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					                                                                                           Presentation Goals
                                                                                               To understand the range of reactions individuals
               Psychological First Aid                                                         experience in the aftermath of disaster.
                                                                                               To introduce you to the concepts of Psychological First Aid.
                      (PFA)                                                                    To understand how providing Psychological First Aid can
                                                                                               assist in mitigating disaster stress.
                   Helping People Cope During                                                  To introduce you to scenario-based exercises that create
                   Disasters and Public Health                                                 opportunities for practicing PFA skills
                          Emergencies                                                          To develop strategies for improving your response to
                        Jack Herrmann, MSEd, NCC, LMHC                                         individuals impacted by disaster and managing one’s own
                                                                                               stress.




                                                                                           Presentation Objectives                                                                  2




Initial concepts and terms
                                                                                                         Psychological First Aid in Practice

    The terms disaster and public health emergency are often used
    interchangeably in such a way that it is assumed that these events
    present the same kinds of problems for the individuals experiencing
    the aftermath of such events.                                                                        Part I: The Human Impact of
    A public health emergency can jeopardize the health of a community
    and place tremendous strain on its healthcare system and community
    resources.
                                                                                                         Disaster
    Psychological First Aid consists of practices intended to provide
    comfort, care, and support to those suffering from disaster-related
    stress.
    Individual and workforce resilience refers to an individual or
                                                                                                        Helping People Cope During Disasters and Public Health Emergencies
    organization’s ability to recover quickly from the setbacks and
    problems that readily occur in times of disaster. PFA can help to
    maintain and build resilience in the populations whose jobs are
    essential to the stability and recovery of a community.


Initial Concepts and Terms                                                             3




Disasters are stressful events                                                             Survivors react in a variety of ways
    Only a small percentage of survivors and responders will                                   Post-trauma reactions
    develop significant post-disaster psychological complications.
    Many will suffer only minor and transient effects.
                                                                                               are expressed through
                                                                                               different pathways
                                                                                                ♦   Emotional effects
                                                                                                ♦   Cognitive effects              Emotional         Cognitive          Behaviora
                                                                                                                                                                            l
                                                                                                ♦   Physical effects
                                                                                                ♦   Behavioral effects
                                                                                                                                          Physical          Spiritual
                                                                                                ♦   Spiritual effects



                                       Adapted from: U.S. Department of Health and
                       (Galea, 2006)   Human Services. (2004).Mental Health Response
                                       to Mass Violence and Terrorism:
                                       A Training Manual.



The Human Impact of Disaster                                                           5   The Human Impact of Disaster                                                             6




                                                                                                                                                                                        1
What impacts how people respond?                                                        Key Disaster Characteristics
   Disaster Characteristics                                                                Onset
                                                                                            ♦ Sudden and without warning vs. with warning
   Response Characteristics
                                                                                            ♦ Time of occurrence (day, morning, afternoon, evening, night)
   Individual Characteristics                                                               ♦ Season (winter, spring, summer, fall, holiday)
                                                                                           Duration
                                                                                            ♦ The threat of impending risk of injury or death
                                                                                           Scope
                                                                                            ♦ Geographic area or region affected
                                                                                           Impact
                                                                                            ♦ The extent to which the population or community
                                                                                              infrastructure has been affected


The Human Impact of Disaster                                                       7    The Human Impact of Disaster                                         8




The Impact of the disaster response                                                     Individual Characteristics
   Response Characteristics                          (Adapted from Zunin/Meyers)
                                                                                           Individual Risk Factors
                                                                                            ♦   Personal Exposure
                                                                                            ♦   Pre-Disaster Functioning and Personality
                                                                                            ♦   Pre-Disaster History
                                                                                            ♦   Age
                                                                                            ♦   Gender
                                                                                            ♦   Culture and Ethnicity
                                                                                            ♦   Socioeconomic Status
                                                                                            ♦   Cognitive and Physical Disabilities
                                                                                            ♦   Family
                                                                                            ♦   Post-Disaster Stressors


The Human Impact of Disaster                                                       9    The Human Impact of Disaster                                         10




Individual Characteristics                                                              Helping People Cope
   Summary of Individual Risk Factors                                                      Most people recover psychologically from disaster.
            Female gender              For women, the presence                             Most will utilize family and friends to cope with their
            Age 40 to 60               of a spouse, especially if                          experience.
            Little previous            he is significantly
            experience or training     distressed                                          Some people will experience intense or persistent
            relevant to coping with    Severe exposure to the                              reactions.
            the disaster               disaster, especially injury,
                                       threat to life, and
                                                                                           Doing nothing may result in long term consequences.
            Ethnic minority groups
            Poverty or low             extreme loss                                        Almost all people can benefit from some level of care,
            socioeconomic status       Living in a highly                                  compassion and support.
            Presence of children in    disrupted or traumatized
            the home                   community
            Pre-existing psychiatric   Secondary stress and
            history                    resource loss


The Human Impact of Disaster                                                       11   The Human Impact of Disaster                                         12




                                                                                                                                                                  2
                                                                                      Who can do PFA?
            Psychological First Aid in Practice
                                                                                         PFA can be provided by anyone working in a
                                                                                         disaster setting
                                                                                          ♦   Mental health professionals
            The Core Components of PFA                                                    ♦   Spiritual care providers
                                                                                          ♦   First responders
                                                                                          ♦   Hospital personnel
                                                                                          ♦   Crisis line workers
            Helping People Cope During Disasters and Public Health Emergencies
                                                                                          ♦   Neighbors, friends, relatives




