Disaster Mental Health Interventions by maclaren1



  George S. Everly, Jr., PhD, ABPP

  Dept of Psychiatry and Behavioral Sciences, The Johns
          Hopkins University School of Medicine
The Johns Hopkins Center for Public Health Preparedness
 The Johns Hopkins Bloomberg School of Public Health

Participants will increase their understanding of:

     1. The JHU resistance, resilience,
      recovery model
     2. What returning military members need
      to feel resilient.
     3. How large and small group crisis
      interventions foster resilience.
     4. What clinicians can do.
     5. What clinicians should NOT do.
1. Johns Hopkins’
An outcome-driven continuum of care

Build Resistance      Enhance Resiliency         Speed Recovery
 Immunity                Rebound                Treatment/Rehab

  Kaminsky, et al, (2005) RESISTENCE, RESILIENCE, RECOVERY, Johns
Johns Hopkins’

Build Resistance            Enhance Resiliency            Speed Recovery
 Immunity                       Rebound                  Treatment/Rehab

  Expectancy                                                    CBT, EMDR
     +                         Crisis Intervention
  Experience                          CISM

Group cohesion
Kaminsky, et al, (2007) RESISTENCE, RESILIENCE, RECOVERY, Brief Treatment & Crisis
  2. What do People Need?
 Honest, Reliable Information
 Interpersonal Support, a Sense of
  Connectedness (UDT/SEAL)
 Confidence, Self-efficacy
 Faith in Leadership (“strength & honor”)
 Belief in Something Greater than
  Themselves (Faith, Duty)
 Future Orientation
3. Group Crisis Intervention
 Debriefings (small group - interactive)
 Crisis Management Briefings (Large or
  small group - informational)
 Battle Mind (Informational and
      Mechanisms of Action
   Information
   Normalization
   De-stigmatization (Hoge)
   Fosters interpersonal support (Yalom)
   Exerts anti-demoralization effect (Frank)
   Peers communicate with unique ethos
         (Sheehan, 2004, FBI Law Enforcement Bulletin)

 Peer-based intervention system, consisting of…
 Basic communication skills
 Assessment/ triage of benign vs. malignant
 Chaplain services
 MH consultation/ support
 An integrated continuum of intervention services
       Crisis Intervention
 A short-term helping process designed
   Stabilize distress
   Mitigate distress
   Assess need for continued care
   Facilitate access to continued care, if
   NOT psychotherapy, nor a substitute for
 Crisis Intervention Principles

 Proximity
 Immediacy
 Expectancy
ARTISS (Military Medicine, 1963)
Regarding war neurosis, removal of the
soldier from the front “returned only five
percent of such casualties to duty” (p.

The treatment principles of immediacy,
proximity, & expectancy (PIE) were later
applied and resulted in 70 to 80 percent
of combat psychiatric casualties
returning to duty.
         Zahava Solomon
 Tested PIE with Israeli soldiers finding all
  3 components active, but expectancy
  most useful
 Re-tested 20 years later finding those
  who received PIE did better in post-
  military life than did those who did not
  receive PIE
 Boscarino, et al., 2005, 2006,
 conducted a random prospective cohort study
  utilizing a sample of 1,681 New York at 1 year
  and 2 years after 9/11. Results indicate that
  brief workplace-based crisis interventions,
  (CISM), had a beneficial impact including
  reduced risks for binge drinking, alcohol
  dependence, PTSD symptoms, major
  depression, anxiety, and global impairment,
  compared with individuals who did not receive
  these interventions.
     CISM: Integrative Crisis
    Intervention and Disaster
          Mental Health
             (Everly & Mitchell, 2008)

 Integrated multi-component intervention
 Utilizing the most effective intervention
  for the target population given the current
  challenge at hand
 Most widely used model: Critical Incident
  Stress Management (CISM)
 Used by United Nations
CISM was found to be superior
to acute-phase psychotherapy,
          post 9/11.

   Psychotherapy tended to
 increase symptoms of PTSD.
4. What Can Clinicians Do?
   Normalize
   Triage
   Provide anticipatory guidance
   Reinforce importance of connectedness
   Foster future orientation
   Foster problem-solving approach to life
   Reinforce role of clinician as consultant
   Practice PFA
                 “Red Flags”
  Dissociation               Reliance upon self-
   Depersonalization          medication
   Derealization             Lack of social support
                              Hyperarousal (severe
 Depression and Guilt         exaggerated startle
   Survivor Guilt             response, explosive
   Psychogenic amnesia
                              Evidence of seizures
   Persistent sleep
    disturbance               Inability to function after
   Panic
   Violent inclinations
   Psychosis
       Predicting Beyond Immediate
1. Dose - response relationship with exposure
2. Peri-traumatic dissociation
3. Peri-traumatic belief one was going to die
4. Negative appraisal of symptoms
5. Physical injuries
6. Peri-traumatic panic
7. Psychogenic amnesia
8. Peri-traumatic depression, despair, numbing
9. History of significant mental illness
10. Significant loss
    Crisis Intervention Triad
                 (Everly & Mitchell, 2008)
   Antidote for impulsivity:
    Slowing down the interaction (assuming medical
    stability and no other objective urgency); suggesting a
    delay in any actions which have lasting consequences;
   Antidote for inability to understand consequences:
    Using the crisis communication techniques of
    summary and extrapolation paraphrasing to assist
    individuals in gaining insight into the consequences of
    actions and to see options; and
   Antidote for hopelessness:
    A supportive, optimistic presence that corrects
    misconceptions, conveys both directly and indirectly a
    future orientation, hope; facilitation of access to
    continued care, if indicated (friends, family, EAP, MHP,
     5. What Clinicians Should
   Traditional patient-focused psychotherapy
   Non-directive counseling
   Confrontation
   Fostering dependency/ transference reactions
   Paradoxical intention
   “I know how you feel”
   Fostering affective abreaction, unless other-
   Dr Everly’s MHC Burnout Club
 1. Be a perfectionist, never accept
 2. Never exercise!
 3. Remember, the glass is always half
 4. Eat as much “fast food” as possible; only
  eat things that had faces (chickens don’t
  count--no lips). Never eat breakfast.
 5. Blame all of your failures in life on your
  parents, your lack of friends, your coercive
  unethical money-grubbing
  outsourcing capitalistic boss, or the great
  right-wing conspiracy.
 6. Accept responsibility for everything and
  everyone, all the time! You must make all
  veterans happy.
 7. Engage in an endless process of controlling
  everything and everyone, especially those
  people/ things over which you have no actual
  control. Empathize…you must feel their pain.
 8. Strive to sleep as little as possible!
 9. Feel guilty when leaving the disaster at end
  of deployment. NEVER take vacations, if
  forced to do so, feel guilty.
 10.Seek out a routine: Sleep until you are
  hungry, eat until you are tired; use ETOH to
  relax, stimulants to get going.
 geverly@jhsph.edu
 Everly, GS, Jr. (2009), Resilient Child. NY:
 Everly, GS, Jr., etal. (2010). Resilient
  Leadership. NY: DiaMedica.
 Everly, GS, Jr. & Mitchell, JT (2007).
  Integrative Crisis Intervention and Disaster
  Mental Health. Ellicott City, MD: Chevron.
 Everlybooks.com

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