DISM411 20 Midterm PDF

DISM411 MIDTERM ▪ Security ▪ Shelter WEEK 7-8: HELPING SURVIVORS...

DISM411 MIDTERM ▪ Security ▪ Shelter WEEK 7-8: HELPING SURVIVORS What to do: PSYCHOLOGICAL FIRST AID Safeguard ▪ Remove from harm’s way Key Points ▪ Remove from the scene ▪ Provide safety and security - Parallel to medical first aid ▪ Provide shelter - Uses skills you probably already have ▪ Reduce stressors - Appropriate for all ages - Consistent with research evidence on risk and resilience following trauma What survivors need: ▪ Basic survival needs Crisis Events What to do: - Crisis events: both large scale and individual Sustain ▪ Provide food, water, and ice o Occur in every community in the world ▪ Provide medical care, alleviate pain - They have physical, social and emotional ▪ Provide clothing consequences for those affected ▪ Provide power, light, heat, air- PFA: First-Line Psychosocial Support conditioning ▪ Provide sanitation - PFA is important, first-line psychosocial support for people affected by crisis events o PFA, like medical “first aid,” is not enough on FUNCTION its own - The term “PFA” was first coined in the 1940s but its use What survivors need: has increased in modern day crisis events ▪ Soothing human contact ▪ Validation that reactions are What is PFA? “normal” Humane, supportive, and practical assistance to fellow human What to do: beings who recently suffered a serious stressor: ▪ Establish a compassionate ▪ Non-intrusive, practical care, and support “presence” ▪ Assessing needs and concerns Comfort ▪ Listen actively ▪ Helping people to address basic needs (like food & ▪ Comfort, console, soothe, and water) reassure ▪ Listening but not pressuring people to talk ▪ Apply stress management techniques What PFA is NOT? ▪ Reassure survivors that their reactions are normal ▪ NOT something only professionals can do ▪ NOT professional counselling ▪ NOT a clinical or psychiatric intervention (although can What survivors need: be part of good clinical care) ▪ NOT “psychological debriefing” ▪ Social supports/keeping family together Why PFA? ▪ Reuniting separated loved ones Connect ▪ Connection to disaster recovery People do better over the long term if they: services - Feel safe, connected to others, calm & hopeful ▪ Medical care, work, school, vital - Have access to social, physical & emotional support services - Regain a sense of control by being able to help themselves What to do: ▪ Keep survivor families intact SAFETY, FUNCTION, ACTION: Psychological First Aid for Disaster ▪ Reunite separated loved ones Survivors ▪ Reunite parents with children OUTCOMES ▪ Connect survivors to available supports Safety Restoring physical safety and diminishing the ▪ Connect to disaster relief services, physiological stress response medical care Function Facilitating psychological function and perceived sense of safety and control Action Initiating action toward disaster recovery and return to normal activity ACTION What survivors need: SAFETY ▪ Information about the disaster ▪ Information about what to do What survivors need: ▪ Information about resources ▪ Safety  What to do: ▪ Adapt what you do to take account of the person’s culture ▪ Clarify disaster information: (what Educate ▪ Respect safety, dignity and rights happened? What will happen?) o Safety: don’t expose people to further harm, ▪ Provide guidance about what to do ensure (as best you can) they are safe and ▪ Available resources protected from further physical or psychological harm o Dignity: treat people with respect and What survivors need: according to their cultural and social norms ▪ Planning recovery o Rights: act only in people’s best interest, ▪ Practical first steps and “do-able” ensure access to impartial assistance without tasks discrimination, assist people to claim their ▪ Support to resume normal rights and access available support activities PFA ACTION PRINCIPLES ▪ Opportunities to help others What to do: 1. Prepare Empower 2. Look ▪ Set realistic disaster recovery goals 3. Listen ▪ Problem solve to meet goals 4. Link ▪ Define simple, concrete tasks ▪ Identify steps for resuming normal Prepare ▪ Learn about the crisis event activities ▪ Learn about available services and supports. ▪ Engage able survivors in helping ▪ Learn about safety and security concerns. tasks Look ▪ Observe for safety. ▪ Observe for people with obvious urgent PFA: WHO, WHEN, WHERE basic needs. ▪ Observe for people with serious distress WHO can benefit from PFA? reactions. - Boys, girls, women, and men who have recently Listen ▪ Make contact with people who may need experienced a crisis event and are distressed support. ▪ Ask about people’s needs and concerns. WHEN should PFA be provided? ▪ Listen to people and help them feel calm. - When encountering a person in distress usually Link ▪ Help people address basic needs and access immediately following a crisis event services. ▪ Help people cope with problems. WHERE should PFA be provided? ▪ Give information. - Anywhere that is safe for the helper and affected ▪ Connect people with loved ones and social person, ideally with some privacy