                                                                                      The Core Components of PFA                                 14




PFA vs. Psychological Debriefing                                                      PFA core components
   PFA is different from psychological debriefing                                        Provide comfort care.
    ♦ Does not require formal training                                                   Recognize basic needs and help solve problems and
    ♦ Does not use a structured/semi-structured format                                   complete practical tasks.
    ♦ Does not involve people “telling their story”                                      Validate survivors’ feelings and thoughts.
                                                                                         Provide accurate and timely information.
                                                                                         Connect people with their support systems.
   PFA
                                                                                         Provide education about anticipated stress reactions.
    ♦   Uses an informal approach
                                                                                         Reinforce strengths and positive coping strategies.
    ♦   Focuses on meeting basic needs
    ♦   Encourages self-efficacy
    ♦   Respects an individual’s own coping style

The Core Components of PFA                                                       15   The Core Components of PFA                                 16




Getting Started                                                                       Be Aware
   Introduce yourself.                                                                   Pay attention to your own reactions and
   Make eye contact, if culturally appropriate.                                          maintain your composure.
   Speak slowly and clearly, and allow the person                                        Identify co-workers or mental health
   to speak with you without interruption.                                               professionals to work with persons that may
   Stay within your expertise.                                                           need additional assistance.
   Be compassionate and genuine. The ‘art of
   being present.’




The Core Components of PFA                                                       17   The Core Components of PFA                                 18




                                                                                                                                                      3
Provide comfort care                                 Provide Comfort Care
                                                        Promote sense of calm
                                                        Maintain safety
                                                        Provide reassurance




The Core Components of PFA                      19   The Core Components of PFA                            20




Recognize basic needs and help solve problems        Recognize Basic Needs and Help Solve Problems
and complete practical tasks                         and Complete Practical Tasks
                                                        Obtain food, clothing, shelter, medication, etc.
                                                        Locate disaster relief services
                                                        Assist with transportation
                                                        Complete forms




The Core Components of PFA                      21   The Core Components of PFA                            22




Validate feelings and thoughts                       Validate Feelings and Thoughts
                                                        Listen attentively and respectfully.
                                                        Don’t push to talk.
                                                        Acknowledge stressful and difficult situations.
                                                        Refrain from judgment.




The Core Components of PFA                      23   The Core Components of PFA                            24




                                                                                                                4
Provide accurate and timely information        Provide Accurate and Timely Information
                                                  Provide information as soon as possible.
                                                  Stay within your expertise.
                                                  Refrain from sharing information that is not
                                                  confirmed.
                                                  Take the time to find the answer.




The Core Components of PFA                25   The Core Components of PFA                         26




Connect to support systems                     Connect to Support Systems
                                                  Help locate family and friends.
                                                  Link to peers.
                                                  Reach out to spiritual care providers, health
                                                  and mental health care professionals.




The Core Components of PFA                27   The Core Components of PFA                         28




Provide education about anticipated            Provide Education about Anticipated
stress reactions                               Stress Reactions
                                                  Acknowledge stress reactions including
                                                  differences in how people react.
                                                  Refrain from ‘over normalizing’ reactions.
                                                  Provide resources for additional information
                                                  and coping strategies.




The Core Components of PFA                29   The Core Components of PFA                         30




                                                                                                       5
Positive coping strategies        Positive Coping Strategies
                                     Instill confidence and ability to cope.
                                     Explore past coping strategies.
                                     Encourage “one thing at a time” approach.
                                     Suggest strategies that are practical and
                                     realistic.
                                     Discourage maladaptive coping strategies.
                                      ♦ Excessive use of alcohol, drugs, low nutritional foods,
                                        repeatedly watching television accounts of disaster,
                                        connecting with psychologically and physically abusive
                                        friends and relatives

The Core Components of PFA   31   The Core Components of PFA                                      32




                                                                                                       6
                               Pacific EMPRINTS
                               Podcast Transcript

“Psychological First Aid (PFA): Helping People Cope During
        Disasters and Public Health Emergencies”

Expert: Jack Herrmann, MSEd, NCC, LMHC
        Senior Advisor, Public Health Preparedness
        National Association of County and City Health Officials (NACCHO)
        Washington, D.C.

Date: January 16, 2008

Slide 1: “Psychological First Aid (PFA): Helping People Cope During Disasters
and Public Health Emergencies”
Opening:
The following presentation was recorded at Pacific EMPRINTS’ 2008 Pacific
Preparedness Conference: Capacity Building to Address Vulnerable Populations,
which took place on January 16, 2008, at the Hilton Waikiki Prince Kuhio Hotel.
Pacific EMPRINTS is honored to present Jack Herrmann, the Senior Advisor on
Public Health Preparedness for the National Association of County and City
Health Officials in Washington, D.C, giving his presentation entitled
“Psychological First Aid (PFA): Helping People Cope During Disasters and
Public Health Emergencies.”

Moderator Anna Daddario:
I am here to introduce Mr. Jack Herrmann. Jack Herrmann is the senior advisor
for public health preparedness at the National Association of County and City
Health Officials. Previously, Mr. Herrmann was Assistant Professor of Psychiatry
and Director of the Program in Disaster Mental Health at the University of
Rochester Medical Center. He has also been a long time volunteer with the
American Red Cross, and has responded to numerous disasters, including the
Northridge California earthquake, the explosion of TWA Flight 800, the crash of
Comair Flight 5191, as well as Hurricanes Katrina and Rita. He was assigned as
the mental health coordinator for the Family Assistance Center in New York City
immediately following the attacks of September 11. His commitment to disaster
mental health has been recognized locally and nationally, with many awards,
including the 2001 American Red Cross National Disaster Services Award. Mr.
Herrmann co-authored the American Red Cross Foundations of Disaster Mental
Health and Psychological First Aid Training Curriculum, and I believe it's an eight
hour course that he has consolidated down into two 50 minute sessions for us.
So please join me in welcoming Mr. Jack Herrmann.



