Healthcare

A Broad Approach to Disaster Mental Health

Managing mental health issues in disaster will be a priority whether you are a medical, non-medical, or mental health volunteer. There are resources throughout this website where you can find: information on post-disaster stress, some general principles as a disaster counseling primer, and some suggestions for psychological first aid in disasters. Here is a broad, pantheoretical outline, excerpted almost in its entirety from World Health Organization website, on the undefined and hidden burdens of mental health problems. They are organized around the letters A, B, C, D, E, and F as follows:

A: Manage and decrease AROUSAL

1. Protect:
• Protect the survivor by assuring basic needs such as survival, safety, security, food, water, medical care, shelter, clothing, etc. Remove survivors from traumatic scenes, media, onlookers, etc.
• Protect yourself: keep calm, be realistic, don’t become a victim!


2. Connect:
• Connect people with their loved ones, family, friends, and community.
• Connect to information, as it is the lifeline in disasters, while providing information early and often.
• Be practical, be supportive and give “comfort communication”.
• Reassure, tell the truth when it is known, explain what is being done to deal with the problem, tell what is known and what is not known, and be credible.
• Connect with support resources.

3. Respect:
• Be sensitive to cultural diversity: Know the cultural group that you are working with and understand that they may respond differently than expected.
• Ask assistance of community leaders.
• Don’t stereotype or be judgmental.
• Respect individual beliefs and values.
• Tell survivors that you are trying to help, and ask them to help you understand.
• If you make a mistake, apologize.

4. Reflect:
• Let people tell their story; use active listening; don’t push for traumatic details; provide support and a forum for people to discuss their reactions, if they are so inclined.

5. Direct:
• People in disasters are often overwhelmed and often are unable to make simple decisions: help them problem-solve in a practical way; define simple, concrete tasks; and set realistic goals.
• Make sure you listen to what their needs are, rather than assume that you know what they need, and direct them step by step to the resources they have identified they need respect their competency in decision making.

B: Encourage functional BEHAVIOR

1. Although panic may be rare, people may react this way when they feel they are trapped, have limited resources, feel at high risk, or perceive a lack of effective management.
   
   Dealing with angry, irrational or aggressive behaviors:

• Avoid overreaction and under reaction: begin with a supportive approach that requires empathic and active listening; avoid being judgmental or dismissing the person as a “complainer”.
• Watch for clues and cues: If the survivor begins to give you clues, verbally and nonverbally, that he or she is beginning to lose control and are not rational, make sure you attempt to set some limits.
• For example, if people are getting too loud, let them know why their behavior needs to cease. A simple explanation can often be enough. If it is not, point out that they cannot stay in the area unless they quite down. Try to help them feel as if they have a choice. Try not to get into a no-win power struggle.
• If a person refuses to follow directive or crisis has occurred and all means of managing the situation have been exhausted, try to avoid physical intervention. Try to remember that most physical aggression is not premeditated violence, but often simply pent-up frustration.
• Be aware of your nonverbal communication.
• The proximity between you and a possibly violent person may be perceived as a threat if you encroach on their “personal space.” Even though you may be speaking in a calm voice, recognize that face-to-face, shoulder-to-shoulder may be seen as a “challenge position.” Be aware of your paraverbal communication -- how you are speaking may be more important than what you are saying.
• Although you may have good intentions, the person may perceive you as the threat. If you cannot manage their aggression, remove yourself from the environment and get appropriate help. Stay safe!

2. Help people deal with their stress and anxiety in a positive manner
   Teach and apply coping techniques in stress management and self-regulation, including such practices as deep breathing, relaxation, exercise, and finding acceptable outlets for boredom and frustration when sitting for days in a shelter.

3. Dependency, immobility and inactivity may precipitate stress. Activities such as music, singing, art, finding humor, prayer, and meditation are helpful.

