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  • 4
  • Did you notice how many different agencies were mentioned by Mayor Shell in this two minute video clip. Fire, Police, Public Health, EPA, National Guard at Camp Murray, Snohomish County, King County, and the WA State Patrol. These were only a few of the active players in the Seattle venue of T2, but they accurately depict the large number of agencies that come together to respond to a disaster. Knowing these relationships in advance of the disaster is critical to promote the 3Cs of response (communication, collaboration, and coordination). There are a large number of new emergency preparedness, planning and response coordinators being created within public health departments as well as other response agencies. We are in a renaissance of emergency preparedness planning in this county. It is important to learn these new names and faces as we build the overall preparedness of the public health community. Many of the T2 health and medical responders at the local, State and Federal levels were working on their first disaster exercise. We need to mentor and train one another. We need to build the training programs that are needed for emergency health planners, as well as establish core competencies for the health care workforce on disaster response. Some of this work is already being done by the CDC, the International Mass Casualty Nursing Coalition, the various academic centers of excellence for public health emergency preparedness throughout the country. One small example is the need to train the health response community in ICS. It is far more important to know the individuals and general capacity of other agencies that you may rely upon in a disaster. For example, Mayor Shell mentions a WA State National Guard from Camp Murray. This is a Civil Support Team. It is a field detection team for WMD. It is not essential to know the details of a CST and the equipment/staff that it responds with, but you need to know the general capacity of the team to do field detection.
  • Transcript

    • 1. Crisis Intervention José A. Capriles Quirós, MD, MPH, MHSA Professor, UPR Center for Public Health Preparedness
    • 2. A NEW AWARENESS
    • 3. “Target Population”
      • Prior to 9-11
          • Severe and persistent mental illness
          • Severe substance use disorders
          • Lack resources to access treatment
          • Hard to reach and difficult to engage
          • Various racial, ethnic cultural groups, women
      • After 9-11
          • Disaster trauma survivors
          • Entire state population
    • 4. Target Population Ecological Model Victims Vulnerable people Emergency responders Entire population Children & parents Victims’ families
    • 5. Vulnerable Populations
      • Predictors of psychological distress post terrorist event :
      • Consequences are related to the quality and extent
      • of exposure - being a victim, watching the attacks,
      • talking on the phone with someone who was lost
      • Silver 2002; Schlenger 2002
      • Female gender is associated with worse short-term outcomes Silver 2002
      • Weak or deteriorating psychosocial resources
      • Norris et al, 2002
      • Those with pre existing physical illness Shlev 2001
      • or mental Illness Yehuda 2002
    • 6. Vulnerable Populations continued
      • Predictors of psychological distress post terrorist event:
      • Prior exposure to violence and trauma (Veterans)
      • Hoven 2002
      • Hispanics and other immigrant populations,
      • including refugees Galea et al. 2002
      • School aged children Pfefferbaum 2003
      • Middle aged and young adults are at greater risk than older adults (contrary to popular belief)
      • First responders - unique exposure & risk
      • Beaton & Nemuth, J Traumatology 2004
    • 7.  
    • 8. Crisis Types
      • Greek Myth - Hercules dipped arrows in Hydra venom
      • Alexander the Great - combustible toxins sulphur
      • Acts of war (e.g., terrorism)
      • Violent deaths (e.g., fatal illness, homicide, suicide)
      • Criminal acts (e.g., robbery, child abuse, kidnapping)
      • Unexpected natural deaths (e.g., heart attack, cancer)
      • Industrial accidents/disasters (e.g., chemical spills)
      • Natural disasters (e.g., earthquake, tornado)
      • Severe illnesses (e.g., cancer)
      • Accidental injuries (e.g., car accident, burns)
    • 9. Goals
          • Crisis events are not a matter of “if” but “when”
          • Planning must take place prior to a crisis
          • One size does not fit all
          • Crisis plans need to have consistent structures and language
          • Crisis planning must be collaborative
    • 10. Goals (continued)
          • Crisis planning must include training and information
          • The connection between crisis planning and response and academic performance
          • Crisis planning is never done
          • Crisis planning/response is PART of a larger process
          • Resources
    • 11. Helping and healing communities
    • 12. Terrorism: definition and examples
        • Illegal or threatened use of force or violence to coerce societies or governments by inducing fear in populations, involving ideological and political motives and justifications. National Research Council, 2002
        • Damaging mental well-being is the exact purpose of terrorism.