  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Slide 2: “Presentation Goals”
Mr. Jack Herrmann:
As Anna said, what I tried to do is condense an eight hour Psychological First Aid
training into two hours of overview and introducing you to what Psychological
First Aid is, some of the key components, and some of the exercises that are
used in familiarizing mental health professionals and non-mental health
professionals with how to engage with disaster survivors in a context of any sort
of disaster or public health emergency. How many of you are mental health
professionals? How about just general public health? EMT, first responders, fire,
police, and others? Non-mental health professionals? Good, good. Actually
that's a great mix because one of the nice things about Psychological First Aid is,
you will hear me talk about it, is it can be done by anyone. In fact, sometimes
you might be better off if you're not a mental health professional because you
don't come in with a lot of expectations about trying to identify psychopathology
or major psychological symptomatology in individuals, and therefore strive for
some kind of clinical treatment that really isn't warranted after the early aftermath
of the disaster. So what I would like to do in the first part of this session is really
familiarize you with Psychological First Aid, or I'll refer to it as PFA. So, over the
next 50 minutes we will look at the range of reactions that individuals experience
in the aftermath of the disaster. I want to introduce some of the key concepts of
PFA. And understand how using PFA hopefully can mitigate any acute or long-
term psychological harm that disaster survivors and others may experience in the
aftermath of these dramatic kinds of events. We will talk a little bit about some of
the scenario-based exercises that go along with doing the Psychological First Aid
training, and the opportunity to practice PFA skills, and look at how to develop
your own strategies for moving your interaction and engagement with individuals
in the aftermath of disaster.

Slide 3: “Initial concepts and terms”
Mr. Jack Herrmann:
So that we're all on the same page, if I use “disaster” or “public health
emergency,” I'm really talking about the same thing. It's important to appreciate
that public health emergencies can jeopardize the health of the community and
the infrastructure by which that community provides health-related services and
resources. PFA or Psychological First Aid is really a practice that is intended to
provide comfort and care to individuals in the aftermath of disaster. It's not only a
practice, but I would actually go so far to say it's really a state of mind; I call it the
art of being present and how to really understand where that individual, client, or
disaster survivor really is and recognize what they need in that moment in time.
So that you're able to come about and bring the right resources to the right
people at the right time, and in essence doing the right thing. We will also touch
a bit on individual and workforce resilience, talking about an individual
organization’s ability to recover quickly from a disaster or public health
emergency, and how PFA can be used to enhance that resiliency.



  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Slide 4: “Part I: The Human Impact of Disaster”
Mr. Jack Herrmann:
So let’s talk first about the human impact of disaster.

Slide 5: “Disasters are stressful events”
Mr. Jack Herrmann:
Contrary to what many people believe, only a small percentage of survivors and
responders will go on to develop severe psychopathology, or severe
psychological consequences from a disaster. So we're saying is that most
people who experience disaster, may experience some kind of psychological
reaction, but the majority of those people will not go on to develop major, life-
altering psychiatric and psychological problems. Most will recover, with only
having experienced very minor symptoms or stress reactions, and those usually
abate over a short period of time. When I'm talking about the reactions that
people experience, what I'm doing is taking a population-based approach to that.
So as we think about types of reactions that people have, in your mind you may
thinking, “I know somebody who had a real severe reaction after a disaster, or
they did this after a disaster.” That may be true. But when you look at
individuals who are exposed to a disaster, by far, the majority of them will recover
without any major psychological problems. One of the models that I like to use is
this exposure model here that if you look at these concentric rings, the closer one
is to the epicenter of the disaster, the more one is at risk for developing more
significant psychological reactions. Now that does not mean that those people
who were in that “A” ring, all of them will develop symptoms or reactions. It just
means, from a big picture perspective, the closer you are to the epicenter to that
trauma or tragedy, the more likely you are to be at risk of developing more
significant psychological reactions.

Slide 6: “Survivors react in a variety of ways”
Mr. Jack Herrmann:
So, how do we experience these reactions? Typically, when you're working with
disaster survivors, you see that there isn't one way that people react. In fact,
when we look at the range of reactions of people have, they experience them
over a number of domains: emotional, physical, cognitive, behavioral, and
spiritual. And so we need to holistically look at the big picture of how people are
responding and not try to pigeonhole that and say, you know, “That is evidence
of some kind of psychiatric disorder.” We need to understand the more holistic
approach of how people experience disaster over these domains, and then we
have a better picture of who might emerge to develop more significant
symptomatology.

Slide 7: “What impacts how people respond?”
Mr. Jack Herrmann:
Now, we may experience these reactions over a range of domains, but there are
other characteristics that impact how people are going to respond within those
domains. The three top ones are: Disaster Characteristics, Response

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Characteristics, and Individual Characteristics. And so what I mean is, the
disaster itself, the type of disaster, can impact how people respond. The
response, whether that's a governmental response, an organizational response,
and individual response, they also can impact how individuals respond. And then
one's own individual characteristics can influence the way people respond as well.

