pay attention to physical needs

• Ask for help!

• Focus on here and now tasks

• Maintain regular contact with loved ones


After the Incident

• Use formal mechanisms (supervision and

staff meetings) to process the event

• Peer support/CISM programs

• Participate in events that create meaning

• Restore normal routines as soon as possible

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