as appropriate to the support. situation People who likely need special attention (to be safe, to access services) HELPING RESPONSIBLY: ETHICAL GUIDELINES 1. Children and adolescents - Especially those separated from caregivers Don’ts 2. People with health conditions and disabilities ▪ Don’t exploit your relationship as a helper. - People who are non-mobile, or who have chronic ▪ Don’t ask the person for any money or favor for helping illness, hearing/visual impairments (deaf or blind), or them. severe mental disorders ▪ Don’t make false promises or give false information. - Frail elderly people, pregnant or nursing women ▪ Don’t exaggerate your skills. ▪ Don’t force help on people, and 3. People at risk of discrimination or violence ▪ don’t be intrusive or pushy. - Women, people of certain ethnic or religious groups, ▪ Don’t pressure people to tell you their story. people with mental disabilities ▪ Don’t share the person’s story with others. ▪ Don’t judge the person for their actions or feelings HELPING SURVIVORS Do’s The task of helping survivors is a difficult one in which, often, any action seems too little given the magnitude of the ▪ Be honest and trustworthy. disaster and its consequences. Nonetheless, disaster mental ▪ Respect a person’s right to make their own decisions. health workers make significant contributions to the recovery of ▪ Be aware of and set aside your own biases and survivors. prejudices. ▪ Make it clear to people that even if they refuse help Helping interventions are best understood in the now, they can still access help in the future. context of when, where, and with whom interventions take place. ▪ Respect privacy and keep the person’s story For example, emergency (when) on-site (where) interventions confidential, as appropriate. with ambulatory survivors (whom) will have as their primary ▪ Behave appropriately according to the person’s culture, objective the providing of a safe and secure base from which age and gender. survivors can regain (within reason) a degree of equilibrium; three weeks following the disaster, interventions provided in How to Help Responsibly community settings are apt to be educational and exploratory with the objective of increasing awareness of the biopsychosocial impact of the event and ways to maximize adults’ and children’s coping; six months later, interventions provided in clinical or find someone else to remain with him/her until the feelings settings may include formal assessment and treatment protocols subside. If possible, consult a physician or nurse regarding utility for persistent symptoms related to post-traumatic stress. of medication. Ensure the survivor’s safety, and acknowledge and validate the survivor’s experience. EMERGENCY PHASE ON AND OFF-SITE INTERVENTIONS At the site(s) of impact and in disaster services areas, DEATH NOTIFICATION: the first mental health services are provided on improvised basis Mental health personnel may be asked to serve on coroners’ or by voluntary bystanders who may or may not have professional medical examiners’ death notification team (Sitterle, 1995). training or skills. When mental health professionals are deployed Mothers Against Drunk Driving (MADD) developed curriculum on to a disaster by an agency, they rarely are the first responders. compassionate death notification for professional counselors and victim advocates (Lord, 1996), which is summarized and Thus, even if a mental health professional enters the printed with the permission of MADD. disaster site only a few minutes or hours of impact, her or his first responsibility is to identify “natural helpers,” join with them in DEBRIEFINGS providing crisis care, and rapidly but sensitively relieve them of these responsibilities. Helping bystander crisis responders to get - Debriefings are structured group meetings or to a safe and appropriate place outside the impact area is a discussions about a traumatic event involving people delicate and important first step in caring for disaster survivors. who normally work together. - Occasionally, it may be necessary to combine various PROTECT, DIRECT, CONNECT TRIAGE, ACUTE CARE, DEATH groups of emergency response personnel together for NOTIFICATION a debriefing, but this should only be done when all the parties were involved together in the same incident. Whether on-site or off-site, initial mental health interventions are - Debriefings are designed to mitigate the impact of such primarily pragmatic.. an event and to assist people to recover as quickly as possible from the stress arousal associated with the event. PROTECT: Find ways to protect survivors from further harm and from further Critical Incident Stress Debriefing (CISD) exposure to traumatic stimuli. If possible: - Create a “shelter” or safe haven for them, even if it is - is one type of debriefing which integrates crisis symbolic. The less traumatic stimuli people see, hear, intervention strategies with educational techniques. smell, taste, feel, the better off they will be - It was originally developed by Dr. Jeffrey T. Mitchell. - Protect survivors from onlookers