Slide 8: “Key Disaster Characteristics”
Mr. Jack Herrmann:
So let me talk a little bit about key disaster characteristics. Well, there are four
key characteristics that can impact how people respond in the context of the
disaster itself. At the onset of the disaster; does it occur suddenly, without
warning, or did we know or had some sort of communication ahead of time that it
was impending? The time of day; when did the disaster strike? What season
was it? Let me use an example. The first disaster I ever responded to was the
LA earthquake in 1994, and one of the first couples I worked with - very young
couple, they were probably in their 20s. We were deployed, I was deployed to
Northridge actually. And we were in the parking lot of this large shopping center
that had been severely destroyed by the disaster, but they had erected this huge
tent, sort of like a circus tent, and that's where we were providing Red Cross
disaster relief services. So I was approached by one of the Red Cross workers
who was interviewing a family about their disaster-related losses, and letting me
know that she was working with the young couple, and the woman was very
distraught and it was difficult to interview her because she was crying and upset.
So I went over to talk with them and come to find out, again they were a young
couple who had two preschool children. The time of the disaster was 4:15 a.m.,
somewhere in that a.m. range, if I recall correctly. Anyway, it was nighttime, and
everybody was sleeping. Mom and Dad were in their room, and the kids were in
another room. The earthquake shook the house, and what happened is that their
doors closed, they couldn't get out. So their children were screaming, in the
other room, for their parents and the parents couldn’t get out of their door
because it was a lodged shut. And all the mother could think about was hearing
her children screaming for her and not being able to get to them; she was playing
that over and over in her mind, and feeling very helpless. Then she talks about
getting them out, finally getting them and how they run outside, it's pitch black,
they see the arching of the power lines that were snapped, and some fires and
earthquakes. And again, very extreme images. But here's a situation where this
is a disaster that happened suddenly, they had no warning obviously; it was in
the middle of the night. And those types of characteristics were playing on her
and her recollection of where she was and how vulnerable she and her children
and her family were. Now looking at a very different picture, for 9/11. I
responded to New York City on that day, and I worked with a few people who
were workers in a building that had been obviously attacked. And they had
evacuated the building and were trying to find their loved ones, to relocate with
their family, which they then couldn't get in touch with. So here's an example of a
disaster that occurred during the middle of the day, but it's during work hours, so
at the beginning of work hours families have already split up from their homes in

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
the morning, and the impact of not being able to connect with that loved ones
was something that was creating that reaction.

Audience member:
How about the fundamental difference between, using your two examples, a
natural disaster which is sort of out of everyone's hand and a man-made, human-
caused disaster?

Mr. Jack Herrmann:
It's interesting. First of all, the data in disaster mental health is evidence-based,
but is very limited. What we know about disaster, based upon a few research
studies that have been conducted, but for the most part it's purely anecdotal;
people's responses to it, and their reactions and writings about those
experiences. So often there's this play between what's worse, a human-caused
disaster versus a natural-caused disaster? And frankly, there isn't any evidence
that suggests that either is worse than the other. But it's a combination of the
factors. And how we subjectively view those disasters can influence the way that
we react. So, what you bring up, the issue that human-caused disasters, that we
see those potentially within our control had we known something was going to
happen. Or terrorist attacks, we should've done something about that before had
gotten to that level versus natural where it's just Mother Nature and there's
nothing we can do. Interestingly, and I think some of the Katrina literature and
some of the Tsunami literature is pointing to this, is that disasters that have
reached the levels of catastrophic or cataclysmic, they tend to look like each
other. You don't see the difference is as much, the magnitude of what is
happening in the context of those events seems to be the same, whether it's
natural and human-caused. You may see much more subtle differences in the
smaller, median disasters or natural disasters. The duration, it's not how long the
disaster lasts, but really, the perception of perceived threat of illness, death, or
injury that one is experiencing in the context of the disaster can influence the way
in which people react. So if I believe that I am at risk of harm, my family
members are at risk of harm, or anything like that, I may be more at risk for
experiencing post-disaster significant symptomatology. The scope of the
disaster, certainly, the greater the magnitude, the likely it is that I may be more at
risk for developing post-disaster stress. Not necessarily psychopathology, I'll
keep saying that over and over. And then the impact that the disaster creates.
How much destruction of the community infrastructure, my access the
transportation, my access to health care, my access to all the normal things that I
would engage in on a day-to-day - being able to go to school, being able to go to
work, being able to go to the grocery store, being able to go to the bank. Again,
where we see more devastating impact we are likely to see people who are much
more at risk of developing more significant post-disaster psychological symptoms.




  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Slide 9: “The Impact of the disaster response”
Mr. Jack Herrmann:
And then finally the response itself can also impact how people respond and deal
with a disaster. If you look at this particular graph, what you see, I don't
particularly like looking at things in phases, because I'm not sure they really
reflect how people react in an experience. But I do believe, just illustratively, this
is helpful to get a sense of when disaster strikes a community and a response is
invoked, that people may be more likely to experience different kinds of
psychological reactions, or just upon the spectrum of reactions based on the time
period of that response. So initially, when they see that people have more
heightened reactions in the early aftermath, and then over time they feel a little
better, and then the anniversary effect might come in. And so it is important if
you are working with disaster survivors, that you understand where they exist in
the scope of this continuum of response and recovery, because that may help
you have a better sense of how they might react and respond and where some of
the challenges may exist in their own recovery.

