4. Defines what constitutes a “public health
emergency”
Created the position of Public Health Emergency
Officer
Third revision, mandates every installation has a
Disaster Mental Health Response Team.
WHY?
DODI 6200.03
5. At the end of this presentation, attendees will have
a better knowledge of
What constitutes a “disaster”
How disasters affect people’s mental health
How everyone can play a role in mitigating
negative mental health outcomes via Combat
and Operational Stress First Aid (COSFA)
Objectives
6. Many definitions (UN, WHO, FEMA, ARC, etc)
Low probability but high consequence events
Types
Natural (Hurricane Katrina, Japan
earthquake/tsunami)
Technological (Buffalo Creek Dam collapse)
Mass violence or “complex” (9/11, Toky0
subway sarin attack)
Disasters are…
7. Anyone of us in this room could be called to
assist in the case of a disaster response.
8. While the immediate concern is physical
safety, research shows behavioral health
casualties may outnumber physical casualties
(Ursano, Norwood, & Fullerton, 2004)
Hospital near WTC was inundated by non-
injured but distressed people (Wang, 2005)
Mental health impact
9. Most common distress symptoms
mood disturbance (e.g. anxious, fearful,
depressed/suicidal, irritable/angry)
intrusive memories of the event, nightmares
hyper-arousal/vigilance, insomnia,
concentration deficits, inability to work
intense longing for the deceased
psychosomatic complaints
dissociation
Mental health impact
10. High exposure to the traumatic event
Population exposure model
Secondary stressors (financial, marital, health probs)
Prior mental health condition/ prior trauma history
Lack of positive social support
Poor coping skills (low self-efficacy/hope, avoidance)
Demographics : female gender and racial minority
(Norris et al., 2002; or see National Center for PTSD Mental
Health Effects Following Disaster: Risk and Resiliency Factors )
Risk factors
12. Diagnose? Most symptoms are transient!
DoDI6200.03 says not to, but what about those wanting
medications?
Acute Stress Reaction (ICD-10; first two days)
Acute Stress Disorder (DSM-5; after 48 hours until 1
month)
PTSD (1 month or longer)
Adjustment Disorder (due to “secondary stressors”)
“traumatic bereavement,” “survivor guilt,” “moral
injury”
Substance Use Disorder
Diagnoses?
13. Galea, Nandi, & Vlahov (2005)
“Studies conducted in the aftermath of disasters during the
past 40 years have shown that there is a substantial burden
of PTSD among persons who experience a disaster.”
prevalence of PTSD among
direct victims of disasters is 30–40%
rescue workers is approx 10–20%
the general population is approximately 5–10%
“PTSD is persistent for a few years after the disaster
among victims with early PTSD onset.”
Norris et. al, (2002) review of 160 samples of disaster
survivors also found a substantial minority also develop
PTSD, MDD, substance abuse, and medical problems
Disasters can lead to PTSD and other
disorders
14. Early mental health intervention is from the onset
of the disaster and up to 4 weeks
Treatment is phased
More practical/simple at first, then more in-
depth/advanced over time (if symptoms persist)
As with all treatment, it is hoped to mitigate long-
term problems
Controversy re: Critical Incident Stress Debriefing
Early intervention
15. Psychological First Aid (PFA) is widely accepted
evidence-informed early intervention
Meant to be utilized by anyone involved (not just MH)
Non-mental health providers may have better success
with those survivors who don’t want to talk to mental
health
Can be done very informally
Meant for survivors AND fellow disaster responders
Mental health providers expertise is providing the
more in-depth follow-up care if needed
Early intervention
16. Core objective is to promote…
Safety
Calmness
Connectedness
Self and community efficacy
Hope
Hobfoll et al. 2007
Psychological First Aid (PFA)
17. Here are some…
BUMED (COS First Aid)
SAMHSA
National Center for PTSD
National Child Traumatic
Stress Network
Center for Study of
Traumatic Stress, USUHS
Medical Reserve Corps
NY State Office of MH
Florida Center for Public
Health Preparedness
American Red Cross
Australian Red Cross
International Federation of
Red Cross/Crescent
World Health Organization
National Fallen Firefighters
Association
US Department of
Homeland Security
Schultz & Forbes, 2013
26 published PFA manuals/field guides published by
various organizations
18.
