Introduction to Planning and Preparedness

In some ways, health care professionals must prepare for disasters the same way as everyone else. The information in the public section of this website will be very helpful for you, in educating yourself about various disaster possibilities in your area (PDF), developing a written disaster plan (PDF), for your home and for your place of work (PDF), compiling and storing your disaster supply kits (PDF), and preparing in other physical and tangible ways for a disaster.

In addition, health care professionals must address another important component of preparedness and planning: mental health. How can you as a health professional prepare and plan for a disaster so that you may not only survive it personally but respond to it in a way that promotes your growth and that of others? Preparedness includes not only the essential actions and information-gathering referenced above, but mental health as well. Being prepared can reduce fear, anxiety, and losses that accompany disasters.

The U.S. Substance Abuse and Mental Health Services Administration (PDF), assembled a group of experts to study what helps people through disaster. The results of these studies included ten common features of a mentally healthy response to disaster events.

These fundamental components of recovery are:

1. An individualized and person-centered approach. Each of us must prepare and plan for disasters in a way that “fits” with how we are human. For example, a disaster that involves relocation will be experienced differently for someone who has recently moved to a city compared to someone who has lived there all of her life. (links to other fact sheets here)
2. Self-direction: Although other people can influence and assist with our response to life events, including disasters, we must keep in mind that each person’s experience of a disaster is unique. Accordingly, we must make personalized decisions based on what we know to be best for us.
3. Hope: Psychologists have found that hope, something that other traditions might refer to as positive outlook or even faith, can help people to prepare for and experience disasters in a mentally healthy fashion.
4. Responsibility: Although resources, including websites such as this one, can help in preparation, ultimately disasters demand that we respond in ways that take responsibility, in ways that are our own.
5. Empowerment: The essence of preparedness is to be empowered, to be able to be a participant in the process of disaster response, not be a mere victim. Additional information about empowerment is located throughout our website.
6. Respect: People experiencing disasters remain, first and foremost, people. A mentally healthy approach to disasters respects and honors personal experience and meaning-making.
7. Peer-support: Although each of us will experience a disaster in ways that are unique to us and to our experience, and although we can count on governmental and other agencies to assist us through these experiences, reliance on those around us and similar to us is also an important feature of a mentally healthy response to disasters.
8. Strengths-based: Our approach to mental health in disaster is founded on the idea that people are fundamentally strong, and that rather than speaking to deficits or shortcomings, we build our response to disasters on these strengths.
9. Non-linear: Although some elements of disasters and our responses to them are predictable in terms of progressing through phases toward a defined outcome, a mentally healthy response to disaster takes its own journey, sometimes with twists and turns and according to its own timetable. Responding to and recovering from disaster is a personal and unique experience.
10. Holistic: This element of preparedness, response, and recovery emphasizes how disasters are part of a whole life and culture and time, and although having some special features, they are not separate from other human experience.

 

Web Links

This site lists SAMHSA’s 10 fundamental components of Recovery (PDF)

 

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 (*Internal link) 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. (*Internal link)
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. (*Internal link)

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 :
   1. Severe injury
   2. Extensive financial loss
   3. Major property destruction
   4. Death of loved one
   5. Social support
   6. Women (higher rates of PTSD and depression)/ children/ elderly
   7. 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.

Web Links

This site contains tips for emergency and disaster response workers.(PDF)

This site tracks disaster behavioral health trainings and conferences.(PDF)

This is a link to SAMHSA’s National Mental Health Information Center (NMHIC).(PDF)

This is a link to SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI).(PDF)

 

 

 

Psychological first aid and health care professionals

In the same way that you respond to medical emergencies through the ethical principles of doing no harm and doing good http://www.aaem.org/aboutaaem/codeofethics.php, there are some principles of mental health first aid that will help you respond helpfully and ethically. Here are some suggestions, adapted and modified from the Substance Abuse and Mental Health Services Administration (SAMHSA) website (PDF).

When you first meet people who have experienced disaster, they will often have intense and appropriate emotions that include intense fear, uncertainty, and apprehension. You can help them manage the stress associated with their initial disaster response through the following “Dos” and “Don’ts”:

DO:

Promote Safety:

• Help people meet basic needs for food and shelter, and obtain emergency medical attention.
• Provide repeated, simple, and accurate information on how to get these basic needs.

Promote Calm:

• Listen (PDF) to people who wish to share their stories and emotions and remember that there is no right or wrong way to feel.
• Smile, use a soft tone and open and welcoming gestures, while allowing the person you are talking with to dictate the distance between you.
• Be friendly and compassionate -- even if people are being difficult.
• Offer accurate information about the disaster or trauma and the relief efforts underway to help victims understand the situation.

Promote Relationships:

• Introduce yourself if they do not know you.
• Ask the person what they would like to be called, and do not use nicknames or first names without permission. With some cultures it is important to always address the person as Mr. or Mrs.
• Use words like “please” and “thank you”.
• Do not make global statements about the person’s character.
• Lavish praise is not believable.

Promote Connectedness:

• Help people contact friends and loved ones.
• Keep families together. Keep children with parents or other close relatives whenever possible, and understand that the way of responding to trauma will vary with levels of development.

Promote Self-Efficacy (PDF):

• Give practical suggestions that will steer people toward helping themselves. This is a time for “tranquilization by the trivial.”
• Engage people in meeting their own needs.

Promote Help:

• Find out the types and locations of government and non-government services and direct people to those services that are available.

DO NOT:

• Force people to share their stories with you, especially very personal details.
• Give simple reassurances like “everything will be okay” or “at least you survived.”
• Tell people what you think they should be feeling, thinking, or how they should have acted earlier.
• Tell people why you think they have suffered by alluding to personal behaviors or beliefs of victims.
• Make promises that may not be kept.
• Criticize existing services or relief activities in front of people in need of these services.

These and other ways of being can interfere with the working alliance (PDF) you might otherwise establish with people you are trying to help.

Look for signs of agitation and increased stress. People in such phases of response to disaster may:

• Challenge or question your authority, in which case you might:
• answer the question calmly.
• repeat your statement calmly.
• Refuse to follow directions, which may be best responded to by:
• not asserting control. Rather, let the person gain control of him- or herself.
• remaining professional.
• restructuring your request in another way.
• giving the person time to consider your request and perhaps pose alternatives.
• Lose control and become verbally agitated, to which you might:
• reply calmly.
• state that you may need assistance to help them.
• Become threatening or intimidating, not responding to your attempts to calm, in which case you should:
  • seek immediate assistance

Adapted from “Nebraska Disaster Behavioral Health Psychological First Aid Curriculum” at this site (PDF).

Summary: People in the midst of disasters, or immediately following, will often have strong feelings of confusion, fear, hopelessness, sleeplessness, anxiety, grief, shock, guilt, shame, and loss of confidence in themselves and others. Your early contacts with them can help alleviate their painful emotions and promote hope and healing. Your goal in providing psychological first aid is to promote an environment of safety, calm, connectedness, self-efficacy, empowerment, and hope.

