Hurricane Katrina Revisited Disaster Mental Health Issues then and

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					Disaster Mental Health Issues:
     Immediate and Over Time

          Bill Martin, Ph D
 Disaster Response Network Coordinator
      MS Psychological Association
Presentation Objectives

   Understand impact of disaster trauma
   Understand roles in disaster response
   Understand disaster mental health
   Understand long term disaster mental
    health needs
Characteristics of Disaster:
   “A disaster is an occurrence such as a
    hurricane, tornado, flood, earthquake,
    explosion, hazardous materials
    accident, war, transportation accident,
    fire, famine, or epidemic that causes
    human suffering or creates collective
    human need that requires assistance
    to alleviate” (SAMHSA).
Nature of the Disaster
influences impact

   Natural vs Human-Caused
   Personal Impact
   Size and Scope
   Visible Impact
   Probability of Recurrence
Who is impacted by a
No one who sees a disaster is
      untouched by it.
Population Exposure

                  (DeWolfe, 2000)
   Seriously injured, families/friends of those
    seriously injured or killed.
   Community survivors exposed or
    experiencing significant damage.
   Responders dealing with casualties
    Health/Mental Health/Media dealing with
   Community at large, businesses, those
    exposed via media
Epidemiology is unclear

 – Keane, Terence. The Epidemiology of
   Post-Traumatic Stress Disorder: Some
   Comments and Concerns. PTSD Research
   Quarterly. Vol 1, No. 3, 1990.
    Wide variations in estimates within and
     across events (ranges 5% - 40%)
    Self report measures predominate

    Vietnam Vets: 15% PTSD current incidence,
     (Kulka et al (1990)).
   Effects of Traumatic Stress in a
    Disaster Situation. NCPTSD Fact
    Sheet. 2000.
    – Natural Disaster       4-5%
    – Bombing                34%
    – Plane Crash into Hotel 29%
    – Mass Shooting          28%
   Kessler, Ronald. Overview of Baseline
    Survey Results: Hurricane Katrina
    Community Advisory Group. Harvard
    Medical School. 2006.
    –   Survey 1000… follow up with 800
    –   Loaded more toward N.O. population
    –   2006: 16% w/Sx PTSD & 3% considered suicide
    –   2007: 21% w/Sx PTSD & 6% considered suicide
          Normal Reactions to
          Abnormal Events
   Resilience is probably the most common
    observation after all disasters.
    – Hurricane Katrina: 26% said life was worse
      afterwards, 60% said about the same and 14%
      said better.
   The effects of traumatic events are not
    always negative.
    – Learn they can “handle” crises effectively
    – Communities can grow closer together
   Most “recover” on their own within 1-2
Disaster Response Phases

               (Adapted from Zunin/Meyers)
    Disaster Mental Health:
       Who are your clients?

   Individuals and families of survivors
   Disaster responders
   Responding agencies and
   Communities (especially over time)
Disaster Response

   Responders work within some
    organization structure
   Little opportunity for individual effort
   Sustained effort is important
   Chaos and confusion reign
National Incident
Management System
   Mandated comprehensive national approach
    to incident management
   Standard operational doctrines
   Applicable to all jurisdictions
   Flexible to scale
   Allows common vocabulary, titles and
    communications across situations and
   Promotes smooth transitions in personnel,
    resources, command and control
ICS Organization:
Functional Structure

                             ICF Commander

                                      Logistics Chief
Operations Chief   Planning Chief                         Finance/
Operations Section

                    Operations Section

                                         Emergency Medical
Suppression Group   Rescue Group
                                           Service Group

                                          Disaster Mental
                                            Health Unit
Planning Section

                                   Planning Section

Resources Unit   Situation Unit   Demobilization Unit   Documentation Unit

                                                                             Mental Health


                 Service Branch                                         Support Branch

Communications    Medical                                                  Facilities    Ground Support
                                  Food Unit               Supply Unit
    Unit           Unit                                                      Unit             Unit
Area Command Post

        Area Commander

  ICP        ICP         ICP
Volunteer and Faith-
Based Groups
   American Red Cross
   Faith-Based
    –   Church of the Brethren Disaster Response
    –   Mennonite Disaster Service
    –   National Organization for Victim Assistance
    –   The Salvation Army
    –   Southern Baptist Convention
    –   United Methodist Committee on Relief
    –    Others
Community Based

   Schools
   YMCA
   Boys and Girls Club
   Others
        Normal Reactions to
         Abnormal Events:
         Acute and Chronic

   Behavioral
   Emotional
   Cognitive
   Physical
   interpersonal

   Getting Along with Others
   Sleep Changes
   Activity Level Changes
   Nightmares/Troubling Dreams
   Job Performance Changes
   Substance Abuse
   Avoidance
   More Accidents