19. PFA vs. “Stress First Aid”
Safety Cover
Calmness Calm
Connectedness Connect
Self and community efficacy Competence
Hope Confidence
23. 1. Continuous Aid:
Check and Coordinate
2. Primary Aid:
Cover and Calm
3. Secondary Aid:
Connect, Competence and Confidence
Print page 5-13
Stress First Aid
24. Ask “how are you doing?”
Assess along stress continuum
Ask about suicidal/homicidal thoughts
Continuous Aid: Check
25. Utilize team approach to assist
Refer to mental health or advise CoC if needed
Continuous Aid: Coordinate
26. Ensure physical safety
Remind of current safety, be reassuring
Primary Aid: Cover
27. Slow, deep breathing. Refocus thinking. Relaxation
Use “grounding” techniques.
Medication? Benzodiazepines contra-indicated?
Primary Aid: Calm
28. Help increase feelings of social support
Spend time with the stressed person
Can use physical touch
Encourage reaching out and accepting
peer/family/church support.
Discourage stressed individuals from isolating
themselves.
Secondary Aid: Connect
29. Restore mental and physical capabilities (like physical
therapy).
Keep on track with activities that need to be done
Restore role functioning. Remind them of successes
Secondary Aid: Competence
31. PFA Field Operations Guide via NCTSN/NC-PTSD
http://www.nctsnet.org/nctsn_assets/pdfs/pfa/2/PsyFi
rstAid.pdf
PFA online training for 6 CE/CMEs via National Child
Traumatic Stress Network website
http://learn.nctsn.org/course/index.php?categoryid=11
PFA Mobile: Smartphone app
http://www.nctsn.org/content/pfa-mobile
More resources for PFA
32. PTSD can happen in first/emergency responders
Upcoming presentations on CgOSC
See also the CDC website
http://www.emergency.cdc.gov/mentalhealth/
40 minute overview course about stress first aid:
http://fireherolearningnetwork.com/Training_Programs/Stres
s_First_Aid_for_Fire_and_Emergency_Medical_Services_Per
sonnel.aspx
30 minute overview course about curbside manner, the
stress first aid for working with affected individuals, rather
than peers:
http://fireherolearningnetwork.com/Training_Programs/Curb
side_Manner__Stress_First_Aid_for_the_Street.aspx
For first responders
34. Brymer, M., Jacobs, A., Layne, C., Pynoos , R., Ruzek,
J., Steinberg, A., Vernberg, E., Watson, P. (2006).
Psychological First Aid: Field Operations Guide. 2nd
Edition. National Child Traumatic Stress Network and
National Center for PTSD.
Hobfoll, et. al (2007). 5 essential elements of
immediate and mid-term mass trauma intervention:
empirical evidence. Psychiatry, 70(4), 316-369.
National Center for PTSD Mental Health Effects
following Disaster, Risk and Resiliency Factors
retrieved from
http://www.ptsd.va.gov/professional/pages/effects-
disasters-mental-health.asp
Norris et. al. (2002). 60,000 disaster victims speak:
Part I. An empirical review of the empirical literature.
Psychiatry, 65(3), 207-239.
References
35. Shultz, J. M. & Forbes, D. (2013) Psychological first aid:
Rapid proliferation and the search for evidence. Disaster
Health, 1(2). 1-10.
Ursano, R. J., Norwood, A. E., & Fullerton, C.S. (2004).
Bioterrorism: Psychological and public health
interventions. Cambridge University Press, NY.
U.S. Department of Health and Human Services (2004).
Mental Health Response to Mass Violence and Terrorism: A
Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD:
Center for Mental Health Services, Substance Abuse and
etal Health Services Administration
Wang, W. (2005) The hospital in its community. In Danieli
and Dingman’s (Eds.) On the Ground After September 11.
Mental Health Responses and Practical Knowledge Gained.
Haworth Press, NY.