Web Links

http://mentalhealth.samhsa.gov (PDF)

http://ncadi.samhsa.gov (PDF)

Treatment Locators

Mental Health Services Locator
(800) 789-2647 (English and Español)
(866) 889-2647 (TDD)

Substance Abuse Treatment Facility Locator
(800) 662-HELP (4357) (Toll-Free, 24-Hour English and Español
Treatment Referral Service)
(800) 487-4889 (TDD)

Hotlines

National Suicide Prevention Lifeline
(800) 273-TALK (8255)
(800) 799-4889 (TDD)

SAMHSA National Helpline
(800) 662-HELP (4357) (English and Español)
(800) 487-4889 (TDD)

Workplace Helpline
(800) WORKPLACE (967-5752)

 

 

Practical preparedness for health care professionals

Many health care professionals, particularly those who volunteer with their professional organizations, can prepare practically for disasters prior to the immediate need. In so doing you will want to keep the following in mind:

• Consult available guidelines for compiling medical equipment and supplies (PDF). These may be transported in a camera bag instead of the more traditional physician or nurse’s bag.
• Communications needs are essential in health care within a disaster zone, and traditional methods of communication may no longer work. Broadband internet (cable modem and DSL), landline telephones, and cell phones all failed in the days following Hurricane Katrina. Consult with disaster relief agencies appropriate to your profession to prepare yourself for communication during disaster work.
• Travel and transportation are often compromised during disasters. Acquaint yourself with disaster status briefing sources in the State of Georgia so that you may plan accordingly for travel to, and movement within, the disaster area. You may also want to have a bicycle available for local transportation.
• Anticipate flexibility around your place of service. Your health care office may be unusable after a disaster. Even if the structure is undamaged, loss of power and ventilation may prohibit seeing patients there. Consider alternative options for practice space in advance of a disaster, and again, contact your state professional association to see about organized alternative office facilities in the event of a disaster.
• Even a relatively minor disaster can cause loss of electricity for prolonged periods, and a major event such as a Category Four Hurricane can destroy the electric grid for three months or longer. A generator can improve quality of life and quality of practice while potentially reducing losses after a disaster.
• All families should prepare for disaster by having essential documents consolidated and readily available. Health care professionals, however, need to anticipate that copies of your credentials, licenses, and hospital photo identification may be necessary for practice during times of disaster. You might consider preparing a folder with copies of DEA license, state controlled substance license, current CV, malpractice insurance face sheet, information on prior policies, CLIA papers, medical school diploma, residency certificate, board certification, and other credentialing documents. You should also anticipate caring for patient records during times of disaster.
• Most insurance policies have specific coverage and exclusions. It is a good idea to scrutinize policies before a disaster to determine potential gaps in coverage, as well as to maximize return on losses afterward.
• Disaster-related travel and practice presents some unique and significant personal health risks (PDF). Being aware of these can contribute to your sense of preparedness in the event of a disaster.

Of course, along with physical preparedness it is essential to educate yourself about potential disasters in your area, to make disaster preparedness and intervention part of your professional identity, and most importantly to develop personal stress-management, coping, and resiliency practices to enable you to do your important work during and after disasters.

Web Links

Information on disaster preparedness from the American Academy of Pediatrics web site. (PDF)

This Centers for Disease Control web page provides information on Health Recommendations for Relief Workers Responding to Disasters. (PDF)

Centers for Disease Control's site for Emergency Preparedness and Response: This site is intended to increase the nation's ability to prepare for and respond to public health emergencies.

 

 

Mental health reactions after disaster: A guide for health care providers

Traumatic events like disasters are characterized by a sense of horror, helplessness, serious injury, and/or the threat of serious injury or death. Disasters affect survivors, public safety and health care workers, and friends and relatives of victims who have been directly involved. Elsewhere on this website we reviewcommon stress reactions to disasters in a way that is oriented toward the Georgia public. Here we will discuss common stress reactions and mental health responses to them from the perspective of health care professionals.

• Everyone who experiences a disaster is affected by it. For most people, the outcome is recovery and resiliency, not psychopathology.
• There are common stress-related reactions to events such as disasters, experienced by everyone, including children and disaster rescue or relief workers. These may last for several days or even a few weeks and may include:
• Emotional reactions: shock, fear, grief, anger, guilt, shame, feeling helpless, feeling numb, sadness
• Cognitive reactions: confusion, indecisiveness, worry, shortened attention span, trouble concentrating
• Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive
• Interpersonal reactions: distrust, conflict, withdrawal, work or school problems, irritability, loss of intimacy, feeling rejected or abandoned
• Psychological first-aid for these symptoms can help reduce their severity and duration.
• There are also more severe post-traumatic reactions to disaster.

WHAT ARE SOME MORE SEVERE REACTIONS TO A DISASTER?

Because stress reactions are so pervasive after a major disaster, it can be difficult to know when a stress reaction is more severe and may require clinical intervention. The following are severe stress symptoms that indicate increased risk for acute stress disorder or posttraumatic stress disorder (PTSD) taken from this site (PDF)

Even more important than the symptoms listed below is the individual’s functional capacity. Symptomatic individuals who can continue to function affectively at work or at home are at much lower risk for developing psychiatric problems that those who are functionally incapacitated.

For more information on the mental health consequences of disaster see this site.

Severe Reactions After Disaster

• Intrusive re-experiencing: terrifying memories, nightmares, or flashbacks
• Extreme emotional numbing: completely unable to feel emotion, as if empty
• Extreme attempts to avoid disturbing memories: such as through substance use
• Hyperarousal: panic attacks, rage, extreme irritability, intense agitation, violence
• Severe anxiety: debilitating worry, extreme helplessness, compulsions or obsessions
• Severe depression: loss of the ability to feel hope, pleasure, or interest; feeling worthless; suicidal ideation or intent
• Dissociation: fragmented thoughts, spaced put, unaware of surroundings, amnesia

WHICH INDIVIDUALS ARE AT RISK FOR SEVERE STRESS RESPONSES?

Some individuals have a higher than typical risk for severe stress symptoms and lasting PTSD, including those with a history of:

Risk Factors for Severe Reactions

• Trauma and Stress: severe exposure to the disaster, especially injury, threat to life, and extreme loss; living in a highly disrupted or traumatized community; high secondary stress
• Survivor characteristics: female; if an adult survivor, being ages 40-60; being an ethnic minority; being of low socioeconomic status; pre-disaster psychiatric history
• Family context: if an adult survivor, having children in the home; the absence of a spouse; if a child, the presence of parental distress; a significantly distressed family member; interpersonal conflict; lack of support in the home
• Resource Context: lacking belief in one’s ability to cope; few, weak, or deteriorating social resources

TREATMENT

For information on treatments for disaster related problems see:

Psychosocial Treatment of Disaster Related Mental Health Problems: A Fact Sheet for Providers

Pharmacological Treatment of Disaster Related Mental Health Problems: A Fact Sheet for Providers

 

Post-Traumatic Stress Disorder: A primer for Health Care Professionals

Elsewhere on this website you will find fact sheets addressing disaster-related stress and resiliency. Most people experiencing disasters will recover and resume normal functioning, but some will go on to develop a constellation of symptoms that collectively is referred to as Post-Traumatic Stress Disorder. This fact sheet is intended to highlight some of the key points of this struggle and prepare health care professionals toscreen and refer for treatment  patients experiencing this disorder.