and the media - CISD is the debriefing protocol most widely used today and it is the technique which will be outlined in this workbook. DIRECT: Kind and firm direction is needed and appreciated. Survivors may CSID was designed to be applied among public safety, disaster be stunned, in shock, or experiencing some degree of response, military, and emergency response personnel but it can dissociation. When possible, direct ambulatory survivors: be used with virtually any population, including children, when it - Away from the site of destruction is employed by a skilled intervention team. - Away from severely injured survivors - Away from continuing danger A debriefing is not psychotherapy, nor is it a substitute for psychotherapy. Instead, it is meant to provide an opportunity for ventilation in a structured and supportive environment. The core CONNECT: focus of a debriefing is the relief of stress in normal, emotionally The survivors you encounter at the scene have just lost healthy people who have been exposed to a traumatic event. The connection to the world that was familiar to them. A supportive, debriefing is not intended to resolve psychopathologies or compassionate, and nonjudgmental verbal or non-verbal personal problems that existed before the traumatic incident exchange between you and survivors may help to give the being debriefed. experience of connection to the shared societal values of altruism and goodness. However brief the exchange, or however Debriefings usually take 2 to 3 hours; marathon debriefings temporary its effects, in sum such “relationships” are important indicate one or more of the following problems: elements of the recovery or adjustment process. Help survivors connect: 1. That the incident was a very traumatic one. - To loved ones 2. That too much time was spent on the fact and thought - To accurate information and appropriate resources phases. - To where they will be able to receive additional support 3. The team was inexperienced or unfamiliar with the debriefing process. 4. The quality of team leadership was poor. TRIAGE: The majority of survivors experience normal stress reactions. Contraindications However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. Sign of panic are Debriefings are not indicated in the following situations: trembling, agitation, rambling speech, erratic behavior. Signs of For use after routine events. intense grief may be loud wailing, rage, or catatonia. In such For a debriefing to be conducted in the absence of a cases, attempt to quickly establish therapeutic rapport, ensure mental health professional. the survivor’s safety, acknowledge and validate the survivor’s For a debriefing to be conducted if too much time has experience, and offer empathy. Medication may be appropriate passed since the traumatic incident. and necessary, if available. For use in mediating management-employee conflicts. For use as a substitute for psychotherapy. ACUTE CARE: Those survivors who require immediate crisis intervention to help TIMING manage intense feelings of panic or grief can be helped by your presence. When possible, stay with the survivor in acute distress Debriefings must be held when the participants are emotionally - PTSD is highly correlated with the development of drug "ready" to accept and benefit from them. This often occurs within and alcohol problems. 24 to 72 hours after exposure to a traumatic incident. However, some traumatic incidents, especially disasters or line-of-duty What Are Evidence Based Treatments for Traumatized Children? deaths require a much longer waiting period since the shock, numbing or denial mechanisms may last for weeks after the What They Are Not: traumatic event. - Rigid - Lockstep REASONS FOR THE THERAPEUTIC EFFECTS OF DEBRIEFINGS - Inflexible ❖ Early intervention: Prevents the concretization of How are EBTs Similar to Usual Treatments for Traumatized traumatic memories. Children? ❖ Opportunity for catharsis: This ventilation of emotions leads to reduced stress arousal. The therapeutic relationship is central. ❖ Opportunity to verbalize the trauma: The opportunity to Therapist creativity and judgment are valued and verbally reconstruct and express specific traumas, critical to success. fears and regrets leads to reduced stress arousal. Flexibility is important in how components are adapted ❖ Structure: Superimposes an orderly process with a for individual children and families. finite beginning and a finite end upon the chaos of a Cultural, religious, developmental, and family values traumatic event. are respected. ❖ Group support: The group experience provides numerous healing factors which are intrinsic to the WHAT IS TF-CBT? group process. ❖ Peer support: Peers can most effectively eradicate the A hybrid treatment model that integrates: myth of uniqueness and can suggest more appropriate stress management techniques. Trauma sensitive interventions ❖ Stress education: Allows for a better understanding of Cognitive-behavioral principles available skills to cope with stressful situations. Attachment Theory ❖ Allows for follow-up: Persons in need of further care Developmental Neurobiology can be more readily identified. Family Therapy Empowerment Therapy FORMAT OF A DEBRIEFING Humanistic Therapy The Mitchell Model of Debriefing (CISD) What Children is TF-CBT Appropriate For? - a 7-stage intervention with the following stages: Children with known trauma history-single or multiple, Introduction any type. Fact Thought Children with prominent trauma symptoms (PTSD, Reaction depression, anxiety, with or without behavioral Symptom problems). Teaching Children with severe behavior problems may need Re-entry additional or alternative interventions. Parental involvement is optimal. TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY Treatment settings: clinic, school, residential, home, inpatient. Traumatic Exposure Among Children and Adolescents Group model: CBITS ▪ 25% of all girls and 10-12% of all boys experience 14 Misconceptions about TF-CBT sexual abuse/assault by the age of 18. ▪ One study (Costello, 2002- Large epidemiological TF-CBT cannot be used with children when there is no study) suggests that 25% of all children/ adolescents parent/caretaker available. have experienced a traumatic event before 16 years of TF-CBT cannot be used with children in foster care. age and 6% at least one in the previous six months. TF-CBT cannot be used with children with complex trauma or multiple traumas. Posttraumatic Stress Disorder (PTSD) TF-CBT cannot be used with children who have symptoms other than PTSD. - Exposure to traumatic event TF-CBT cannot be used with children younger than five - Reexperiencing symptoms or older than 14. - Avoidance symptoms TF-CBT cannot be used with children with special needs - Hyperarousal symptoms or developmental delays. TF-CBT cannot be used with children from a variety of Other Psychiatric Disorders cultural backgrounds. o Adaptation for Latino families ❖ High level of comorbidity with PTSD o Adaptation for Native American families ❖ Other psychiatric disorders: - Depression Difficulties Addressed by TF-CBT - Generalized Anxiety Disorder - ADHD C.R.A.F.T.S - Substance Abuse 1. Cognitive Problems Long-term Consequences of Untreated Childhood PTSD 2. Relationship Problems 3. Affective Problems - Significant risk for depression and other psychiatric 4. Family Problems disorders.  5. Traumatic Behavior Problems ❖ Feeling Identification 6. Somatic Problems ▪ Accurately identify and express a range of different feelings. Core Values of TF-CBT - Board games (e.g., Emotional Bingo) - Feeling brainstorm C.R.A.F.T.S - Color My Life or person ▪ Traumatized children may have restricted Components-Based range of affect expression. Respectful of Cultural Values ▪ End on a positive note. Adaptable and Flexible Family Focused COGNITIVE PROCESSING Therapeutic Relationship is Central Self-Efficacy is emphasized ❖ Help children and parents understand the cognitive triad: connections between thoughts, feelings, and Child and Parent Components behaviors, as they relate to everyday events. ❖ Help children distinguish between thoughts, feelings, Individual sessions for both child and parent. and behaviors. Parent sessions - generally parallel child sessions. ❖ Help children and parents view events in more accurate Same therapist for both child and parent and helpful ways. ❖ Encourage parents to assist children in cognitive TF-CBT Components processing of upsetting situations, and to use this in their own everyday lives for affective modulation. P.R.A.C.T.I.C.E Cognitive Processing of Trauma Psychoeducation and Parenting Skills ▪ Identify child and parent trauma-related cognitive Relaxation distortions, from trauma narrative or otherwise. Affective Modulation ▪ Use cognitive processing techniques to replace these Cognitive Processing with more accurate and/or helpful thoughts about the Trauma Narrative trauma. In Vivo Desensitization ▪ Encourage parents to reinforce children’s more Conjoint parent-child sessions accurate/helpful cognitions. Enhancing safety and social skills o Ex: it’s my fault, I’ll never be like other kids, she’s lost her innocence, you can’t trust any PSYCHOEDUCATION men, etc. ▪ Responsibility vs. Regret Goals: TRAUMA NARRATIVE ▪ Normalize a child’s and parent’s reactions to severe stress. Reasons to directly discuss traumatic events: ▪ Provide information about psychological and physiological reactions to stress. Gain mastery over trauma reminders. ▪ Instill hope for child and family recovery. Resolve avoidance symptoms. ▪ Educate the family about the benefits and need for Correction of distorted cognitions. early treatment. Model adaptive coping. ▪ PSYCHOEDUCATION GOES ON THROUGHOUT THERAPY! Identify and prepare for trauma/loss reminders. Contextualize traumatic experiences into life. PARENTING SKILLS IN VIVO MASTERY OF TRAUMA REMINDERS ❖ TF-CBT views parents as central therapeutic agent for change. ❖ Mastery of trauma reminders is critical for resuming ❖ The goal is to establish parent as the person the child normal developmental trajectory. turns to for help in times of trouble. ❖ To be used only if the feared reminder is