A Mental Health Response to Disaster - Mental Health America

A Mental Health Response to Disaster - Mental Health America

6/18/2015 A Mental Health Response to Disaster 1 6/18/2015 American Red Cross Disaster Mental Health Agenda • American Red Cross – Overview of S...

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A Mental Health Response to Disaster



American Red Cross Disaster Mental Health

Agenda • American Red Cross – Overview of Services and Structure • Psychological Impacts of Disaster

• Disaster Mental Health – Overview and Interventions



American Red Cross • Non-profit humanitarian organization • U.S. Congressional Charter • Guided by seven fundamental principles: • • • •

Humanity Impartiality Neutrality Independence

• Voluntary service • Unity • Universality

American Red Cross Core Business Lines • • • • •

Disaster Cycle Services Service to the Armed Forces Health and Safety Training & Education Blood Services International Services



Disaster Cycle Services

American Red Cross Disaster Relief Services • • • • • • • • • •

Food and Water Shelter Direct Client Assistance Disaster Health Services Disaster Mental Health Services Disaster Spiritual Care Services Reunification Services Distribution of Relief Supplies Information and Referrals Recovery casework



Division Structure (7)

Region Structure (62)



Staff Structure - Division

Volunteers make up more than 90% of the Red Cross disaster workforce.

Staff Structure - Region

Volunteers make up more than 90% of the Red Cross disaster workforce.



Psychological Impacts of Disaster • Vary widely • Dependent on individual factors, such as age, culture, previous functioning, etc. • Occur in all domains of functioning • • • • •

Emotional Cognitive Physical Behavioral Spiritual

Psychological Impacts of Disaster • Many people are resilient and will naturally return to their pre-disaster level of functioning • This is the most common outcome • Over 50% of population resilient after 9/11

• On average, 30-40% of direct victims of disaster will experience one or more disorders such as PTSD, depression or anxiety • Children emerge with greater risk • 5-10% of people in the community-at-large • 10-20% of responders are at risk

• Early intervention reduces risk Galea, S., Nandi, A., & Vlahov, D. (2005) The epidemiology of post-traumatic stress disorder after disaster. Epidemiologic Reviews, 27, 78-91.



Disaster Response Phases

Myers and Zunin, 1990; DHHS, 2000 & 2004; Herrmann, 2004

American Red Cross Mission of Disaster Mental Health To provide mental health support to disaster survivors and responders across the disaster continuum of preparedness, response and recovery.



Disaster Mental Health • 3,500 independently-licensed, master’s level (or higher) mental health professionals, including: • • • • • • • •

Psychologists Clinical Social Workers Marriage and Family Therapists Licensed Professional Counselors School Psychologists School Counselors Psychiatric Nurses Psychiatrists

Disaster Mental Health in Preparedness • Community-based, resilience-building education models: Examples: • Coping in Today’s World: Psychological First Aid and Resilience for Families, Friends and Neighbors • Pillowcase Project – school-based disaster preparedness curriculum for elementary school students • Psychological First Aid - training for Red Cross disaster responders



Disaster Mental Health Response

Three-Element Intervention Strategy

Element 1: Identification of Mental Health Needs Goal 1 - Triage disaster survivors • Red Cross Disaster Mental Health utilizes PsySTART triage system based on evidence-based risk factors: • Exposure to disaster – e.g.. Impact on self, family, pets, home, belongings and financial security • Previous history of mental illness • Previous disaster experience • Individual resilience



Element 1: Identification of Mental Health Needs Other instances requiring Disaster Mental Health intervention include clients who present with significant stress symptoms: • A person is crying uncontrollably, withdraws over an extended period, or otherwise exhibits significant distress; • A client is so distressed or has extreme limitations that require advocacy to get through the interview with the caseworker or access other critical disaster services; • A client or worker behaves in such a way that makes it difficult for the service provider to provide services; • A distressed worker or client asks for coping support, or has it requested for them by someone else.