• Disasters are sufficiently unusual and traumatic to predispose some people who experience them to post-traumatic stress disorder.
• Some people will experience a short-term acute stress disorder characterized by dissociation (PDF) and other PTSD-like symptoms, but not develop PTSD.
• Vulnerability for PTSD (PDF) is complex and debated, but it is clear that no one predictor serves to discriminate who will develop PTSD from who will not. In general, the likelihood of a person developing PTSD depends on:
• Previous history of trauma
• Intensity of the present trauma
• Personal loss or injury
• Proximity to the traumatic event
• Degree of control and emotional response to the disaster
• Amount of post-disaster support
• Symptoms of PTSD (PDF) occur in four dimensions:
• re-living symptoms
• avoidance symptoms,
• numbing symptoms, and
• arousal symptoms
• 1. The traumatic event is persistently re-experienced in one or more of the following ways:
• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
• Recurrent and distressing dreams of the event
• Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)
• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• 2. & 3. The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
• Efforts to avoid thoughts, feelings, or conversations associated with the trauma
• Efforts to avoid activities, places, or people that arouse recollections of the trauma
• Inability to recall an important aspect of the trauma
• Significantly diminished interest or participation in significant activities
• Feeling of detachment or estrangement from others
• Restricted range of affect (e.g., unable to have loving feelings)
• Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
• 4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following:
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
• The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Comorbidity, or other problems commonly associated with PTSD, include:
• Substance abuse (PDF) or dependence
• Feelings of hopelessness, shame, or despair
• Vocational problems
• Relationships problems including divorce and violence
• Physical symptoms, those typically associated with anxiety (PDF)
• Children can develop PTSD as well. Young children may have separation difficulties, or suddenly regress around toilet training or other developmental tasks. Children of early elementary school age (ages 6 to 9) may act out the trauma through play, drawings, or stories. They may complain of physical problems or become more irritable or aggressive. They also may develop fears and anxiety that don't seem to be caused by the traumatic event. The presentation of PTSD in adolescence (PDF) is more similar to that in adults.
• Onset of PTSD is also a bit complicated, as symptoms usually start soon after the traumatic event, but they may not emerge as the syndrome until months or years later. They also may come and go over many years.
• The course of PTSD is also complicated in that about half (40% to 60%) of those who develop it get better at some time. However, about 1 out of 3 people who develop PTSD always will have some symptoms.
• Various treatments (PDF) are available, including psychotherapy and medication.

Becoming acquainted with PTSD as a health care provider can help you detect and respond to it as it presents in some patients who have experienced disasters.

Web Links

Training Manual for Mental Health and Human Service Workers in Major Disasters (PDF)

For Mental Health and Human Services Workers in Major Disasters (PDF)

What is Posttraumatic Stress Disorder? (PTSD)

 

 

Mental health for health care responders following a disaster

The time immediately following a disaster, whether human-caused or natural, is critical to mental health. This is a time and space in which our preparedness can pay off, in reducing paralyzing anxiety, uncertainty, and isolation. This is a time when we are faced with what is sometimes impossible to “fix,” and so it is important to do what we can, to remind ourselves that we have some control and responsibility, and to stay focused on meaningful work and activity. There will be time for analysis (“Why did this happen?”) and sense-making later. Now is the time, since we can’t do everything, to do what we can.

Here are some helpful suggestions for health care providers borrowed and modified from the Prepare.org website:

• Check the area around you for safety. In the case of hurricanes or tornados or of biological, chemical or radiological threats, listen for instructions on local radio or television stations about safe places to go. Georgia911.org maintains information on state disaster status and this GEMA site has up-to-the-minute situation reports
• Draw on your preparedness (PDF) in consulting and following your disaster plan, gathering your emergency supplies of food and water and fuel (PDF) and medical equipment.
• Contact your professional organization, as you are able:
• Georgia Medical Association
• Georgia Psychiatry Organization
• Georgia Nursing Association
• Physical Therapy Association of Georgia
• Georgia Chiropractic Association
• You may also be able to contact a specific disaster response committees or subgroups of your profession: (e.g., physicians (PDF), chiropractic (PDF), physical therapists (PDF), and nurses (PDF)).
• Be acquainted with and follow your professional guidelines for rendering aid in disasters (PDF), perhaps assisting others in appropriate disaster first aid
• Remember that the health care infrastructure (hospitals, clinics, referral and insurance agencies) will be affected by the disaster, and anticipate and respond to these changes in a flexible and dynamic way.
• Be prepared for some “ripples” of disasters, in that some natural hazards, like severe storms or earthquakes, may recur in the form of new storms or aftershocks over the next several days. Part of your mental health preparedness should involve acquainting yourself with common or possible disasters in the Georgia area and knowing the different consequences of each.
• Remain calm. Pace yourself. Start to practice stress management and coping. You may find yourself in the position of taking charge of other people. Listen carefully to what people are telling you, and deal patiently with urgent situations first. This is a time for focusing on the large questions (how to secure food, clothing, and shelter) but also doing what you can to be patient and trusting.
• If the disaster was widespread, listen to your radio or television station for instructions from local authorities. Information may change rapidly after a widespread disaster, so continue to listen regularly for updates. If the power is still out, listen to a battery-powered radio, television, or car radio. Research shows that mental health during disasters is enhanced by the experience of connection and control, and diminished by isolation and retreat. Try to stay connected with others by whatever means possible. Even if you do not need to go to a shelter – page of links, no pdf version it is helpful to remain in contact with and to be around others.
• Consult disaster-specific guidelines such as the following:
• General
• National Center for Environmental Health's Emergency Preparedness and Response Branch (EPRB) 24-Hour Emergency Telephone: (770) 488-7100
• Hurricane-Related Information for Health Care Professionals
• CDC Emergency Preparedness & Response
• Medline Plus Disasters and Emergency Preparedness
• Hurricane Disaster in the U.S.: Interim Health Recommendations for Relief Workers (Centers for Disease Control and Prevention)
• Technical Assistance
• Requirements for Opening Shuttered Hospitals (PDF)
• Rural Emergency Medical Services and Trauma Technical Assistance Center (PDF)
• Worker Safety
• Worker Safety during Hurricane Cleanup
• Worker Safety After a Flood (PDF)
• Traumatic Incident Stress: Information For Emergency Response Workers
• Drugs and Medical Devices
• Safety of Medications Potentially Damaged by Flooding or High Temperatures
• Information Regarding Insulin Storage and Switching between Products in an Emergency
• Medical Devices and Hurricane Disasters (PDF)
• Impact of Severe Weather Conditions on Biological Products

Web Links

This is a very helpful overview of what to do during disasters from Prepare.org that contains references to external links.

The Georgia Emergency Management Agency coordinates and maintains disaster response facilities and procedures in the state.

Georgia911.com This is a very comprehensive and up-to-date site. If computer access is available during a disaster, one should go to this website first.

 

 

 

Making disaster preparedness part of your professional identity

Nurses, physicians, and other health care professionals have numerous responsibilities and areas of potential professional emphasis. Including disaster preparedness as one of these areas of emphasis can help you respond to disasters in a helpful and professional way. Here are some suggestions, based on helpful principles of preparedness and planning, for enhancing your preparedness for disasters.