   Startle Easily
   Under-Controlled Anger
   Under-Controlled Crying
   Persistent Sadness
   Feelings Helplessness/Hopelessness
   Poor Frustration Tolerance
   Don’t Feel Pleasure like before
   Difficulty Concentrating
   Difficulty with Memory
   Difficulty with Learning
   Trouble Solving Problems
   Short Attention and Confusion
   Difficulty Making Decisions
   Immune system weakened
   More Diseases
   Problems Healing Injuries
   Changes in Eating Habits
   Weight Loss/Gains
   Changes in Sleeping Patterns
   Fatigue… less Endurance

   Relationship Conflicts
   Parenting Problems
   Disruption of Support Systems
   Changes in Preferred Activities with
    Family and Friends
   Changes in Job, or Job Performance,
    or Job Satisfaction
Disaster Vulnerabilities
   Severity of exposure, especially injury
   Living in disrupted community
   Female gender
   Age in middle years (40-60)
   Little previous disaster experience
   Ethnic minority group membership
   Poverty & Low SES
   Presence of children in the home
   Significantly distressed spouse
   Psychiatric history
   Secondary stress
   Weak or deteriorating psychosocial resources
            Special Needs of
   Reactions comparable to survivors, plus…
   They arrive with their own emotional baggage
   Unrealistic goals for their involvement
   Should be heroic, invulnerable, professional
    – Belief that only other (cops, firemen, military, mental
      health folks, etc) can understand
   Unrealistic expectations from supervisors
   Failure to pace self… stay in emergency mode
   Underestimates impact of vicarious trauma
General Rule…

   Those most vulnerable before a
    disaster are most vulnerable after a
Needs following Disaster

   Maslow revisited
    – Safety
    – Food/Water/Shelter
    – Re-establish social units
    – Empowerment
    – Recovery
       Coping Continuums

   At Risk    <--------->   Safe
   Chaos      <--------->   Control
   Confused   <--------->   Informed
   Avoidant   <--------->   Engaged
   Helpless   <--------->   Empowered
   Grief      <--------->   Resolution
      Disaster Mental Health

   General Issues:
    – Best to conceptualize as “Normal reactions to
      abnormal circumstances”
    – Most adapt and adjust over time
    – Most will not see self as having mental health
    – Most will not seek traditional mental health care
          And may be confused about what “mental health care”
    Traditional Mental Health

   Psychiatrists
   Psychologists
   Social Workers (Licensed)
   Psychiatric Nurses
   Licensed Counselors
   Marriage/Family Counselors
   But there are so many others now
   But there are so many others now

   And the profusion of providers
    confuses the “product”
Contemporary Mental
Health Providers
   “counselors”… for      crisis managers
    every problem          crisis debriefers
   peer counselors…       clinicians
    for every peer         advocates
   “social workers”       life coaches
   case workers           mentors
   case managers
   therapists
   “family” workers
    Immediate Intervention:
     Psychological First Aid
   Contact & Engagement       Linkage
   Safety & Comfort            w/Collaborative
   Stabilization               Services
   Information Gathering
    & Assessment
   Practical Assistance       Take care of yourself
   Connection w/ Social
   Information on Coping

   Be polite, respectful and sensitive
   Be observant
   Be calm, patient and responsive
   Keep language simple and at appropriate
    developmental level
   Speak slowly
   Give only accurate information
   Stay in the here and now

   Do not make assumptions
   Do not pathologize.
   Do not emphasize deficits… look for
   Do not “debrief” but be sure to listen
   Do not speculate or pass on
    unconfirmed information
Contact and Engagement

   Introduce self… ask about immediate needs
   Be sensitive… intervention is intrusive
   Be calm... Remember the label on the pickle
   Ensure immediate safety & comfort
   Enhance predictability & self control
   Provide simple information
   Promote social engagement
Stabilization (if needed)

   Observe for signs of being
   Help “normalize” experience
   Consider alternative activities
    (breathing exercises, a walk, etc)
   Consider sources of social support
   Consider use of “grounding” or
    “thought substitution”
Information Gathering
   Nature and severity of disaster experience
   Exposure to death or serious injury
   Post disaster circumstances and ongoing threats
   Separation and loss issues
   Physical illness/Medication or Mental Health issues
   Available social support
   Thoughts about harm to self or others
   Substance use practices
   Prior successful coping experiences
Practical Assistance