Slide 10: “Individual Characteristics”
Mr. Jack Herrmann:
And then, one's own individual characteristics can influence how people are
going to respond and react in the context of the disaster. I talked a little bit about
personal exposure, so the closer you are to the epicenter the more likely at risk
you might be. The role of pre-disaster functioning and personality. If you are a
mess before the disaster, chances are you'll be a mess after the disaster.
Clearly, pre-disaster functioning can influence the way that we respond. Our own
history of disaster - have we ever experienced disaster in the past? And how did
that go? And how did our experience go? Were we able to cope? Were we able
to persevere and move through that? Or were we not? And we find that they
were extreme challenges, and they weren't able to cope and persevere, so what
happened as far as their own pre-disaster history? We also know that individuals
who experience prior traumatic events, personal trauma, it could be rape or
personal violence, domestic violence. Those individuals may be more at risk for
suffering post-disaster stressors. Age is also a function, and it's interesting
because if you look at the literature you see that children are vulnerable
populations, you see older adults are a vulnerable populations, we also know that
people who are in their middle years are a vulnerable population. So depending
on what you're looking at, any age can be a risk factor, it's just the context of
where the individual is. Some people say that the reason why some people in
their middle years may be more at risk is because of the pressure, the economic
pressures, the career pressures, the parental pressures on them, may make
them more at risk. But again, what this illustrates is that it really is a big picture
that accounts for how people are going to react, not the fact that they're 40, or
they are 90, or they are 12. Gender. There is certainly literature that suggests
that females may be more at risk than males. I tend to always get a barrage of
questions when people hear that, but again, just to ward some of that off - we
don't know the mechanism behind that but what some people suggested is that

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
females are more in tune with their emotions, and stress their concerns and
reservations more. And men may just be better stuffers than females are. But
clearly, some of the literature does suggest that females may be more at risk for
suffering post-disaster stress. Culture and ethnicity. Again, it may not be the
color of one's skin that makes them a risk factor, but it could very well be a lack
of ability to communicate in a language, or the dominant language, when the
disaster strikes. It may be that inavailability of resources for that primary culture,
primary language that places someone at risk. So, it is much more complex than
just saying, “This person is of African-American descent, therefore they are going
to be at more risk. This person is not English-speaking, therefore they are going
to be at more risk.” We need to have a deeper appreciation of the sub-levels of
culture and ethnic issues that can place people much more at risk. Same thing
for socioeconomic status. Some studies suggest that if you come from lower
socioeconomic status, that you may be at more risk. Now anecdotally, I know
some disasters I have worked on, I have had very distraught rich people; they
lost their Mercedes, they lost their big homes, they lost their jobs, and therefore
couldn't pay for their Mercedes or their big homes. So it's important to put this
into perspective, but at least from a population-based approach for the literature
that does exist in this area, it suggests that individuals from lower socioeconomic
status may be more at risk. As are those who are suffering from cognitive and
physical disabilities, things we have heard maybe earlier this morning in the
keynote, or in some of the other sessions that you're involved in. Family
composition can also be a risk factor. Again, if there's pre-existing history of
trauma in the family, the composition itself. Mothers are more at risk.
Interestingly enough, females who have male counterparts or spouses or
partners who are extremely distraught may themselves be more at risk. So if
your husband or your male partner’s a mess, chances are that's going to
increase your risk as well. And then the post-disaster stressors that just exist in
the context of the aftermath of disaster can increase people's risk factors.

Slide 11: “Individual Characteristics”
Mr. Jack Herrmann:
If you look at the research that's been done, here's a summary of some of the
individual risk factors that can at least help point us towards who may be at more
risk for developing post-disaster psychological stress of significance. And again,
the reason why this literature base is so important is because if we consider,
especially in large-scale disasters, the number and magnitude of people who are
impacted and the amount of resources available to intervene and work with
people, we know that that's disproportionate. There are only so many disaster
responders, and if you're working in large, catastrophic disasters, even medium-
sized disasters, there may not be enough resources to provide one-on-one
intervention. Not that that's needed, but what I'm saying, is that the resources
may be limited. And so by understanding who is at risk, or who may be at more
risk, we can target those limited resources, and further assess those risk groups
and be able to intervene in a timely fashion. There's a question?


  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Audience member:
Just when I looked at this, I was wondering what audience this pertains to? Is
this America? Is this somewhere else?

Mr. Jack Herrmann:
Yes, this is predominantly a U.S. audience.

Audience member:
Another comment. It's interesting looking at the religious factors, at least the way
I see it; the less religion the more at risk one is...

Mr. Jack Herrmann:
I think that is a good point. The reason you don't see it up here is because this is
currently what exists in the literature. There's very little domestic literature on the
religious influence and the religious characteristics is associated with disaster.
While I think that there's more that is emerging, you don't see that in the disaster
mental health literature per se. But I would not argue with you that there may be
some relevance there between someone's religiosity and their increased risk for
going on to suffer more significant psychological stress.

Slide 12: “Helping People Cope”
Mr. Jack Herrmann:
So, when we consider then the characteristics that influence how people respond
and think about this big picture of disaster survivors. As I mentioned earlier,
most people will recover psychologically from disaster. They will utilize their
family and friends, their support systems, but some will go on to experience more
persistent, challenging reactions. And so, while the literature, again, it's very
limited. We are, I think, making good assumptions that by doing nothing may
increase the risk for people going on to experience more entrenched, more
difficult psychological reactions. And as a result of that, our feeling is that almost
all people can benefit from some kind of level of care, compassion, and support.
And that's really what the foundation is for Psychological First Aid, which I’ll talk
about.

Slide 13: “The Core Components of PFA”
Mr. Jack Herrmann:
Let's talk more about the core components of PFA.

Slide 14: “Who can do PFA?”
Mr. Jack Herrmann:
Let me talk about the responder reactions, and again the literature suggests that
they are a risk group. But, saying that, the majority of disaster responders: first
responders, police, fire, EMS, the initial first responders. The majority of them
will come through a disaster unscathed. What I mean by that is that they won't
develop severe psychological sequelae; the consequence of psychopathology.
And that is important that the research suggests that certainly there is a group,

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  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
who will go on to develop those severe reactions, but as a whole the majority of
those in those professions will not. And in fact don't require any intervention at
all; they will find a way to cope with their issues resulting from the disaster, they
won't need a major intervention in order to get through that. They will be fine on
their own. In fact, there are some studies that suggest that imposing or
mandating an intervention in the early aftermath, that in and of itself, may
heighten their risk for developing post-disaster psychological consequences, and
I will share some of that with you in a minute.