• In addition to affiliating with the disaster preparedness and intervention components of your professional organization , you may consider becoming part of a disaster-specific group such as these for physicians (PDF), chiropractic (PDF), physical therapists (PDF), and nurses (PDF).
• Allocate some of your continuing education to development of core competencies for disaster practice (PDF). Doing an internet search on disaster-specific continuing education courses will reveal numerous options in this category.
• Educate yourself about various disasters, health care responses, and the mental health implications of each, through review of websites such as:
  • Biological agents
  • Center for the Study of Bioterrorism and Emerging Infections: Notification procedures to report known or potential bioterrorism incidents
  • Johns Hopkins Center for Civilian Biodefense: Biological agents fact sheets and information on preparedness and response for hospitals, physicians, and public health practitioners
  • US Army Medical Research Institute of Infectious Diseases: Courses on diagnosis and treatment of victims of biological terrorism
  • Medical Management of Biological Casualties Handbook
  • US Food and Drug Administration Bioterrorism Web Site
  • Center for Biologics Evaluation and Research: Frequently asked questions on countering bioterrorism
  • AMA member of The Partnership for Anthrax Vaccine Education
  • Radiological agents
  • American College of Radiology: Disaster Preparedness
  • "Medical Management of Radiological Casualties": Information on disaster preparedness for health care providers, compiled by the Armed Forces Radiobiology Institute
  • Chemical agents
  • US Army Research Institute of Chemical Defense: Training for medical personnel in the medical management of chemical casualties (Medical Management of Chemical Casualties Handbook (PDF)
  • US Department of Transportation's Office of Hazardous Materials Safety
  • US Environmental Protection Agency: Chemical Emergency Preparedness and Prevention Office
  • Preparedness
  • American Academy of Family Physicians: Resources including how to prevent, diagnose, and treat post-traumatic stress disorder
  • American Academy of Pediatrics: Disaster preparedness to meet children's needs
  • American College of Physicians — American Society of Internal Medicine: Information on what to do when a biological weapon is suspected
  • American College of Surgeons: Unconventional Civilian Disasters: What the Surgeon Should Know
  • Association for Professionals in Infection Control and Epidemiology (APIC) Mass Casualty Disaster Plan Checklist: A Template for Healthcare Facilities (PDF)
  • Centers for Disease Control and Prevention
  • In a Moment's Notice: Surge Capacity in a Terrorist Bombing (PDF) - This report provides health care systems, providers and community planners with solutions to potential challenges that may be faced in a terrorist bombing, and it can serve as a vital resource in the health care response for a number of other mass casualty situations.
  • Office of Public Health Emergency Preparedness and Response
  • National Center for Environmental Health, Division of Emergency and Environmental Health Services (PDF)
  • Agency for Toxic Substances and Disease Registry: Emergency Response and Medical Management of Hazardous Material Incidents
  • Federal Emergency Management Association (FEMA)
  • Rapid Response Information System
  • National Disaster Medical System
  • UCLA Center for Public Health and Disasters: Bioterrorism: Are You Prepared? (PDF)
  • US Department of Health and Human Services: Answers to questions about anthrax prevention and treatment
  • US Department of Homeland Security: Center for Domestic Preparedness
• Volunteer by consulting Georgia disaster information clearinghouses such as Georgia911 to identify immediate and long-term needs. Personal stories of health care volunteers (PDF) suggest that such volunteering can provide important personal and professional benefits.

Web Links

This is an excellent University of Washington/CDC on-line training module. (PDF)

 

 

Immediate mental health response to a disaster

Coping With a Traumatic Event:

What Is a Traumatic Event?

An event, or series of events, that causes moderate to severe stress reactions, is called a traumatic event. Traumatic events are characterized by a sense of horror, helplessness, serious injury, or the threat of serious injury or death. Traumatic events affect survivors, rescue workers, and friends and relatives of victims who have been directly involved. In addition to potentially affecting those who suffer injuries or loss. They may also affect people who have witnessed the event either firsthand or on television. Stress reactions immediately following a traumatic event are very common, however, most of the reactions will resolve within ten days.

Common Responses to a Traumatic Event
Cognitive	Emotional	Physical	Behavioral
poor concentration confusion disorientation indecisiveness shortened attention span memory loss unwanted memories difficulty making decisions	shock numbness feeling overwhelmed depression feeling lost fear of harm to self and/or loved ones feeling nothing feeling abandoned uncertainty of feelings volatile emotions	nausea lightheadedness dizziness gastro-intestinal problems rapid heart rate tremors headaches grinding of teeth fatigue poor sleep pain hyperarousal jumpiness	suspicion irritability arguments with friends and loved ones withdrawal excessive silence inappropriate humor increased/decreased eating change in sexual desire or functioning increased smoking increased substance use or abuse

How Do You Interact with Patients after a Traumatic Event?

The clinician should be alert to the various needs of the traumatized person.

• Listen and encourage patients to talk about their reactions when they feel ready.
• Validate the emotional reactions of the person. Intense, painful reactions are common responses to a traumatic event.
• De-emphasize clinical, diagnostic, and pathological language.
• Communicate, person to person rather than “expert” to “victim,” using straightforward terms.

What Can You Do to Help Patients Cope with a Traumatic Event?

Explain that their symptoms may be normal, especially right after the traumatic event, and then encourage patients to:

• Identify concrete needs and attempt to help. Traumatized persons are often preoccupied with concrete needs (e.g., How do I know if my friends made it to the hospital?).
• Keep to their usual routine.
• Help identify ways to relax.
• Face situations, people and places that remind them of the traumatic event rather than shy away.
• Take the time to resolve day-to-day conflicts so they do not build up and add to their stress.
• Identify sources of support including family and friends. Encourage talking about their experiences and feelings with friends, family, or other support networks (e.g. clergy and community centers).

Who Is at Risk for Severe and Longer Lasting Reactions to Trauma?

Some people are at greater risk than others for developing sustained and long-term reactions to a traumatic event including disorders such as post traumatic stress disorder (PTSD), depression, and generalized anxiety. Factors that contribute to the risk of long-term impairment such as PTSD are listed.

• Proximity to the event. Closer exposure to actual event leads to greater risk (dose-response phenomenon).
• Multiple stressors. More stress or an accumulation of stressors may create more difficulty.
• History of trauma.
• Meaning of the event in relation to past stressors. A traumatic event may activate unresolved fears or frightening memories.
• Persons with chronic medical illness or psychological disorders.

What Can You Do to Treat Patients in Response to a Traumatic Event?

Helping survivors of traumatic events, their family members, and emergency rescue personnel requires preparation, sensitivity, assertiveness, flexibility and common sense.

• Refer patients to a mental health professional in your area who has experience treating the needs of survivors of traumatic events.
• Provide education to help people identify symptoms of anxiety, depression, and PTSD.
• Offer clinical follow-up when appropriate, including referrals to mental health professionals.

Information available at this site (PDF).

 

Secondary stress and the health care provider

The following perspective, offered by an ER physician, does not necessarily reflect the views of the Division of Mental Health, Developmental Disabilities and Addictive Disease. It is offered as a point of view about the personal and professional costs of working with suffering.

I think, perhaps, I have seen enough pain for one life. I know, I know, I'm only 40 years old. I'm soft now. I used to love intubations and resuscitations; I used to love the thump of the defibrillator, the thrill of blood from deep wounds, the surprise of something horrible on a CT scan. I was once thrilled by helicopter blades whirring and ambulance light bars flashing, by anxious voices over radios. I wanted to see bullet holes and bullet fragments. I was irresistibly drawn to the chaos of disaster. But then, I used to be separate from it all, outside it, a young, powerful man with a kind of immortality and immunity to the suffering of this world. But that is fading with the years, and fading fast.