        • Examples in USA:
        • 2001 WTC and Pentagon Attacks
        • Fall 2001 Anthrax Attacks
        • 1995 Oklahoma City Bombing
    • 13. Crisis events are not a matter of “if” but “when”
      • Where are safe places?
      • Definition of a crisis
        • Extremely negative
          • Involves actual and/or threatened death and/or physical and/or emotional injury.
        • Uncontrollable/Unpredictable
          • Cannot be stopped, mitigated, or predicted.
        • Depersonalizing
          • Is not sensitive to status, wealth, power, or position.
        • Sudden and unexpected
          • Occurs without warning.
    • 14. Variables impacting trauma potential
      • Type of disaster
        • Natural disasters are typically less traumatic than are man-made disasters or human caused crises.
      • Source of physical threat/injury
        • Physical threat or injuries due to accidents/illness are less traumatic than are threats and/or injury due to assault violence.
      • Presence of fatalities
        • Crises resulting in non-fatal trauma to significant others are less traumatic than are events that result in sudden and unexpected death.
        • In addition, events that involve sudden and unexpected death will be complicated by grief reactions.
    • 15. Implications
      • Need Outreach and Direct Care
      • Build Community Resiliency and Capacity
      • Rely on Existing Resources
      • Utilize A Phased Approach
      • Build in Diverse Strategies
      • Form new Collaborations and Partnerships
    • 16. Implications
      • Opportunities for Community Education and New Relationships
      • Paradigm Shift in Role of Mental Health Professionals (eg. Different interventions, settings, etc.)
      • New Skills Needed for New Realties
        • (eg Consultation re: “psychological warfare”)
    • 17. Survey Results
      • “ Public Perspectives MH Effects of Terrorism” Poll
        • 61% fear terrorism more than natural disaster
        • 77% believe info on strategies to cope with fear and distress needed, equal importance to securing physical installations
        • 57% do not think the PH system is meeting the MH needs resulting from the threat of terrorism
        • Information received after a crisis significantly shapes reactions over the weeks and years following
      NASMHPD, NMHA and Consortium for Risk and Crisis Communications, 2004
    • 18. Madrid March 11, 2004
    • 19. Madrid March 11, 2004
    • 20. Disaster stages Before Preparedness
    • 21. Disaster stages Before Preparedness During Acute/ Intermediate
    • 22. Immediate Reactions
      • Disbelief
      • Disorientation
      • Fear
      • Feeling time is slowed down
      • Feeling numb or disconnected
      • Feeling helpless or irrationally
      • failing to avoid danger
    • 23. Disaster stages Before Preparedness During Acute/ Intermediate After Recovery
    • 24. Plan for Intervention Assist With: Physical Needs
      • Establish safety, medical, food, water, shelter, communication to public regarding event
      • and future risks
      • A good crisis management worker can:
      • “ Cook a meal, empty the garbage, make coffee, change a bed, file, type, sort papers, answer phones, drive a van, stock supplies, put up a tent, operate a radio, mark a trail, cut wood, baby-sit, and fold clothes, in addition to his/her professional role” Institute of Medicine 2002
    • 25. During: Acute phase
      • Immediate response
      • Comfort, support, psychological first aid
      • Clinical screening
      • Attend to needs of directly affected and vulnerable populations
      • Individual, family/group interventions across the lifespan
      • Public messages
      • Support to caregivers
    • 26. Early Responses to 9/11 Attacks Nationwide – 1week
      • 20% of Americans know someone who was missing, hurt or killed
      • 64% had a shaken sense of safety & security
      • 43% less willing to travel by airplane
      • Positive Adaptation – growth, altruism, activism, creativity, empathy
      • American Psychological Assn Feb 2002
      • Gallup 2001
    • 27. After: Recovery phase
      • Expect most people will be OK
      • Identify those with delayed effects
          • Risk populations: medically injured, prior history of SA or violence/trauma, families of deceased, etc.