Dr. Sharyne Shiu Thornton:
Could you hypothesize that due to the nature of being a first responder with the
training that one receives, there is a deeper sense of self control, a sense of self-
efficacy, and a sense of self-confidence, which is very different than if you're a
survivor?

Mr. Jack Herrmann:
I don't think I could've said it any better than you did. And I think that was nicely
said. And in fact, research suggests, the more education and training, sense of
cohesiveness that those first responders get, the more likely they will be able to
cope with disaster than their counterparts who don't feel that sense of
cohesiveness, who don't feel confident in the jobs that they are doing, don't feel
that they've been trained to perform the duties they need to perform in that
response capacity. So yeah, I think you captured that about very nicely. Well,
when I started I said one of the things I like about Psychological First Aid, it really
can be provided by anyone in a disaster setting. There are some models, PFA
models out there that recommend that they are administered by mental health
professionals. Frankly, being a mental health professional, I don't feel the need
to promote that. I really do believe that PFA can be performed by anyone. In
fact, probably should be known by everyone who's in a position to respond in the
context of whatever their role is from a disaster response perspective. And also
just the general community should probably have a good understanding of how
to support themselves and their family members and neighbors and friends in the
context of disasters. So from my perspective, PFA really can be done by anyone.

Slide 15: “PFA vs. Psychological Debriefing”
Mr. Jack Herrmann:
How many of you are familiar with psychological debriefing, Critical Incident
Stress Debriefing? A few people. How many people have never heard of critical
incident stress debriefing? Okay. For those of you that haven't. Psychological
debriefing has been around for decades, and in fact has been used during war
times, in the battle where the troops were removed, brought together in a group,
asked to share their experiences in the hopes that that would alleviate any kind
of psychological issues that they might've been having as a result of what they
encountered in the context of that battle to get them back to the front lines.
There's also operational debriefings, which means bringing people together,
having them look at the logistics of the response, and identifying where some of

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
the key challenges were in the hopes that they can better prepare to respond
logistically the next time. Well, psychological debriefing or Critical Incident Stress
Debriefing, CISD, really made its mark in the mid-80s. There was a group in
Baltimore, Maryland, who developed a model that was primarily used for first
responders where they brought together like groups of individuals, policemen
and firemen, paramedics and EMTs, who had just experienced a significant
incident. Maybe an incident where there was death of children or the death of a
coworker. It brought them together, and brought them through this kind of semi-
structured process of getting them to share their experience: talk about where
they were, what they saw, what they heard, what they smelled, provided them
some education about common symptoms, normal reactions, and then try to
assess some of those who went on to develop more significant reactions, and
then sent them on their way. Quite a big push, still somewhat is today. What
happened in the mid-to-late 90s, is that there was a meta-analysis that was
conducted by researchers looking at studies that had used, or groups that had
used psychological debriefing. And they want to look at the outcomes of that
intervention. And so, what they found at that point, was that in fact, bringing
together people to talk or tell their story didn't necessarily mitigate or prevent
psychological consequences. So that was the implication there, that somehow
going through this would mitigate long-term psychological consequences. In fact,
the reviews of the study showed that it didn't necessarily do that - in fact, it made
some cases worse. And there was a huge uproar about that. And in the fall of
2001, the National Institute of Mental Health convened an expert panel, bringing
together people in the mental health profession and the first responder
profession, and began to look at evidence and came back with the same findings.
As an acute or early aftermath intervention, psychological debriefing may not be
appropriate for some populations, and in fact it may have an opposite effect and
may be more harmful in some populations. And so you began to see that shift
from people using psychological debriefing, and in fact, the group who had
coined the CISD, Critical Incident Stress Debriefing, adapted their model to what
was called Critical Incident Stress Management, which is more a continuum of
interventions. Of which CISD is still one of them. Chances are if they had just
probably had taken off the CISD card, they probably would've gotten a lot more
support, at least in the academic arena for their approach. But be that as it may,
we see this kind of trend towards moving away from psychological debriefing and
CISD and more towards Psychological First Aid. There are many reasons for
that. One of the reasons is that PFA is a much more informal approach; it
doesn't follow a prescribed structure. It also doesn't focus on getting people to
tell you their story and their experience around that dramatic event. It focuses on
meeting an individual's basic needs. Certainly, what we are finding is that when
people are in crisis, we've learned a lot about crisis intervention and its efficacy
and the importance of meeting people's needs; where they are at that point of
time. It encourages self-efficacy and not relying on somebody to take you by the
hand and do everything for you, but helps activate your own internal coping
mechanisms. And also respects individuals coping style; they may not be ready


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  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
to talk, they may not be ready to engage in some kind of activity, so we shouldn't
be pushing them to do so against their will.