   Most immediate needs
   Clarify the need
   Discuss their action plan or help
    develop an immediate action plan
   Provide instrumental support in taking
    Connection with Social
   Enhance access to primary support
   Encourage use of immediately
    available support persons
   Discuss importance of support seeking
    and of helping others
Information on Coping
   Reality based information about situation
   Basic information about normal stress reactions
   Basic information on ways of coping (resiliency)
   Demonstrate simple relaxation techniques
   Assist with developmental issues
   Assist with anger management issues
   Address highly negative emotions (i.e. guilt and
   Help with sleep problems
   Address substance abuse
   Lots of brochures and booklets available
          Linkage with
     Collaborative Services

   Direction to additional needed services
   Promote continuity in helping
    relationships (and describe limitations
    in your intervention)
      Long Term Recovery

   Community resources significant
    – Health and mental health resources
    – Social services
   Basic infrastructure
        Economic
        Transportation

        Housing

        Cultural
Long-Term Stress Impact
   Anxiety and vigilance      Isolation and
   Anger, resentment and       hopelessness
    conflict                   Health problems
   Uncertainty about the      Physical and mental
    future                      exhaustion
   Prolonged mourning of      Lifestyle changes
   Diminished problem
      Long Term Recovery

   Recall that most will not seek
    traditional mental health services

   May have already seen multiple
    “counselors” and still have problems

   So… what to do?
      A Recommendation:
      Resiliency Training

   Let’s “package” some immediately
    useful psychological knowledge into a
    more easily digestible product for the
Resiliency Training

   A “psychoeducational” model
Resiliency Training

   A “psychoeducational” model
   Delivered through existing and
    established organizations/agencies
    – They already have credibility
    – They already have a population
Resiliency Training

   A “psychoeducational” model
   Delivered through existing and
    established organizations/agencies
   Not likely to produce any fees
Resiliency Training
   A “psychoeducational” model
   Delivered through existing and established
   Not likely to produce any fees
   Possible role for MPA… and for Professional
    – Sponsoring these psychoeducational “classes”
    – Public education about Psychology and what it
      has to offer

   Are hardy, resilient people just born
                 that way?
   Resiliency skills can be taught, are
    learned and, when practiced, increase
    our hardiness; our ability to withstand
    sudden and longer lasting stress.
Resilience (simply) is…
an ability to endure more stress and
respond more effectively, even in
longer lasting crises.
Ways to Build Resiliency

   Take care of             Take decisive action
    yourself                 Move toward goals
   Take control of          Accept that change
    what you can              is part of living
   Avoid seeing crises      Keep things in
    as insurmountable         perspective
   Realistic                Stay focused
    expectations             Keep at it
   Make connections
    with others
Take care of yourself

 – Avoid unnecessary risks
 – Build a nest
 – Eat well
 – Drink fluids
 – Get active, maybe even exercise
 – Have rest periods
 – Have recreation periods
 – Pace ourselves
Take control

 – We think “moods” control our behavior.
 – More often, “behavior” controls “moods”.
 – Change your behavior and your mood will
 – Make decisions about what you will do
   and when you will do it and then do it.
 – Schedules and routine are our friends.
Avoid seeing crises as

 – We can’t change facts, change reality.
 – Ultimately, we can only adapt to reality.
 – But we can change how we think about,
   talk about events, and that will change
   how we feel and react.
Realistic Expectations

 – We “judge” outcomes based on our
 – If our expectations are unrealistic, then
   we are bound to be dissatisfied,
 – We can try to get more accurate, realistic
   information, so expectations are realistic.
 – Focus on what can be done, not what
   can’t be done.
Make Connections

 – Family
 – Friends
 – At work
 – Civic groups
 – Faith-based groups
 – Assisting others
Take decisive action

 – Avoidance and passivity are most
   predictive of worse adjustment.
 – Accomplishment, even little steps, builds
   sense of control and confidence.
Move toward your goals

– Set goals… hourly, daily, weekly…
– Make a plan
– Start with a here and now focus
– Impose some structure, some routine
– What can I do now that will move me
  toward a goal
Change is part of living

   Accept that change is a necessary,
    unavoidable part of living
    – Changes in life circumstances
    – Changes in goals
    – Changes in expectations

   Then adapt, make the changes that
    seem better for you… now
Keep things in perspective

 – Watch how we describe things to
 – Avoid those generalities… those “never”
   and “always” and “should” and “must”.
 – Get those facts… things as they are and
   not things as we wish they were… or
   think they ought to be.
 – Accurate information leads to more
   effective coping.
Stay focused

 – Write that plan… day by day
 – Write that journal… day by day
 – Keeps us focused
 – Allows us to see and measure progress
Keep at it

 – Perseverance has much to do with
   successful coping
 – A journey of a thousand miles is still one
   step at a time
 – Focus on the steps… not just on the end
   of the journey
Disaster Mental Health Issues:
     Immediate and Over Time

          Bill Martin, Ph D
 Disaster Response Network Coordinator
      MS Psychological Association

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