          • Major depression, substance abuse, trouble at work, domestic discord and violence, suicide
      • Clinical work with people who have PTSD and lasting psychological effects
      • Broad community outreach - information dissemination/education
      • Lessons learned , evaluation, research
    • 28. Before: Preparedness
      • Debrief from previous events
      • Focus on prevention
          • Strengthen community resilience, reduce risk factors, improve coping capacity
      • Build response infrastructure
          • Coalitions, partnerships, networks
          • Model and role definition
          • Curriculum development, training
          • Communications/command structures
      • Develop rapid response plan
    • 29. Major Disaster Phases of Behavioral Health Response Acute phase Timeline Days 1-2 Rapid deployment teams provide immediate crisis intervention, State employees form core of response
    • 30. Major Disaster Phases of Behavioral Health Response Acute phase Days 1-2 Rapid deployment teams provide immediate crisis intervention, State employees form core of response Days 3-14 Teams expand to include volunteers from community-based behavioral health agencies Timeline Intermediate phase
    • 31. Major Disaster Phases of Behavioral Health Response Acute phase Days 1-2 Rapid deployment teams provide immediate crisis intervention, DMHAS and DCF employees form core of response Days 3-14 Teams expand to include volunteers from community-based behavioral health agencies Day 14+ FEMA declaration Services provided by contracted agencies, teams phase-out operations Timeline Intermediate phase Recovery phase
    • 32.
      • Traditional Role
      • Office-based treatment
      • Multiple treatment sessions
      • Therapeutic relationship
      • Client comes to you
      • Broad spectrum of disorders
      • Egalitarian environment
      • Collateral contact = provider
      Adapting to new roles/situations
    • 33.
      • Traditional Role
      • Office-based treatment
      • Multiple treatment sessions
      • Therapeutic relationship
      • Client comes to you
      • Broad spectrum of disorders
      • Egalitarian environment
      • Collateral contact = provider
      • New Role
      • Street-based treatment
      • Psychological first aid
      • One shot intervention
      • You go to client
      • Focus on trauma
      • Hierarchical: top down
      • Collateral = fire chief, police captain or faith leader
      Adapting to new roles/situations
    • 34. Crisis Response Public Safety
    • 35. Crisis Response Public Safety Public Health
    • 36. Crisis Response Public Safety Behavioral Health Public Health
    • 37. Crisis Management Model Crisis intervention (caring for people during the crisis) Caring for people after the crisis (support long-term healing) Crisis prevention (caring for people before the crisis) Support short- to long-term copings, preventing secondary symptoms Long term planning of prevention; optimizing crisis management Short term relief in order to prevent collapsing of persons or systems developed by A. Englbrecht & R. Storath, graphics: C. Enders
    • 38. Functions to Protect and Respond to Public Psychological Health
      • Basic resources – food, shelter, communication, transportation, and medical services
      • Interventions and programs to promote individual and community resilience
      • Surveillance for psychological consequences
      • Screening criteria for individuals
      • Treatment for acute and long-term effects of the trauma
    • 39. Functions to Protect and Respond to Public Psychological Health
      • Human Services - contribute to psychological functioning, reuniting families, child care, housing, job assistance
      • Risk Communication, dissemination of information
      • Training of service providers to respond. Prepare and protect them against psychological trauma
      • Capacity to handle large increase in demand for services - “Surge Capacity”
      • Case finding to locate individuals who need MH services but are not utilizing conventional means; including the underserved, marginalized, and unrecognized groups of people
    • 40. CRISIS PREPARATION PLAN: TASKS
      • Establish policies and procedures
      • Incident Command Systems
      • Create assessment tool to evaluate plan
      • Organize and train
      • Conduct response exercises
      • Respond to the crisis
      • Evaluate crisis response
    • 41. CRISIS PREPARATION PLAN: STEPS IN DEVELOPMENT
      • Establish a multidisciplinary working group
      • Review existing plans/procedures
      • Determine essential elements of crisis plan
      • Conduct hazard analysis/capability assessment
      • Develop strategies
    • 42. It’s All About Relationships
      • Interagency Cooperation
      • and Coordination
      • Integrate MH with other
      • services
      • Systems issues reign
      • supreme as barriers to
      • providing effective MH
      • services
      • Evidence-based
      • treatments will have little
      • value if can not be
      • delivered
      • Norris 2002
    • 43. Crisis Intervention and Terrorism Summary Types of Intervention Level of Intervention SOCIETAL COMMUNITY NEIGHBORHOOD FAMILY INDIVIDUAL Public Safety Public Education Capacity Building Family Self-Help Networks Traditional Healing Public Policy Service Coordination Training/Education Family Education Clinical Treatment Green et al, in press Public Health
    • 44.  

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