I wonder how much pain we have to witness, or be part of, to make an adequate career. I have been informed that expertise in emergency medicine requires something like seven years, or 40,000 patient encounters. But how much suffering is sufficient to say, "Thanks, that's plenty. I quit"? I don't know the number. I'm sure that it differs for every woman and man who practices medicine. But we seldom admit it, because we equate that feeling with weakness.

We walk through it as if it is nothing. We put our clumsy hands into the bodies of the wounded, we take away their breath to give them synthetic airways. We listen as they open a dark door into their dark worlds, where daughters are raped by fathers, where children are left with strangers while mothers get high, and the strangers beat them mercilessly. We sit by strangers and say things like, "I'm sorry, but your child's injuries were too severe, and despite everything we did, she died."

She died. We say that over and over. He died, she died, they died. He has a hemorrhage in his brain, she has a heart attack, they are in surgery, he will never walk again. This is who we are. We are the messengers of chaos, the wardens of entropy, where the dissolution of the universe takes the very personal appearance of death and wounds and terrible illnesses. And where the technicalities of medicine's inadequacy simply mean loss, and loss becomes screams and sobbing before it becomes a sterile news clipping or obituary.

At the sharp point of medicine, the very tip where all bad things go first, we balance our lives, and cover up our hard secret with science and research, with our desire 'to help the suffering, to save lives', and with the necessarily callous humor that no one else grasps.

Our secret, brothers and sisters, is that for every bit of pain we see, a little bit stays inside. In some secret place in our hearts and minds, we accumulate it. Sometimes, a professional will be knocked down and out by a single dose of it. Like a nuclear weapon, it melts their circuits. But most of us get accumulated small doses, and the effects are stochastic, unpredictable.

But, I predict, the effects are greater than we know. Thanks to the politics and rules of modern medicine, we see more pain, more rapidly, with less chance to process it than ever before. It comes in great waves in some centers, day after day of violence and tragedy, death, pain and misery. And all those who face it are like Caligula's guards, ordered to drive back the sea with swords and shields.

In some places, like mine, it comes in smaller waves, but no less devastating. Worse, perhaps, since the longer I live here in one small place, the more likely I will see friends and family and co-workers and others I know, lying supine on the gurney before me, with cancers, accidents, assaults and death.

That's the thing. Love makes it all harder. When we are younger, we love intensely, passionately, but not with the depth, or desperation, of our years. Now, husband of my lovely wife, father of my perfect children, I fear for them. Or maybe, I fear for me, for the possibility that I might lose them, or that I might have to face their suffering.

And this love makes me feel the loss of other spouses and parents more acutely. I imagine myself in their situations. I hurt for them. Maybe I'm doing the right thing, 'mourning with those who mourn', but it takes so much out of me, out of all of us, when we do it over and over and over again, and when we put a little more inside us each time, one more artifact of someone else's agony, one more memory of a scream, of a look, of a sob.

As I grow older, I realize that some wounds will always be with us. I can call up images that I will never be rid of, at least not in this life. All I can hope is that in heaven, where suffering is not even a memory, I will see my patients, and they will see me, and the best we will be able to do is, "don't I know you?" I won't remember their troubles, they won't associate my face with their former pain, as people in this life certainly must.

That's my hope, for me and for all who labor in a job that casts us daily into all the troubles of humanity. And if you don't want to wait around for heaven to ease your pain, it's OK to say, 'enough'.

---

Those who interact with trauma survivors are themselves exposed to a form of traumatic stress. More recent diagnostic formulations of Post-traumatic Stress Disorder such as those in DSM-IV have broadened the definition of trauma to include participation in others’ traumatic response. As you see and treat patients who have experienced disaster, whether in the emergency period immediately following it or thereafter, you will be exposed to secondary stress and traumatization, the focus of this fact sheet.

• Secondary stress has also been termed Secondary Traumatic Stress Disorder (STSD), vicarious traumatization, compassion fatigue, or empathic strain.
• Some helpers exposed to stress develop PTSD, but the experience of the full syndrome is only one of the ways in which professional helpers are affected by their exposure to secondary traumatic stress (PDF).
• Your vulnerability to secondary stress (PDF) is influenced by:
• personal history, current life circumstances, as well as proximity and personal connection to the events and people involved in the disaster
• your level of empathic engagement with your patients’ experience of the disaster
• your perceived similarity to the victims of the disaster
• Secondary stress involves the following features:
  • A broadened sense of “what can happen,” sometimes experienced as a “loss of innocence” or as cynical detachment influencing your frame of reference and identity, worldview, and spirituality.
  • Cognitive distortion around normalcy and baseline rates. Our awareness that planes actually do crash and innocent appearing adults actually do molest children can transform into an expectation that every plane is likely to crash and every adult is likely to hurt our child. When we lose our sense of perspective in this way, we enter the world of the traumatized.
  • Heightened arousal and vigilance, a way of being human in which we are characteristically aroused and remain constantly on our guard because we anticipate danger at every turn.
  • Avoidance, as we find ourselves organizing our lives around what might happen, rather than what is happening.
  • Emotional consequences of involvement, experienced as:
  • Threats to self-capacities of emotional management, self-worth
  • Changes in basic beliefs about psychological needs (i.e. safety, trust, esteem, intimacy, and control)
  • Loss of hope and meaning; increased cynicism and pessimism; nihilism, existential despair
  • Anger at the disaster or the perceived causes
  • Symptoms similar to those of the patients being treated; a blurring (PDF) of what experiences are “ours” and what belongs to the victims (a process involving dissociation)
  • A sense of unworthiness and survival guilt (PDF)
  • A persistent and extreme sadness, or dysphoria
  • A sense of mourning and grief
  • Behavioral changes such as:
  • Becoming judgmental of others
  • Tuning out
  • Having a reduced sense of connection with loved ones and colleagues
  • Becoming cynical or angry and losing hope or a sense of meaning
  • Developing rescue fantasies, becoming over-involved, taking on others' problems
  • Developing overly rigid, strict boundaries
  • Feeling heightened protectiveness as a result of a decreased sense of the safety of loved ones
  • Avoiding social contact
  • Avoiding work contact
• Secondary stress can affect your:
  • Relationship with meaning and hope
  • Ability to get your psychological needs met
  • Intelligence
  • Willpower
  • Sense of humor
  • Ability to protect oneself
  • Memory/Imagery
  • Existential sense of connection to others
• Dangers of secondary stress lie in both direct negative effects (intrusive imagery, disrupted beliefs) and in our way of responding to it (numbing, over-generalized negative expectations, cynicism).

Coping with secondary stress:

• Self-assessment: Ask yourself, "How am I doing? What do I need? How have I changed?” Discuss the questions and answers with a colleague, friend, or therapist.
• Protect yourself through awareness of your vulnerability and recognition of the negative consequences of your work as echoed in the voices of others (PDF)
• Work to cultivate a:
• Sense of strength
• Self-knowledge
• Confidence
• Sense of meaning
• Spiritual connection
• Respect for human resiliency
• Address the stress of your work through practicing self-care. Nurture yourself by focusing on sources of pleasure and joy, and allow yourself to escape when necessary.