PsySTART Wallet Card



PsySTART Risk Factors • Risk factors are used as a first step in a continuum of triage, screening, secondary clinical assessment, and referral • Developed by Red Cross Disaster Mental Health Responder and disaster research psychologist • Based on multiple research studies on children and adults: • Direct research using PsySTART itself (Theinkurta, et. al. 2006, Marshal et. al. 2008) • Large scale reviews of DMH literature: (Norris, et al, 2001, Galea, 2005, Neuria, 2008, Digrande, 2011) • Meta-analytic reviews of PTSD risk following traumatic events (Ozer, 2003, Brewin, 2000)

Element 1: Identification of Mental Health Needs Goal 2 - Mental Health Surveillance • Purpose: • To deploy to areas with higher ratios of high risk clients • To inform state and local MH agencies of client needs • To monitor worker exposure

• Process: Supervisor/manager collects data from DMH workers and aggregates to determine areas with higher risk



Example of Mental Health Surveillance

Element 2: Promote Resilience and Coping Enhanced Psychological First Aid • Make a connection • Help people be safe • Be kind, calm and compassionate • Meet basic needs • Listen • Give realistic reassurance • Individual psychoeducation

• Encourage good coping • Help people connect • Give accurate and timely information • Make a referral to a Disaster Mental Health worker • End the conversation • Take care of yourself



Element 2: Promote Resilience and Coping • Public health messaging and consultation Help communities normalize stress reactions after disaster • Examples: Bus advertisements, Public Service Announcements

• Support state and local mental health agencies/professionals through training and consultation • Community resilience training

Element 3: Targeted Disaster Mental Health Interventions

• • • • •

Secondary assessment Referrals to community resources Crisis Intervention Casualty support Advocacy



Disaster Mental Health Disaster Mental Health Responders Do NOT Do: • • • •

Psychotherapy Formal mental health evaluations or diagnosis Individual psychological debriefings (e.g., CISD) Long-term trauma therapies

Why Not? • Focus is short term • Building strong therapeutic alliance is not appropriate • Some interventions have concerns about efficacy or secondary trauma • Best time to talk is…when you feel like it, not necessarily when a group debriefing is scheduled • Lack of pre-screening can be problematic for groups



Disaster Mental Health in Recovery • Continued assessment and support of disasteraffected community, first responders and Red Cross workforce • Participate on Long Term Recovery Groups to identify and assist in filling service delivery gaps • Public health messaging and consultation • Support state and local mental health agencies/professionals through training and consultation • Community resilience training

When to Utilize Disaster Mental Health Responders • • • •

All size disasters – house fires to hurricanes Large number of displaced survivors One or more fatalities High-risk populations involved: • Children • Elderly • Survivors with Access and Functional Needs

• High levels of responder stress • Transportation/Aviation Incidents



For More Information: J. Christie Wrightson, MSW, LICSW Senior Associate, Disaster Mental Health American Red Cross National Headquarters [email protected] Find your local Red Cross chapter: www.redcross.org

Disaster Distress Helpline Overview, Discussion, Q&A



Agenda • Disaster Distress Helpline & Behavioral Health • Overview of DDH Services • Additional Resources • Discussion / Q&A

Disaster Behavioral Health

Mental Health Concerns • • • •


Pre-existing mental/behavioral health concerns aggravated, triggered by event New behavioral health concerns emerge after event Access to care affected by event Special considerations for individuals & families with access and functional needs



Distress Risk Factors Who is most at risk for distress? •

Survivors living or working in impacted areas: higher degree of exposure, greater the risk for distress or trauma (“circle of impact”)

Loved ones of victims (traumatic loss)

First responders, rescue & recovery workers; disaster relief & emergency workers

Other considerations: •

Pre-disaster mental health concerns

History of challenging or difficult recovery from past disasters

Pre-disaster experience of family violence, domestic violence, sexual violence, other issues of crime/victimization

Access & functional needs

Media exposure (inside/outside impacted areas)

Distress Reactions Disaster Distress: •

Norris, 2002: 9% minimal reactions; 51% moderate; 23% severe; 17% very severe

Possible Distress Reactions Include: Mild to Moderate (Transitory)  Severe to Very Severe (Psychopathology) •

Trouble sleeping

Difficulty concentrating and performing daily tasks, including at work or school

Irritability; increased feelings of worry and anger

Withdrawal and isolation

Feelings of hopelessness

Setbacks during anniversaries, other event reminders

Increased substance use; risk for abuse or addiction

Persistent anxiety

Depression; suicidal thoughts, ideation, attempt

Also: Post-Traumatic Growth



Research •

The occurrence of natural and man-made disasters increased in the U.S and its territories by 39% from 2000-20101 …