innocuous (not ❖ Explain the rationale for parent inclusion in treatment, if it’s still dangerous). i.e., not because parent is part of the problem but ❖ Hierarchical exposure to innocuous reminders which because parent can be the child’s strongest source of have been paired with the traumatic experience. healing. ❖ A therapist MUST have confidence that this will work, or ❖ Emphasize positive parenting skills (praise), enhance it won’t. enjoyable child-parent interactions. CONJOINT PARENT-CHILD SESSIONS RELAXATION ❖ Share information about child’s experience. ❖ Reduce physiologic manifestations of stress and PTSD. ❖ Correct cognitive distortions (child and parent). ❖ Develop individualized relaxation strategies for ❖ Encourage optimal parent-child communication. manifestations of stress (headache, stomachache, ❖ Prepare for future traumatic reminders. dizzy, racing heart, etc.). ❖ Model appropriate child support/redirection. o Focused breathing/mindfulness/meditation Enhancing Safety Skills o Progressive, other muscle relaxation. o Physical Activity ▪ May be done individually or in joint sessions. o Yoga, singing, dance, blowing bubbles ▪ Develop children’s body safety skills. o “If it’s not fun, you’re not doing it right”. ▪ Develop a safety plan which is responsive to the child’s and family’s circumstances and the child’s realistic AFFECTIVE MODULATION abilities.  ▪ Practice these skills outside of therapy. ▪ Personal injury ▪ For sexually abused children, include education about ▪ Injury or fatality of loved ones, friends, associated healthy sexuality. ▪ Property loss ▪ For children exposed to DV, PA, CV, may include ▪ Pre-existing stress education about bullying, conflict resolution, etc. ▪ Low level of personal and professional preparedness ▪ Stress reactions of significant others EMPIRICAL SUPPORT FOR TF-CBT ▪ Proximity to scene of impact ▪ Self-expectations 6 completed randomized controlled trials (RCT) using ▪ Prior disaster experience comparison treatments, conducted in Pittsburgh, New ▪ Negative perception/interception of even Jersey and across both sites. ▪ Low level of social support >500 sexually abused/multiply traumatized children, ▪ Previous traumatization 3-18 years old. 2 ongoing RCTs for children exposed to sexual abuse or TYPES OF EMERGENCY WORKERS domestic violence as primary traumas, ages 4-12 years old. - Emergency workers may be members of highly trained All of the 6 completed studies supported the superiority teams, victims trying to help those who have been more of TF-CBT over other active treatments for traumatized seriously affected, or bystanders children with regard to improvement in a variety of domains: PTSD, depression, anxiety, internalizing, Many Types of Helpers Respond to Emergencies externalizing, sexualized behaviors, shame, abuse- related cognitions. ▪ Search and rescue workers ▪ Fire and safety workers ▪ Transport drivers WEEK 9-10: HELPING THE HELPERS ▪ Medical personnel and paramedics (EMTs) ▪ Medical examiner and staff ▪ Police, security, and investigators ▪ Rescuing and aiding survivors, and the tasks of body ▪ Clergy recovery, identification, and transport are but few of the ▪ Mental health and social service personnel stressors that contribute to high levels of emotional ▪ Elected officials distress among disaster workers (Uranso, RJ. , ▪ Volunteers who staff shelters, provide mass care, McCaugher, B.G., & Fullerton, C.S. 1994) assess and repair the infrastructure ▪ Disaster mental health work with helpers requires a ▪ Media professionals broad clinical background and specific knowledge of stress reactions, post-traumatic stress disorder, crisis STRESS REACTIONS OF DISASTER WORKERS intervention, the nature of emergency work, stress management, and other intervention protocols - Stress reactions may result in psychic numbing, short-term appropriate to the disaster environment impairment of memory, problem-solving abilities, and communication STRESSORS ASSOCIATED WTH DISASTER WORK - Stress reactions in disaster workers are normal and to be expected - Disaster work is a combination of negative and positive experiences Common Stress Reactions of Disaster Workers - Experiences may involve profound feeling of grief, despair, helplessness, horror, and repulsion 1. Emotional Occupational Hazards ▪ Shock ▪ Anger ▪ Exposure to unpredictable physical danger ▪ Disbelief ▪ Encounter with violent death and human remains ▪ Terror ▪ Encounter with suffering of others ▪ Guilt ▪ Negative perception of cause of the disaster ▪ Grief ▪ Negative perception of assistance offered victims ▪ Long hours, erratic work schedule, extreme fatigue 2. Cognitive ▪ cross-cultural differences between workers and community ▪ Impaired concentration ▪ Inter-agency/intra-organizational struggles over ▪ Confusion authority ▪ Distortion ▪ equipment failure and perception of low-control ▪ Intrusive thoughts ▪ lack of adequate housing ▪ Decreased self-esteem ▪ encounter with mass death\ ▪ Decreased self-efficacy ▪ encounter with death of children ▪ Self-blame ▪ role ambiguity ▪ difficult choices 3. Biological ▪ Communication