Fortunately, health care professionals have tools to manage secondary stress: we have knowledge of the ways in which trauma affects people, we have skills for soothing arousal and processing states of distress, and most importantly, we have each other, a support system with the potential to help each of us maintain perspective and find understanding during those times when we get caught in the web of secondary traumatic stress. We are not invulnerable, but if we maintain a strong sense of community among ourselves, we can be resilient (PDF).

 

 

 

How to facilitate resiliency in yourself and your patients following disasters

Mental health professionals have spent a long time studying post-traumatic stress disorder (PDF) as a response to disaster. But more recently they have focused on resiliency (PDF), defined as “the ability to spring back from and successfully adapt to adversity,” and defined by a 15 year-old high school student as, "Bouncing back from problems and stuff with more power and more smarts." Resiliency is also sometimes referred to as psychological hardiness (PDF), wellness, and positive psychology. Regardless of the name we give it, resiliency and the ability to “bounce back from [disasters] with more power and more smarts” is an important goal of mental health, and health care providers can do a lot to facilitate resiliency in their patients.

Each of us has a built-in capacity for resiliency, "a self-righting tendency" that operates best when we have resiliency-building conditions in their lives. These resiliency conditions (PDF) take place along three dimensions of our experience: I AM, I CAN, and I HAVE. This fact sheet will discuss each of these as it relates to disaster recovery for both patients and providers.

I AM refers to personal characteristics, including

• Self-esteem or the sense that we have of ourselves as capable, loveable, and worthy. Psychological research (PDF) suggests that our beliefs about how we can cope may be as important as coping behavior itself.
• Mastery, confidence, perceived control, hope, and optimism (PDF) have been shown to relate positively, strongly, and consistently to mental health in both the short-term and long-term recovery from disaster as illustrated in powerful personal stories such as this (PDF).
• Recognition of personal strengths as well as suffering. Although our suffering in response to disaster must be acknowledged with compassion and empathy and patience for ourselves, we must also remind ourselves of our capacity to master this experience.

I CAN as an element of resiliency refers to recognition of not just self-esteem but self-efficacy (PDF), which is different from recognizing our personal strengths: it is the difference between “I am good at reading” (self-esteem) and “I can read” (self-efficacy). In self-efficacy we have a sense of our specific

abilities and assets and talents as they relate to recovery. Recognizing our problem-solving skills and those of our patients they relate to disaster recovery can enhance resiliency, and promote our ability to “bounce back with more power and more smarts.” In building this element of resiliency, you might ask yourself, and encourage your patients to ask themselves:

• What can I bring to this experience, in terms of talents and skills, that maybe only I can bring? It may be as simple as organizing a reading time for children in a shelter or as complicated as serving as a historian of the disaster.
• What tools do I possess in terms of kindness or gratitude or perspective-taking that I can bring to this experience? How can I bring them courageously and clearly? What gifts do I have, to give? (PDF)

I HAVE refers to the supports around each of us that promote resilience. These are like the airbags in our cars that even when we crash can keep us from being wounded too seriously: the “I have” of resiliency in disaster recovery might include:

• Our access to service agencies, which can provide us with basic food, clothing, shelter, and protection during times of disaster.
• Our financial resources (PDF) that, even when depleted, can provide us with basic needs during recovery.
• Careful management of these resources can promote resiliency and recovery.
• Our relationships with significant others (PDF) and with our professional community always influence our mental health, but are particularly important during times of disaster recovery, when relocation and other influences may disrupt our interactions with support systems. An important feature of the “I have” component of resiliency involves maintaining our relationships with family and friends, and when necessary, rebuilding relationships in the same way that we might rebuild homes or schools.
• Our participation with communities such as spiritual or religious groups, schools, and service organizations can remind us that we are not unique, that we are not alone, and that we can survive and even thrive following disasters.

In summary, relatively few of us who experience disasters become depressed or develop PTSD; most of us exhibit resiliency -- the ability to deal with adversity without becoming overwhelmed by it. We can learn to respond to adversity with resiliency rather than depression and hopelessness.

 

 

 

Self-care for Health Care Professionals During Disaster Response

Taking care of yourself will help you to stay focused on taking care of others. Often health professionals and other responders do not recognize the need to take care of themselves and to monitor their own emotional and physical health during their involvement with disasters -- especially when recovery efforts stretch into several weeks. This can cause some responders to experience unnecessary consequences such as burnout (PDF) or compassion fatigue (PDF).

The following guidelines contain simple methods for self-care during disaster response. Read them while you are involved in health care disaster work, and during the period after the disaster.

• Pace yourself. Rescue and recovery efforts at the site may continue for days or weeks.
• Take frequent rest breaks (PDF). Rescue and recovery operations take place in extremely dangerous work environments. Mental fatigue over long shifts can place health care workers at greatly increased risk for poor decision-making and treatment lapses.
• Watch out for each other. Approach the disaster as a team (PDF) and rely on other professionals for consultation and perspective and support.
• Be conscious of those around you. Health care responders who are exhausted, feeling stressed, or even temporarily distracted may place themselves and others at risk (PDF) .
• Maintain as normal a schedule as possible: regular eating and sleeping are crucial. Adhere to the team schedule and rotation.
• Maintain adequate nutrition (PDF) and try to eat a variety of foods and increase your intake of complex carbohydrates (e.g. breads and muffins made with whole grains, granola bars).
• Stay hydrated (PDF), with clean water and juices.
• Whenever possible, distance yourself from the disaster (PDF) site to maintain boundaries and achieve perspective. Eat and drink in the cleanest area available. Communicate with your loved ones at home as frequently as possible.
• Give yourself permission to feel rotten: You are in a difficult situation.
• Recurring thoughts, dreams, or flashbacks are normal-- do not try to fight them. These responses to trauma will decrease over time and paying less attention to them will break the cycle of anxiety.
• Recognize and accept what you cannot change -- the chain of command, organizational structure, waiting, equipment failures, etc. Practice spirituality even in this difficult time.
• Accept that your “hidden wounds and hidden healing" (PDF) as you respond to the disaster are yours, and keep appropriate boundaries around how you involve others in your experience. There are some pieces of your experience that you will want to share, and some that you will want to forget. But if the disaster facility includes mental health support, consider using it.
• Participate in memorials, rituals, and use of symbols (PDF) as a way to express feelings

Web Links

CDC and NIOSH Traumatic Incident Stress Info

Disaster Response and Recovery Handbook (PDF)

 

Culturally competent health care disaster response

Among the many lessons learned from Hurricane Katrina is that of the need for health care professionals to educate themselves in cultural competence and sensitivity (PDF). As related to health care in disasters, culture refers to “a common heritage or set of beliefs, norms, and values.” Here are some important concepts to keep in mind about culturally sensitive disaster health care:

• The term “culture” is as applicable to whites as it is to racial and ethnic minorities. Culture is about shared meanings.
• Today’s America, like today’s Georgia, is unmistakably multicultural. Since there are a variety of ways to define a cultural group (e.g., by ethnicity, religion, geographic region, age group, sexual orientation, or profession), many people consider themselves as having multiple cultural identities.
• Culture (through culture-bound syndromes (PDF)) influences the origin, course, and response of various mental and medical processes. In short, culture counts.
• Culture influences all aspects of mental health in disaster response (PDF): stress, coping, resiliency, and help-seeking.
• Culture is a concept not limited to patients, but also applies to the professionals who treat them. Every group of professionals embodies a “culture” in the sense that they too have a shared set of beliefs, norms, and values. Unfortunately, this means that health care providers may view symptoms, diagnoses, and treatments in ways that sometimes diverge from their clients’ or patients’ views, especially when the cultural backgrounds of the consumer and provider are dissimilar, and this divergence of viewpoints can create barriers to effective care.