4. Present options and redirect to constructive tasks.

5. Get people to help each other.

6. Remember, it is often the secondary stressors (*Internal link) that are more difficult than the primary event.

7. Identify those who might be high risk and using negative coping: substance abuse, impulsive or destructive venting of anger, poor reality testing, etc.

C: Promote CLEAR COGNITION

1. Keep people oriented and provide reality testing.

2. Clarify what has happened.

3. Help them identify realistic goals and set up small steps to achieve those goals.

4. Remember, thinking may be clouded. It might be difficult to listen and retain. Repeat often, have written information available.

5. Be patient.

6. Help “reframe” irrational thinking.

7. Identify those that are unable to perform necessary everyday functions, unable to make simple decisions, disoriented to time and place, or experiencing paranoia, hallucinations, extreme disturbances of memory and practice psychological first aid.

D: DIAGNOSE ways of responding to the disaster

1. Focus on “normalcy” of disaster stress response
   Most people will experience post-disaster stress (*Internal link) including the following components:
1. Physical
2. Emotional (fear, anger, irritability, hopelessness, etc.)
3. Cognitive (decision-making, decreased attention span, memory problems, struggle to listen to directions)
4. Behavioral (crying, increased substance abuse, change in sleep, etc.)
5. Spiritual (questioning values and beliefs, loss of meaning)

2. When people are distressed over their symptoms:
1. remind them that they are “normal people, experiencing a normal response to an abnormal event.”
2. Remind them also that they may not function as well as during normal times, but that most will return to normal functioning and that some may even emerge healthier and more resilient (*Internal stress)
3. Remember that the expectation is recovery: remind people that things may never be the same, but that they will get better

3. Remember, individuals are very vulnerable and suggestible in this stage. Often they are very reluctant to seek mental health assistance for fear of being labeled.

4. Less is more:
1. Don’t initially over-diagnose or over-treat.
2. Don’t use mental health jargon!

5. Do identify people at high risk for traumatic response, using the acronym PIE:
1. Proximity
2. Intensity
3. Exposure

And remembering specific risk factors :

4. Severe injury
5. Extensive financial loss
6. Major property destruction
7. Death of loved one
8. Social support
9. Women (higher rates of PTSD and depression)/ children/ elderly
10. Pre-existing psychiatric illness

Remember that some disaster-related symptoms may also be due to medical issues: delirium from medical problems, dehydration, withdrawal, etc.

6.  Consult or refer whenever you feel the problem is beyond your skills or capabilities, including for some of the following responses:

1. Suicidal/Homicidal thoughts
2. Serious regression/isolation/withdrawal
3. Inability to function in everyday life
4. Significant disturbances of memory/disorientation/confusion
5. Psychotic symptoms: hallucinations, paranoia, etc.
6. Abuse of alcohol/drugs

E: Educate

1. Better than any medication -- INFORMATION treats anxiety during crisis

2. Be interactive, be firm, be direct.

3. Educate individuals regarding:
1. Normal responses - what to expect
2. Stress management techniques
3. Adaptive behaviors
4. When to seek additional help
5. Reinforce resiliency (*Internal link) (Remember that positive adaptation in the face of adversity is NOT extraordinary—it is the RULE, not the exception!)
6. Resources in community, on-line, etc.

F: Fellow Colleagues

1. Have a support system available - don’t isolate.

2. Pay attention to your own reactions. Keep your arousal and anxiety down and practice self-care (*Internal link) during the time of disaster response. Basic self-care includes: reasonable work hours, rest, exercise, healthy diet with limitations on alcohol and caffeine intake.

3. Use the buddy system to monitor yourself and your fellow colleagues.

4. Limit exposure:
1. Don’t work more than 12-hour shifts.
2. Rotate from high intensity to lower intensity if possible.
3. Take breaks.

5. Be reasonable with yourself. You are not responsible for making everything okay.

6. Keep in touch with your family and loved ones.

7. Remember why you are here.