Slide 16: “PFA core components”
Mr. Jack Herrmann:
And so when we look at the core components of Psychological First Aid, at least
what I have found, there are a number of models out there; PFA is not new. In
fact, the American Psychiatric Association talked about Psychological First Aid in
a 1942 paper. So, this is not a new invention, it's been around and probably
used a lot more internationally; certainly Denmark has an American Red Cross
there and they have a whole training focusing around PFA for a number of years.
So it is being used by the international community much more than it has been
domestically. But many of the models look similar, and it comes down to whose
model do I want or don't want to pay for. But here are some of the major
components of Psychological First Aid. Providing comfort care, recognizing what
people's basic needs are and helping them meet those needs with very simple
problem-solving and focusing on practical tasks. Validating what they are
thinking and feeling and helping them acknowledge that they had just
experienced a very stressful situation. Providing accurate and timely information
to them. Connecting them with their social supports. Educating them about
anticipated stress reactions, and I use the word anticipated there because many
of you have probably heard the phrase, normal reactions to abnormal situations.
But I don't believe it's actually a good phrase, or a helpful phrase to use, because
sometimes what we do is over-normalize symptoms and reactions that people
are having, and in fact gives us permission to overlook them. If you look at a list
of reactions that people have in the context of disaster, those reactions in and of
themselves, may become, meaning many people will experience them, it doesn't
necessarily mean they're normal. So is it unusual for someone to experience
depressive affect or suicidal ideation in the aftermath of the disaster? No, not at
all. But should we just assume suicidal ideation is normal and overlook it?
Absolutely not. And so I tend to use the word anticipated reactions, these are
things that we know are common from a population-based approach that the
majority of people given a similar situation would respond this way. But again,
we need to take the context into perspective. So if someone is experiencing
suicidal ideation, depressive affect, or not interested in eating, they've kind of lost
in energy and lost interest in the things that they like to do. Each of those
symptoms by themselves means nothing. But together, again, over a period of
time, may be a sign of something more significant. So, I tend to use anticipated
stress reactions in the core components of PFA to really help people understand
that what you're feeling, chances are others in your situation are feeling that too.
But here is how you know, if it's something you need to be concerned about or
worry about or if you to need to reach out for help. And finally, reinforcing
strengths and positive coping strategies.




  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Slide 17: “Getting Started”
Mr. Jack Herrmann:
I said earlier that PFA, while it may be practical things that one can do when
providing care to individuals, I also said that I really believe it's a state of being; I
call it the art of being present with someone. It's being able to establish that
rapport and letting them know that your interaction with them is predicated on
being there because you want to help them. You're interested in what's
happening to them and you want to reach out and assist them in any way that
you can. And so it is important in the context of getting started with that
engagement that you take a look at some of these things. Introducing yourself,
making eye contact if it's culturally appropriate. Being able to speak clearly and
slowly and articulate your thoughts so that you know that people are
comprehending what you're saying. And not trying to interject your own thoughts,
feelings, and perspectives on them without understanding where they are first.
Also stay within your expertise, don't be talking about things that you’re
hypothesizing on or just think you know, when you really don't. But most
importantly, you should be compassionate and genuine. If you're not, people will
feel that, and they won’t want anything to do with you. Your ability to engage
with them, their ability to help, will be thwarted because people will sense that
you not genuine, or that there's another motive for you interacting with them. So
genuineness and a sense of compassion is probably the key of being able to
provide Psychological First Aid.

Slide 18: “Be Aware”
Mr. Jack Herrmann:
Being aware of your own surroundings and attentive to what your needs are
versus the other person's needs. But also, if you're not a mental health
professional, it is helpful if you know where some of your resources are around
you in case you do encounter someone who may need more than what you can
provide. And that's also a key to performing Psychological First Aid. As I said
earlier, you need to know what your limitations are.

Slide 19: “Provide comfort care”
Mr. Jack Herrmann:
Psychological First Aid is not permission to be a mini-counselor. What it is, it's a
mode of being able to help people, but you need to recognize when you've
reached your capabilities and capacities and be able to refer people on for
additional assistance.

Slide 20: “Provide Comfort Care”
Mr. Jack Herrmann:
In providing comfort care, you want to promote that sense of calm. If you're
jittery, crazy, and freaking out, then don't be surprised if the person that you're
working with is going to mirror that same reaction. You want to help maintain
safety. I mean, I've seen people try to engage with individuals, and there is a
burning building right behind them, or they are standing in some kind of

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
treacherous area; you need to bring them to some kind of safe place. And you're
not providing them reassurance that, “There, there, everything will be all right,”
you can't know that. The reassurance you are providing them is you are there to
help support them in any way you possibly can and you will do whatever you
need to do to help them feel more assured that there are resources there to
answer the questions, that you will be able to help them as much as possible
within the context of the disaster situation to get their needs fulfilled. But you
don't want to placate them by saying, “There, there,” and “Everything will be
alright,” because sometimes it won’t be and that will not reflect well on you. At
least in being able to help in short trusts.

Slide 21: “Recognize basic needs and help solve problems and complete
practical tasks”
Mr. Jack Herrmann:
Helping meet their basic needs, solving problems, and completing tasks.

Slide 22: “Recognize Basic Needs and Help Solve Problems and Complete
Practical Tasks”
Mr. Jack Herrmann:
Again, at the base of what makes us beings, is that we need to feel safe and
secure and also to take care of our most primitive needs: food, water, shelter,
maybe medication or feeling that sense of safety. So, what this means is that in
order to be able to help people do that we want to assist them in locating disaster
relief services. You may even have to reach out and help them fill out paperwork,
because people can become disorientated at times, they may not know
information that if you asked them the day before when there wasn't a disaster,
they'd be able to recount very quickly. But because of the disaster, it throws off
that equilibrium, it throws off their ability to recall information. We may need to
assist them with transportation - helping them get from Spot A to Spot B. And
again, looking at where they are in the present and what are their most
immediate needs. And sometimes in my experience, I have dealt with people
who have nothing, they've lost everything, but their biggest need at that moment
is, in my mind, something that is useless, or not an immediate need. What you
have to do is help reflect back for them, what do you need right at this moment in
time? How is it by us getting this is that going to help you right now?

Slide 23: “Validate feelings and thoughts”
Mr. Jack Herrmann:
You want to keep them present-focused in what they need to do to take care of
their imminent and basic needs.

