Disaster Behavioral Health

Implications for Community and Migrant Health Care

Centers

Taking the Next Step in Emergency Preparedness

Research Professor Schools of Nursing and Public Health andCommunity Medicine

Randal Beaton, PhD, EMT

Faculty Northwest Center forPublic Health Practice University of Washington

“You can observe a lot by watching”*

*Berra, 1998

NMDS drill (May 13, 2004)

Aims of Disaster Behavioral Health

• To prevent maladaptive psychological and behavioral reactions of disaster victims and rescue workers (to promote resilience)

and/or

• To minimize the counterproductive effects maladaptive reactions might have on the disaster response and recovery

Objectives:

• To identify the Psychosocial Phases of a Disaster with implications for Community and Migrant Health Centers

• To analyze the psychological, social and behavioral patterns observed in the aftermath of disasters including resilience

• To identify strategies to promote and preserve resilience in Community and Migrant Health Center patients & staff

Questions

Psychosocial Phases of a Disaster

Module 1

• Identify the psychosocial phases of a community-wide disaster and to describe the behavioral health tasks for Community and Migrant Health Centers associated with each phase

Learning Objective

Psychosocial Phases of a Disaster

* From Zunin & Myers (2000)

*

• Warning—e.g., weather forecast

• Educate your patients and staff

• Inform of hazards and risk

• Instruct them in ways to stay safe

• Evacuate or “stay put”

Implications/Tasks of each Phase for Disaster Personnel - Pre-disaster

• Risk communication: To reduce anxiety, must also tell people what they should do (without jargon)

• Education using multiple media and multiple languages and messengers, e.g., DOH pandemic influenza campaign

• Drills and exercises should include mental health component

Pre-Disaster

TopOff 2: Seattle, May 2003

Impact

• Prepare for surge- disaster victims will arrive with minutes/80% will be walk-ins

• Advise/instruct/give directions- people will follow leaders and follow instructions (panic is rare)

• Risk communication update- as more is known

• Leadership- is crucial: based on plan & flexible

• Washington state county crisis lines – DSHS/MHD

– http://www1.dshs.wa.gov/Mentalhealth/

http://www1.dshs.wa.gov/Mentalhealth/crisis.shtml

WA State County Crisis Lines (DSHS/MHD)

Heroic

Disaster survivors themselves are true “First Responders”

Honeymoon (community cohesion)

• Survivors may be elated and happy just to be alive

• Realize this phase will not last

Disillusionment

• Reality of disaster “hits home”

• Provide assistance for the distressed- no currently accepted community standard for disaster mental health care= PFA is new & largely untested

• Disaster “issues”• Losses & hardships

Working Through Grief (coming to terms)

• This is when disaster victims actually begin to need psychotherapy and/or medications (only a small fraction)

• Trigger events—reminders

• Anniversary reactions—set back

Reconstruction (“a new beginning”)

Still, even following recovery, disaster victims may be less able to cope with next disaster

What to Say!

DO SAY:

• Can you tell me what happened?

• I’m sorry.

• This must be difficult for you.

• I’m here to be with you.

What Not to Say!

DON’T Say:

– I know exactly how you feel.

– Don’t cry.

– Don’t feel…

– I’m here to help you.

– It could have been worse.

Temporal Patterns of Behavioral Responses

Module 2

• Describe the various temporal patterns of behavioral health outcomes following a disaster

Learning Objective

Question

A. An acute reaction of distress followed by recovery

B. The onset and persistence of PTSD

C. Delayed onset PTSD

D. Resilience

What is the most common behavioral health reaction observed in the aftermath of most disasters?

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

ns

Resilience

Resilience

• Differs from recovery

• Individuals “thrive”

• Relatively stable trajectory• Resilience is often seen in a majority of

disaster survivors

Ways to Promote Community Resilience in the Aftermath of Disaster

• Reunite family members

• Engage churches and pastoral community

• Ask community and migrant health clinic leaders, teachers, and authorities to “reach out”

Risk Factors that Deter Resilience

• Job loss and economic hardships

• Loss of sense of safety

• Loss of sense of control

• Loss of symbolic or community structure

Pre-existing Vulnerability Factors that May Deter Resilience (Risk Factors)

• Lack of resources- lower SES• Lack of social support• Current or history of mental disorder• Lack of a sense of community connectedness

and community cohesion• Lack of plan; lack of training• Child or geriatric status• Language and cultural barriers• Severity of physical injuries & kin/friend fatalities

Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

ns

Acute/Recovery

Acute Distress and Recovery

Post-disaster recovery usually occurs within:

• Days

• Weeks

• A few months

Acute distress and recovery (with or without any intervention) is next most common pattern typically observed in 10-30% of disaster survivors

Temporal Patterns of Mental/Behavioral Responses to Disaster

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

ns

Acute/Chronic

Chronic Distress

•Acute/Chronic Distress and/or Lasting Maladaptive Health Behavior Outcomes•This pattern, while relatively rare (typically 5-15%), accounts for a disproportionate percentage of consumables– counseling, medications and disability

Adapted From Bonanno (2004)

0

10

20

30

40

50

60

70

80

90

100

Event 2 Years

Dis

rup

tio

ns

Delayed

Delayed Onset Distress

Module 2: Temporal Patterns of Mental/Behavioral Responses to Disaster

Delayed onset distress

• This is the least frequent pattern observed; generally seen in less than 10% of disaster survivors (perhaps more common in children)

• One study of 9/11 survivors in Manhattan area reported delayed onset PTSD at one year (but not at earlier times) in 5% of study subjects

Post trauma Growth

• Research suggests that 10% or more of disaster survivors actually experience positive psychosocial changes in the aftermath of a crisis.

(Tedeschi et al., 1998)

Module 2: Temporal Patterns of Mental/Behavioral Responses to Distress

Post-traumatic Growth (Tedeschi, et al, 1998)

0102030405060708090

100

Pre-event

Event 2 years

Dis

rup

tio

ns

APA Fact Sheets on Resilience to Help People Cope With Terrorism and Other Disasters

http://www.apa.org/psychologists/resilience.html

Fact Sheets

Field Manual for Mental Health and Human Service Workers in Major Disasters

http://www.mentalhealth.org/publications/allpubs/ADM90-537/default.asp

Summary

• The disaster behavioral health needs of a disaster affected community depend on the psychosocial phase of the disaster

• Most individuals are resilient and are able to cope with the stressors associated with a disaster

• Some individuals and communities are more vulnerable to the negative impacts on disaster behavioral health

Summary (continued)

• Most short-term psychological and behavioral reactions to disasters are “normal” and do not require a psychological evaluation or treatment

• Some acutely distressed individuals may need and benefit from Psychological First Aid

• A relatively small number of disaster victims may require long term counseling and medications