breakdowns ▪ Low funding or allocation of resources ▪ Fatigue ▪ Negative perception by community ▪ Insomnia ▪ Weather conditions ▪ Sleep disturbance ▪ Over-identification with victims ▪ Hyper arousal ▪ Human errors ▪ Somatic complaints ▪ Time pressure ▪ Impaired immune response ▪ Perceived mission failure ▪ Headaches Personal Situation/Stressors 4. Psychosocial  ▪ Alienation o Encounter with death of children ▪ Social withdrawal o Role ambiguity ▪ Increased stress within o Difficult choices ▪ Relationships substance abuse o Communication breakdowns ▪ Vocational impairment ▪ Low funding/allocation of resources ▪ Perception by community ▪ Weather conditions - It is recommended that disaster mental health services for ▪ Over-identification with victims workers be pre-arranged with their purpose and protocols ▪ Human errors understood and accepted by command staff and team ▪ Perceived mission failure managers ▪ Proximity to scene of impact - On-scene mental health support is delivered through ▪ Prior disaster experience consultation, defusing, debriefing, or crisis intervention ▪ Level of social support services ▪ Previous traumatization THE RESCUE WORK CULTURE Unlike the time needed to conduct debriefings (2- 4 hours), defusing can be brief (10-30 minutes) and offered The culture among rescue workers combines shared continuously throughout the operation. values and individual differences Myers (1987) noted that emergency service workers TEACHING RELAXATION TECHNIQUES TO DISASTER WORKERS often seem to possess contrasting personality traits - Disasters workers have a deep commitment to working long Gentleness Great strength hours without breaks and may quickly dismiss suggestions trust Caution about using time to relax. High self-confidence High self-criticism Guidelines Dependence Independence Toughness Sensitivity 1. Inquire about how long they have been on the job and about previous disaster experience. For example, whereas emergency workers often have a 2. Inquire about how coping styles (how he/she see their high capacity for trust among each other, they tend to fellow workers coping, what he/she typically does to be cautious about the competencies of individuals relax). perceived as outsiders; 3. Inquire about unexpected stressors. Rescue workers may demonstrate mental and 4. Inquire about sleeping patterns and level of fatigue. emotional resilience during an operation, but have 5. Provide rationale for relaxation, first validating fatigue intense emotional reactions afterwards because of and its effects. Discuss disaster workers’ general their sensitivity to the feelings of survivors and their vulnerabilities (e.g., inability to stop working or thinking families. about the disaster). If mental health workers tactfully acknowledge those 6. Begin instruction and demonstration of techniques polarities, it may serve to achieve the confidence of (e.g., muscle relaxation, conscious breathing, rescue workers while increasing their willingness to autogenics, visualization, etc.). Remember, the disclose feelings of vulnerability or self-criticism, and circumstances and settings that you will be teaching in receive emotional support are, more often than not, far from ideal. You may have from five to fifteen minutes to demonstrate the value of DEFUSING INTERVENTION relaxation. The challenge is to efficiently facilitate the experience of relaxation in the midst of chaotic - Defusing refers to a process intended to facilitate environments. opportunities for rescue workers to express their thoughts and feelings about the rescue tasks at hand without feeling Stress Management obligated to do so. - Defusing gives rescue workers the opportunity to better - Stress management is key to emergency management. understand their own reactions and allows mental health Successful stress management is built on prevention and workers to look for indications of workers who may be at risk planning, a solid understanding of roles and responsibilities, for long-term stress reactions. support for colleagues, good self-care, and seeking help when needed. - Crisis response professionals may be repeatedly exposed to ▪ Exposure to unpredictable physical danger unique stressors during the course of their work. Successful ▪ Encounter with human remains implementation of any stress management plan requires ▪ Stress reactions of significant others overcoming some obstacles and barriers, including priority ▪ Encounter with suffering of others setting, resource allocation, organizational culture, and ▪ Perception of cause of the disaster stigma. ▪ Perception of assistance offered victims ▪ Long hours, erratic work schedules, extreme fatigue Stress Reduction Strategies ▪ Cross-cultural differences between workers & community ▪ Reduce physical tension by using familiar personal ▪ Inter/intra agency struggles over authority strategies (e.g., take deep breaths, gentle stretching, ▪ Time pressures meditation, wash face and hands, progressive ▪ Lack of adequate housing relaxation) ▪ Equipment failure and perception of control ▪ Pace self between low and high-stress