Slide 24: “Validate Feelings and Thoughts”
Mr. Jack Herrmann:
Validating their feelings and thoughts, meaning listening to them attentively and
respectfully. Not trying to interject your own feelings and thoughts. Even not
pushing them to talk; so if someone was to say, “I don't want to talk to you right

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
now,” respect that. You're not helping them by pushing them to talk or share
their feelings. We have this sense that by getting it out that's going to make
people feel better. That isn't necessarily true. In some situations, by opening
Pandora's box, you may be putting them at more risk, because you may not be
able to help them once it's unleashed. Or you may have just unleashed
something that is going to create this downward spiral. This sense that we need
to get people to talk in order to get them through this, is really false and we need
to be very careful about what we do to encourage people to talk, and what
settings they are being encouraged to talk in. Help them acknowledge that this is
stressful, and a difficult situation, and refrain from judging. People might say, “I'm
worried about my great-grandmother's crocheted blanket, and its been in the
family for 150 years.” And you as a responder might say, “You're lucky to have
gotten out of that house alive! Why are you focused on a blanket?” You know,
refrain from judging where people are at that moment in time. Just recognize
that's where they are, and help move them towards what's going to be useful for
them at that moment without dismissing or minimizing what their concerns are.

Slide 25: “Provide accurate and timely information”
Mr. Jack Herrmann:
Providing accurate and timely information. How many of you are familiar with,
what has it been, a couple years since the mine explosion, where information
came out that all of the miners were alive, and only within minutes or hours,
finding out that the majority of them had died. Giving accurate and timely
information is critical for preserving people's psychological well-being. During
times of crisis, there is a need for information. It is important not to just give
information without grounding it or making sure it's accurate. It's important that
before you give that information that you truly know it's accurate, and you have
first-hand knowledge of that information. So the key messages here is that
people want more information, as opposed to less.

Slide 26: “Provide Accurate and Timely Information”
Mr. Jack Herrmann:
So provide it as soon as possible, stay within your expertise, or refrain from
sharing information that isn't confirmed or that you've heard four or five parties
out. When you don't know it, take time to find out, and say, “I don't have this
information right now. What I'm going to do is try to find it, and I'll come back and
seek you out as soon as I know it.” And the longer it takes you to find that
information, you should be touching base with individuals to let them know that
you haven't forgotten them.

Slide 27: “Connect to support systems”
Mr. Jack Herrmann:
Connecting them to their support systems.




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  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
Slide 28: “Connect to Support Systems”
Mr. Jack Herrmann:
Again, most people who experience a disaster, will use their families to cope;
they won't need a mental health professional, they won't need a physician, they
won't need to go through some clinical intervention, or need medication in order
to deal with it. Linking them with their support systems will be enough. Linking
them to their family or friends, their peers, reaching out to spiritual care providers,
or other professionals that they may have relationships and may be comforted by.
You need to ask them, who would you want here if you could have them? And
hope that you're able to do that. Worst-case scenario, see if there's opportunities
to link them with others who may be in their setting and could provide them with
more comfort and assurance.

Slide 29: “Provide education about anticipated stress reactions”
Mr. Jack Herrmann:
Provide education about anticipated stress reactions.

Slide 30: “Provide Education about Anticipated Stress Reactions”
Mr. Jack Herrmann:
Again, it is important to acknowledge that in most cases, what people are
experiencing are likely to be reactions that are similar to what everyone else is
experiencing in that situation. But also, you want to acknowledge that people
react differently, not everyone reacts the same. So what you see this person
doing, may not be how you express what you've been through. Don't over-
normalize those reactions but also don't over-pathologize those reactions as well,
and provide them resources so that they know. And again, leading them to
literature, leading them to community resources that can help them understand
better what they're going through and what resources are in that community to
help them should they experience these reactions over a longer period of time
than what they feel comfortable with.

Slide 31: “Positive coping strategies”
Mr. Jack Herrmann:
Promote positive coping strategies.

Slide 32: “Positive Coping Strategies”
Mr. Jack Herrmann:
You want to instill confidence that they can do this. It's not they can do this on
their own, they may need the support and assistance of others, but they can do
this. Find out how they could cope with past experiences that were difficult and
challenging. Encourage them to take that one day at a time, one thing at a time
approach. And also suggest strategies that are practical. You want to explore
with them what they are more likely to. If you are going to suggest an array of
things to help them cope, suggest that things that they are likely to follow through
with. Most of the time those are the things they have tried before and have been
successful with. So you want to pull that out of people, and you want to

  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.
discourage maladaptive coping. You know, there may be a tendency to use
alcohol to self-medicate, you might see increases in smoking, gravitating towards
junk food, watching television repeatedly; there are certain studies that suggest
that the more television exposure that individuals have, the more at risk they may
be for longer term psychological consequences. Okay, we are done with this
part. Thank you. Anybody who has any questions feel free to come up and I'll
take those in between sessions, and I hope I'll see you all in the next session.

Closing:
Once again, that was Jack Herrmann, the Senior Advisor on Public Health
Preparedness for the National Association of County and City Health Officials.
For more presentations from the Pacific EMPRINTS 2008 Pacific Preparedness
Conference: Capacity Building to Address Vulnerable Populations, please watch
Pacific EMPRINTS’ website for upcoming offerings.

Additional Resources:
   1. Psychological First Aid Online Training Course:
       http://www.naccho.org/topics/emergency/pfa/PFA_Start.html




  The Pacific Emergency Management, Preparedness and Response Information Network and
  Training Services is funded by the U.S. Department of Health and Human Services Assistant
            Secretary for Preparedness and Response Grant No. T01HP6427-0100.

				
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