It is essential that health care professionals develop cultural competency, through the following steps:

• Develop and maintain a current (PDF) and projected profile of the cultural composition of your Georgia community as it relates to health care during disasters. This should describe the community’s composition in terms of race and ethnicity, age, gender, religion, refugee and immigrant status, housing status, income and poverty levels, percentage of residents living in rural versus urban areas, unemployment rate, language and dialects, literacy level, and number of schools and businesses. Include in the profile information about the values, beliefs, social and family norms, traditions, practices, and politics of local cultural groups, and historical racial relations or ethnic issues. Gather information in consultation with community cultural leaders who represent and understand local cultural groups. Identify potential cultural influences in your area of Georgia as they relate to disaster response.
• Complete a self-assessment (PDF) of cultural awareness and sensitivity in general and specific to health care (PDF) to identify areas for potential growth.
• Educate yourself about some common cultural influences as they relate to health care during times of disaster.
• Enlist cultural brokers (PDF) (persons with cultural backgrounds similar to your anticipated disaster service constituency) in your staff and employees in order to bridge, link, or mediate among persons of different cultural backgrounds for the purpose of reducing conflict and producing positive change.
• Participate in and provide ongoing cultural competency training to assure that you can understand and respond to various cultural influence on health care during times of disaster.
• Ensure that your health care services are accessible, appropriate, and equitable during times of disaster. Identify and take steps to overcome the reluctance of various ethnic groups to use your services because of mistrust or service barriers such as racial and ethnic discrimination, language barriers, transportation issues, and the stigma associated with health-care services.
• Cultivate empathy (PDF) (the ability to feel your way imaginatively into the others’ experience) as a pathway toward being culturally sensitive. As expressed by a nurse serving in post-disaster relief:

“I would never want to remove the idea that there is a definite importance to cultural competence. But I also believe there was something within me as a nurse, as a woman, as a mother, that allowed me to care for those patients. I couldn’t speak Spanish, but I still felt like I conveyed the message that ‘I am going to figure out what it is you need, or die trying.’ I feel any nurse who has that compassion can develop the cultural competence.”

Web Links

Providers Guide to Quality and Culture (PDF)

Developing Cultural Competence in Disaster Mental Health Programs (PDF)

Disaster Nursing (PDF)

Interpersonal Skills Promoting Cultural Sensitivity

 

How do health care professionals contribute to community disaster preparedness?

Based on a very helpful set of principles of preparedness, we offer the following specific ways in which health care professionals might contribute to mental health community planning for disasters in ways that will allow you to respond personally and also be able to do your important work in your communities. Some of this information is based on a document prepared by the American Association of Pediatrics that you may want to consult in its entirety.

• Educate yourself about the mental health components of disasters as they relate to health care using the resources of your professional organization along with this website.
• Bring your perspectives to a disaster mental health plan (PDF) through consideration of:
• Community Demographic Characteristics
• Who are the most vulnerable people in the community? Where do they live? What are their specific health care needs?
• What kinds of families live in the community (i.e. single-parent households)?
• How could individuals be identified and reached in a disaster?
• Are policies and procedures in place to collect, maintain, and review current demographic data for any area that might be affected by a disaster?
• Cultural Groups
• What cultural groups (ethnic, racial, and religious) live in the community?
• Where do they live, and what are their special needs?
• What are their values, beliefs, and primary languages as they relate to health care and to mental health disaster preparedness?
• Who is knowledgeable about the culture or is an informal leader in the community?
• Socioeconomic Factors
• Are there recognizable socioeconomic groups with special needs?
• How many live in rental property? How many own their own homes?
• Does the community have any special economic considerations that might affect people’s vulnerability to disaster and their health care needs?
• Mental Health Resources
• What mental health service providers serve the community?
• What skills and services does each provider offer?
• What gaps, including lack of cultural competence, might affect disaster services?
• How could the community’s mental health resources be used in response to different types of disasters?
• What is the relationship between the health care and the mental health care communities?
• Non-governmental Organizations’ Roles in a Disaster
• What are the roles of the American Red Cross (ARC), interfaith organizations, and other disaster relief organizations?
• What resources do non-government agencies offer, and how can local mental health services be integrated into their efforts?
• What mutual aid agreements exist?
• How can mental health providers collaborate with private disaster relief efforts?
• Community Partnerships
• What resources and support would community and cultural/ethnic groups provide during or following a disaster?
• Do the groups hold pre-existing mutual aid agreements with any state or county agencies?
• Who are the key informants/gatekeepers of the impacted community?
• Has a directory of cultural resource groups, potential volunteers, and community informants who have knowledge about diverse groups been developed?
• Are the community partners involved in all phases of disaster preparedness, response, and recovery operations?
• Emphasize the health care implications of disasters in your contribution to preparedness. Although this may seem obvious, bringing to the public some specific health care perspectives (PDF) is an essential contribution to mental health.
  Remember that in many disasters the obvious victims are only the tip of the iceberg:
• The Impact Pyramid
  

  Individual victims Family and social networks Rescue worked, medical care providers, their families, and social networks Vulnerable populations and impacted businesses Ordinary people and their communities

• Help disaster preparedness and planning groups tailor disaster planning to the local risk situation. Hurricanes and tornadoes and floods (PDF) for example, are far more likely in Georgia than are earthquakes.
• Collaborate with other professionals working in the mental health field, such as social workers, psychologists, and especially schools.
• Emphasize the psychosocial implications of disasters (PDF) in your planning, as systems of health care delivery are often disrupted in the event of a disaster. Make yourself available to community and school boards and as a guest speaker, taking advantage of disaster-specific lecture materials (PDF) to lend your perspectives on the health care components of preparedness.
• Volunteer through your professional organization or through the Red Cross (PDF) to enhance your familiarity with disaster preparedness and your contribution to community planning.

Web Links

Joint Commission Planning Guide

Disaster Psychiatry (PDF)

Nursing Disaster Preparedness (PDF)

AAP CHILDisaster (PDF)

 

Coping and disaster recovery for the health care professional

During the recovery phase following the disaster, both you and your patients will continue to experience stress, grief, and perhaps even some symptoms of depression and anxiety (PDF). During this recovery phase, physical problems such as changes in sleep and appetite, digestive problems, more susceptibility to colds or other illnesses, and increased use of alcohol and other drugs are also common. We may also have emotional responses, such as fear, irritability, nightmares, difficulties concentrating, feelings of betrayal, and loss of interest in everyday activities.