activities ▪ Personal injury ▪ Use time off to “decompress” and “recharge batteries” ▪ Injury or fatality of loved ones, friends, associates (e.g., get a good meal, watch TV, exercise, read a novel, ▪ Self-expectations listen to music, take a bath, talk to family) ▪ Level of personal and professional preparedness ▪ Talk about emotions and reactions with coworkers ▪ Property loss during appropriate times o Pre-existing stress o Encounter with mass death DEBRIEFING RESCUE WORKERS rescue experience that make a memorable impact. Target most prominent thoughts. Originally developed by Jeffrey Mitchell (1983) to mitigate the stress among emergency first responders, critical 5. Reaction phase incident stress debriefing (CISD) is now a widely used protocol with victims and providers of all kinds (e.g. In this phase, workers are encouraged to teachers, clergy, administrative personnel) in a wide range discuss the emotions they experienced during of settings (e.g. school, churches, community centers) the course of the operations Two types of protocols commonly used: o Initial debriefing protocol 6. Symptom (Stress Reaction) phase o Follow-up debriefing protocol The rationale for this process is that providing early In this phase, workers stress reactions are intervention, involving opportunities for catharsis and to reviewed in the context of what they verbalize trauma, structure, group support, and peer experienced at the scene, what stress support are therapeutic factors leading stress mitigation reactions have lingered, and what they are experiencing in the present Initial Debriefing Protocol (IDP) 7. Teaching phase 1. Preparation As debriefing becomes a more common intervention , workers are increasing Make necessary arrangements with incident understanding the effects of stress commander or rescue team managers and o Defining traumatic stress obtain information about the conditions of the o Common stress reactions rescue operation and if there are particular o Factors associated with adaptation concerns about individual workers to trauma Try to limit each debriefing group to 8-10 o Self-care and stress management workers but anticipate as many as 20-30 workers. The greater the number of workers 8. Re-entry phase attending, the less time each person has to actively participate The final phase of the debriefing is allotted to The number of debriefings that workers discuss unfinished issues, reactions to the should attend is best guided by the length and debriefing, a summation of the debriefing, conditions of the rescue operations and the and the referral process degree of worker exposure to traumatic stimuli Large Groups Debriefing Protocol Arrange to work with a co-debriefer and discuss respective roles - Occasionally, circumstances require that you provide a Arrange for a private quiet room for 2-4 hours “debriefing” to a large number of workers and adjustments Those in attendance should not be on call. to the formal debriefing protocol are necessary. The protocol Have educational/referral handout ready for large group debriefing protocol are necessary. The Schedule time for post debriefing discussion protocol for large group debriefing involves a modification of with co-debriefer the process and content of the eight steps used in formal debriefings. 2. Introduction Review Confidentiality: personal disclosures WEEK 11: HELPING ORGANIZATION are to be held in strict confidence by the group Explain Group Rules: inform attendees that FIVE KEY STEPS TO ORGANIZATIONAL DISASTER MENTAL no one is required to talk, but participation is HEALTH CONSULTING encouraged. Agree on length of time. Facilitate Participant Introduction: depending Initial Entry and Contact upon the number of workers in attendance, worker introductions may include name, role, Determine the most appropriate official to consult. hometown or vicinity, and whether or not there has been previous experience with Introductions (description of consultant’s background) debriefing Consultant’s inquiries about perceived organizational needs. 3. Fact phase Administrator’s expectations of mental health services Consultant’s description of potential mental health Depending on the number of workers in services attendance, the next phase of the debriefing Mutually agreed upon plan about how to get started. is asking participant/volunteers to describe from their own perspective what happened, Information Gathering where they were, what they did, and what they experienced sensorily (perception of sights, Conduct assessment of need for services. Interview and speak smells, sounds) with various level department chiefs and other key informants. Feedback and The Decision to Intervene 4. Thought phase Provide a well-organized presentation of information gathered. In this phase, workers are asked to describe Manage resistance to change by demonstrating appropriate their cognitive reactions or thoughts about empathy concerning the inordinate stress on the organization their experience. In many instances, there are and its personnel and by focusing on maintaining a collaborative several events