The psychological impact these events have on a significant proportion of people who experience them2 …

… Demonstrates the need for a hotline network with the capacity to provide disaster crisis counseling and emotional support in any part of the country with immediacy. •

Five intervention principles3 following disasters to promote among those affected: 1) Sense of safety 2) Calming 3) Sense of self– and collective efficacy 4) Connectedness 5) Hope

1: http://www.fema.gov/news/disaster_totals_annual.fema 2: Norris, F.H., Friedman, M.J. and Watson, P.J. 60,000 Disaster Victims Speak: Part II. Summary and Implications of the Disaster Mental Health Research, Psychiatry 65(3) Fall 2002 240 3: Hobfoll, S.E., Watson, P., Bell, C.C., et. al. Five Essential Elements of Immediate and Mid–Term Mass Trauma Intervention: Empirical Evidence, Psychiatry 70(4) Winter 2007 pp285-286

DDH: Public/Private Partnership • HHS / SAMHSA • Link2Health Solutions - National Suicide Prevention Lifeline - Veterans Crisis Line - Oil Spill Distress Helpline • MHA-NYC - 9/11 Terrorist Attacks, Hurricane Katrina - Project Liberty & Project Hope



DDH: Overview of Services •

National hotline (1-800-985-5990) and SMS (text ‘TalkWithUs’ to 66746) service available to anyone in the U.S. states/territories before, during & after natural and human-caused disasters

Goal: To assist individuals and families experiencing emotional distress related to disaster, in order to help them move forward on the path to recovery

Also: • Complements existing local / state / national - I & R / crisis hotlines • Multi-lingual interpretation services in 100+ languages; live 24/7 crisis counseling in Spanish available via the hotline and SMS (text ‘Hablanos’ to 66746) • Hotline available to all U.S. territories: Pacific Islands can text “TalkWithUs” or “Hablanos” to 1-206-430-1097 & Caribbean Islands to 1-212-461-4635 • TTY (1-800-846-8517) available, and texting also promoted to deaf and hard of hearing

DDH: When Someone Calls or Texts… •

Psychological First Aid - NCTSN PFA Online http://learn.nctsn.org

Disaster Crisis Counseling for Crisis Contact Centers Active Listening







Using… Normalization

Crisis Assessment, Intervention and Referral

Guiding Principles



Sample DDH Caller Scenarios* *Names, other identifying information changed or omitted for confidentiality

12/2012, MI – Caller is struggling related to the shootings in CT. Caller has a history of anxiety and was last in treatment a year ago. Caller stated that she has two small children and she has felt overwhelmed with anxiety and fear since the shootings. She is able to confide in her mother and her husband, but is frustrated that their suggestions to occupy her time and stay away from news programming are not helping.

4/2013, MA – Caller reports being a runner at the Boston Marathon and was at the finish line, a minute after the bombing took place. He considers himself very lucky but is having a hard time coping with the trauma. He states that his wife was also running but left the course midway and he was not able to communicate or reunite with her until much later.

3/2014, WA – Middle-aged caller residing near the area impacted by the Washington State landslide reported feelings of sadness and grief, as a neighbor had died in the landslide. The caller also indicated feelings of frustration as [she/he] could not engage in [her/his] usual activities as the roads in the area had been closed off. These feelings had also been exacerbated by the recent death of a family member.

DDH: Why Offer Texting? Prevalence of mobile phones, SMS/Texting Study: preferred method of communication for teens, increasingly also for adults Growing form of outreach and engagement for other Helplines and social services Opportunities to reach individuals whom otherwise may go unnoticed Engaging individuals in circumstances when they can’t make phone calls (anonymity, safety) Best practices in Emergency Preparedness and Response



Sample DDH Texter Scenarios* *Transcribed directly, so misspellings/grammar intentional; identifying information changed or omitted for confidentiality

Things have been difficult and very stressful. I lost everything during Katrina and still deal with the emotions of that daily and now having to deal with this again and on the anniversary of it just makes things even more emotional. No one really seems to understand why I am so emotional about the situation! In Katrina I swam and our home washed away! Even where we evacuated to had 18 feet and swam to a roof top. Its just been really hard to deal with