What can you do to cope, and to facilitate patient coping, in your journey toward recovery from disaster? Here are some helpful suggestions:

• Use grounding, a technique designed to keep your experience in the “here and now” and remind you that you are alive and present to life. Teach patients this technique as well.
• Take time every day to focus on your breathing (PDF) as a calming and centering strategy. You can educate patients about the contribution of conscious breathing to wellness, and demonstrate this in your work as well.
• Experiment with watching your thoughts to identify those that may be catastrophic or lead to feelings of hopelessness and helplessness. A healthy outlook on life, for both you and your patients, makes resiliency and recovery more achievable.
• Challenge negative beliefs. Replace such thoughts as, "I always have bad luck...nothing will better from now on...everything is going wrong," with, "Is there any real reason to think that...maybe things will change for the better?"
• Adjust self-talk. Convert negative messages into positive ones. For example, replace "I’ll never get through this," with "I can do this, but it’s normal and okay to feel scared and overwhelmed."
• Use previous ordeals that have been successfully overcome as a "power base."
• Consider alternative outcomes for worst-case scenarios. For example, "I can still see my friends, I can enjoy the little things in life."
• Imagine how this event will be viewed in the future, remembering how things do change over time.

Some patients will be resistant to these strategies and perceive you as suggesting that their struggles are “all in their heads.” Educating them with some easily understood techniques and examples will tend to diminish this perception.

• Learn to manage anxiety (PDF) through such strategies as guided imagery and relaxation (PDF). Include information about anxiety and its management in your office literature and handouts.
• Teach your patients about the need for support systems or groups (PDF) to reach out and connect with others, especially those who may have shared the stressful event. Consider affiliating with the a disaster-specific subgroup such as these for physicians, chiropractic (PDF), physical therapists (PDF), and nurses.
• Use empathic listening (PDF) in your interactions with patients around disaster. Also, seek out in your circle of friends, family, and spiritual community those who will listen empathically to you.
• Teach patients the need for emotional expression (PDF), and practice this yourself. “Getting things out” helps.
• Exercise (PDF) can contribute to greater well-being following disaster. Teach patients this principle (PDF) and help them to develop an appropriate exercise plan. Practice it yourself.
• Use prayer, meditation, or other spiritual practices, which are common and helpful coping strategies.
• Understand that your service to others (PDF), even in the midst of your own response to the disaster, can help you cope with your struggles in a kinder and clearer way.
• Use creativity (PDF) to fill your life with “food for your soul.”
• Take planned breaks such as going to the movies or doing some light reading to remind yourself that you are recovering and that you are well.
• Maintain relationships with your pets to give and be given coping gifts.
• Nourish yourself through healthy eating and drinking, and avoid self-medication, alcohol, or other drugs.
• Write about (PDF) your experience in detail, just for yourself or to share with others.

Remember that people who engage fully in recovery from disaster discover unexpected benefits. As they gradually heal their wounds, survivors and health care providers alike find that they are also developing inner strength, compassion for others, increasing self-awareness, and -- often the most surprising -- a greater ability to experience joy and serenity than ever before.

Web Links

Stress Management for Patient and Physician (PDF)

Common Responses to Trauma (PDF)

Coping with Disasters (PDF)

Become a Survivor (PDF)

Tips for Survivors (PDF)

Promoting Family Health after Disaster

Returning home from a disaster assignment

Disaster work can be a unique and very rewarding experience as disaster response workers feel part of a family and all work toward a common goal. There is a sense of adventure as we face the unique problems of each disaster setting, a sense of shared pride as we ease the suffering of survivors, and a sense of personal satisfaction in our ability to help.

But we also experience things that most people -- including our families, friends, and co-workers -- could not begin to understand or appreciate, things far apart in time and space and power from our everyday lives. One of my practicum students spoke of an “airlock” between the hospital entrance and the psychiatric inpatient ward, in which he experienced the distance between that space and the space in which he ordinarily lived, both going into and coming out of that space. Here are some suggestions, excerpted and elaborated from this document (PDF), on how to ease the airlock transition from the disaster place to your home place.

Return is a Process, not an Event: I think in my own work about the process of atmospheric reentry (PDF): too direct an approach to returning home and you burn up, too indirect and you bounce off. Try to get it just right. Be patient with yourself.

Rest: Often, you may not get enough rest while working on a disaster, and when you return home you will feel exhausted. It may take several days to catch up, and both family members and employers need to understand that you need time to yourself before beginning a full schedule of normal activities.

Pace: On a disaster relief operation, you perform your job as fast as possible to provide the greatest amount of assistance in the shortest possible time. It may take time to return to the more relaxed pace of your co-workers and family members.

Sharing: You will want to talk to family members and co-workers about your experiences, and they will be eager to tell you about theirs. What you were doing may seem much more exciting and significant, but remember that their experiences are as important to them as yours are to you. If they seem to accuse you of being away when the washer overflowed, or the kids threw up, it’s only their way of saying, “We missed you.”

Emotions: When you return home, some feelings or emotional swings associated with disaster-related stress may surprise or frighten you. If you anticipate some of these emotions, you can manage them better.

Disappointment: You may find that others are not interested in hearing about your experiences, or that your reunion with your family and co-workers does not live up to your expectations. You may expect they will be happy to have you home and be surprised to find they are angry at your absence. Anticipating this response will help you in managing it better as well.

Frustration and conflict: Your needs may not match those of family or colleagues. Although you may want nothing more than a good home-cooked meal, your family may be looking forward to going out to eat.

Anger: Problems presented by your family, friends, or co-workers may seem very trivial compared to those facing the disaster victims you just left. Try to remember that the folks at home feel that their problems are just as important to them right now. Appreciate how your own anger and grief.

Survivor identification: The actions or characteristics of people at home may remind you of your experience with disaster victims. You may experience emotional reactions that can surprise and confuse not only you, but also them. Patiently try to help others understand the reasons behind your reactions.

Daydreaming: This is a part of response to trauma, and is healthy dissociation (PDF) and part of your own response to trauma. You may find yourself wishing you could return to the disaster you just left, or be sent out again right away. Remember you are more important to the folks at home than you can imagine; they just express their appreciation differently.

Mood swings: These are normal after returning home, as they are one of the ways to resolve conflicting feelings you have experienced on the operation. You may change from happy to sad, tense to relaxed, or outgoing to quiet without much warning. When you have time to put your disaster work into perspective, they will pass.

Children: It can be hard to explain to children why you must be away. If you tell them why you are leaving, and call home while you are away, it will help calm their fears. When you return home, try not to frighten them with stories about what you have seen and done. Tell them about the disaster in a way that is appropriate to their level of development, and involve them in preparedness efforts for your family. This will help them feel as if they are part of what you have been doing and reduce their fears about similar disasters at home.

Your participation in disaster relief work is a gift to the world. Practicing self-care and developing resiliency during the process of your return will allow you to continue giving your gifts.

Web Links

Adjusting to life after relief work

Support for Relief Workers

 

National Consensus Statement on Mental Health Recovery

Our approach to mental health recovery is consistent with the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration (SAMHSA) which has developed the following guidelines:

Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

The 10 Fundamental Components of Recovery

Self-Direction: Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.

Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.

Empowerment: Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.

Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

Non-Linear: Recovery is not a step-bystep process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). Th e process of recovery moves forward through interaction with others in supportive, trust-based relationships.

Peer Support: Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

Respect: Community, systems, and societal acceptance and appreciation of consumers —including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.

Hope: Recovery provides the essential and motivating message of a better future— that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefi ts individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefi ts of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation.

Resources
www.samhsa.gov
National Mental Health Information Center
1-800-789-2647, 1-866-889-2647 (TDD)
Original Link