within the entirety of the planning relationship. Implementation ❖ Recommend formal recognition of staff for their contributions to the disaster effort, including those who Interventions should have written procedures which include clear stayed behind to “mind the store.” job/role descriptions of disaster mental health staff, crisis ❖ Offer a wide range of services: management, liability, and a clear timeline. Assist in establishing sources of information for organization: newsletters, bulletin boards, Termination briefings by administrators, brochures about resources, etc. Evaluate interventions. Make recommendations, if any, for future Large and small group educational services. Revise disaster plan, policies, procedures accordingly. presentations on mental health reactions of adults and children to disaster, self-help ORGANIZATIONAL STRESSORS ASSOCIATED WITH DISASTER stress management suggestions, and where to call for additional help. Routine workload requires continued attention while Distribute brochures addressing mental role conflict and discomfort increase as a result of new health reactions of adults and children to and competing demands. disaster, self-help stress management Routine management procedures are ruptured and suggestions, and where to call for additional tolerance among departments and personnel often help. decreases as stress, role conflict, and extreme fatigue set in. ESTABLISHING DISASTER MENTAL HEALTH SERVICES Relationships with county, state, federal, and non-profit organizations are altered. Pre-Disaster Organization Preparedness Limited credit may be given if emergencies are handled effectively; harsh judgments may increase if handled All organizations can benefit from analyzing potential crisis emergencies are poorly. situations. Preparedness can include strategies to manage worst Increased media scrutiny of procedures. case scenarios, including the potential effects of fatalities, Increased scapegoating as personnel seek to relieve employees unable to get to work, and damaged facilities. Though anxiety. it isn’t possible to fully prepare for the numerous types of disaster Actual or perceived decreased safety, increased many aspects of managing a crisis can be anticipated (Kutner, management demands for flexibility, and other 1996). disaster-precipitated stress result in staff having less tolerance for ambiguity and may result in their Establish a Disaster Mental Health Preparedness questioning their allegiance to the organization and the Committee. value of their job. Committee membership should represent Disruption and increased stress results in a decrease administrative, environmental, allied mental health, in man- agers’ ability to see the “big picture.” and community relations interests. Establish an emergency management organization ORGANIZATIONAL RESPONSE PLAN chart. Establish objectives of disaster mental health services. Though each organization may have its unique structure, cultural Establish procedures for emergency response. mores, and set of needs, disaster mental health consultants Incorporate procedures into the organization’s overall should consider each of the following elements in designing the disaster plan. organization’s response plan: Develop memorandum of understanding between the organization and other key agencies within the ❖ Provide outreach to staff: Personnel who are disaster community (e.g., Red Cross, local mental health). victims commonly do not seek mental health Hire outside disaster consultant for planning and assistance. Create a marketing campaign to prevent support of administration during course of disaster. the stigma of seeking assistance or participating in Train mental health staff in disaster mental health plan, activities offered (e.g., “support services for normal roles, responsibilities (see Team Formation and reactions to abnormal situation”). Development section). ❖ Expect and prepare to address an increase in personnel Have education materials pre-assembled for problems related to substance abuse, marital and distribution. family dysfunction, and financial concerns. Schedule regular mock exercises with outside review. ❖ Offer screening for staff who are primary, secondary, or Review and update Emergency Plan regularly (including tertiary victims if they meet at least one of the following evaluation of resources and what might hinder criteria: implementation) Their work area has been relocated because of property damage. They are new hires or are new in their positions. Prepared and Arranged by: They have pre-existing health and/ psychological issues. ❖ Encourage managers to know the impact of the disaster on their staff in order to provide effective Kiara Marie Geronimo Laraine Rhose Orenia support: Do employees have specific safety concerns? Psychological Society QC, Educational Committee Are there employees with injured relatives? Are there employees who have had to relocate residence? Is there an increase in on-the-job accidents? Is there greater tension among employees or departments? How significant is the change in work productivity?