I'm having panic attacks and freaking out about this hurricane coming. I just can not seem to focus and push the storm back for a bit to get myself back in control

Do u think [town] will get hit hard kuz i live in a old trailer and have 3 kids so i wanted 2 know if i need 2 leave thanks

I was really looking for advice about where to go. Im handling my fears fine just trying to find a safe place for me and my family. Trying to be prepared

Evac from [city], daughter need dialysis, mom elderly they not getting along is driving me to tears. I want to go home! Need to talk to someone . Need help!!!

DDH: Key Players

SAMHSA • Funder & key federal partner

Link2Health Solutions

Core Region Centers (CRCs)

Affected Area Centers (AACs)*

• Administrator, a subsidiary of the non-profit MHANYC; also administers the National Suicide Prevention Lifeline network

• Crisis Contact Centers that comprise the DDH Network

• Temporary Network Crisis Contact Centers located in disasterimpacted areas

Key Stakeholders • Agencies, Institutions, Organizations that serve disasterimpacted communities



DDH Core Region Centers

DDH: Additional Services







Outreach & Training Outreach - Identify key stakeholders - Develop relationships - Network & coordinate services throughout all phases of a disaster - Via stakeholders, promote the DDH to disaster survivors, loved ones, first responders, rescue & recovery workers (self-care resource) - Advocate for inclusion of disaster behavioral health needs/services Training and Technical Assistance - Training & TA provided for DDH-networked ‘Core Region Centers’ and ‘Affected Area Centers’ - Disaster Preparedness, Response and Recovery resources available for all 160+ Lifeline-networked crisis centers via the Lifeline Network Resource Center, online portal for crisis center staff - Trainings/presentations for external stakeholders

Resources Program Literature - DDH outreach resources (brochures, wallet cards) geared towards disaster distress risk groups and available to stakeholders for distribution; in English & Spanish; brochures have blank spaces for adaptation to promote local resources :

Local Service



Communications Disaster Distress Helpline Website - http://disasterdistress.samhsa.gov  Resources for providers, risk groups, general public  Education & Information  Updated regularly + immediately following major disasters

Social Media -




Additional Resources Disaster Distress Helpline & FEMA ESF / RSF: Dept. of Health and Human Services • Support Agency for ESF 6 • Coordinator / Primary Agency for ESF 8 • Coordinating Agency for RSF Health and Social Services HHS Disaster Behavioral Health Concept of Operations (ConOps) • Updated February 2014 • Available at HHS ASPR “At-Risk, Behavioral Health & Community Resilience” (ABC) Resource Section: http://www.phe.gov/preparedness/planning/abc



Additional Resources SAMHSA Disaster Technical Assistance Center (DTAC) • http://www.samhsa.gov/dtac


SAMHSA set out to develop a mobile app that: • Provides the evidence-based resources of the Disaster Kit. • Identifies local treatment facilities. • Shares resources directly from the app via text message or email. • Functions with limited internet connectivity. • Would be a valuable tool for behavioral health disaster responders.



What next? DISCUSSION: How can you effectively utilize the DDH as a resource? • Promote the DDH as a resource to individuals and communities served & as resource for self –care among staff and colleagues who may be at risk for vicarious trauma, burnout, etc. • Provide the DDH with information and other disaster-specific resources for inclusion in our call center resource databases to assist callers and texters in distress; • Connect through social media before, during and after disasters to share resources, communicate with the public re. behavioral health, coping, etc.; include DDH services in press releases, blog updates, other communications as appropriate (particularly when large-scale disasters impact multiple regionsas a reminder, after providing crisis counseling DDH always refers callers back to local services for follow-up care & support); • Coordinate service delivery before, during and after disasters so that behavioral health is included in any response plans; invite DDH L2HS staff to participate in forums, coalitions, list-servs, etc.

Communication – Coordination – Collaboration – Cooperation (National VOAD)

For More Information…

Christian Burgess, Director [email protected] / 212-614-6346



“It helped me for you to listen … … because no one else has wanted to.” - Caller to Disaster Distress Helpline after Hurricane Sandy

Discussion / Q&A