1. PROTECTING AND PROMOTING THE PSYCHOSOCIAL HEALTH OF DISASTER WORKERS:CONTEXT, RESPONSIBILITIES, OPPORTUNITIES Tulane School of Social Work New Orleans, LA March 20, 2009 RADM Brian W. Flynn, Ed.D.Assistant Surgeon General (USPHS, Ret.)Adjunct Professor Of PsychiatryAssociate Director Center for the Study of Traumatic Stress Dept of Psychiatry

2. Disaster Work Wonderful! Rewarding! Challenging! Satisfying! Stressful! Frustrating! Exhausting! Dangerous!

3. All Disaster Workers Experience Stress… Cartoon Credit: Dan Piraro

4. Assumptions And Biases: You are working/responding as part of a structure/organization Resilience means many things (in all contexts) In the workplace, leadership and organizational culture trump most everything else

5. Assumptions And Biases: There exist individual, family, and organizational opportunities/ responsibilities to promote health and promote resilience Optimal functioning requires all Failure of any assures compromise of all If we focus only on stresses during the event, we have lost essential opportunities

7. Factors: (Source: Chaffee, M., Willingness of Healthcare Personnel to Work in a Disaster: An Integrative Review of the Literature. Disaster Med Public Health Preparedness. 2009; 3:42-56)

8. Type of disaster

9. Concern for family and loved ones

10. Concern for pets

11. Education & training

12. Personal obligations

13. One’s value in the response

14. Belief in duty to care

15. Availability of PPE

16. Support for basic needs

18. High value

19. Personal meaning

20. Novelty

21. Prestige

22. Honor

23. “Doing good”Source: Flynn, 2002

24. Who Are We Talking About?

25. We Are Talking About… Workers other than traditional first responders Workers themselves, families of workers, coworkers/supervisors of disaster workers MH workers in above categories More specifically….

26. Workers Deployed To The Disaster Site Federal: FEMA, NDMS, CDC epi, FDA, Agriculture, Corps of Engineers, SAMHSA, others State/Local: health (epi, food/water/waste, public information), highways, utilities, social services, mutual aid Contractors: Infrastructure assessment/repair, debris removal, food/water/ice delivery, others Volunteer: Faith based organizations, ARC, others MH workers in all of the above!

27. Workers Who Are Deployed To A Site Other Than The Impacted Area Workers deployed to command centers Workers assigned to supply centers State/County mutual aid workers MH workers in all of the above!

28. Workers Who Remain At Their Usual Workplace But Assume Different/ Additional Duties Related To The Disaster Government workers Business Civic/religious leaders School personnel MH workers in all of the above!

29. INTERLOCKING RELATIONSHIPS ORGANIZATIONAL INDIVIDUAL FAMILY

30. RESTORE:RESiliency TOolkit for REsponders “RESTORE” TOOLKIT Pre-Event INDIVIDUAL Pre-Event ORGANIZATIONAL Disaster Event INDIVIDUAL Disaster Event ORGANIZATIONAL Post-Event INDIVIDUAL Post-Event ORGANIZATIONAL

31. Dimensions of Preparedness, Response, And Recovery… Community Family Consumers Personal Community Family Organizational

32. Examples From The Workplace Coworkers Supervisors Supervisees Clients/customers/patients/students

33. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience CONOPS Hiring/ Selection Pre-event training/pre-paredness Event Long-term Aftermath Immediate Aftermath

34. Organizing Today’s Presentation… Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

35. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

36. Risk assessment Clarity of role/mission Assessment of capability/capacity Appropriate linkages in place Anticipating full range of individual, organizational, stakeholder impacts Is range of BH roles included? Are all impacted individuals aware of CONOPS Is staffing/preparation consistent with CONOPS Is there a match of potential roles and individual skills/ temperament, etc. Do stakeholders (funders, boards of directors, etc.) agree with CONOPS? CONOPS Individual Organizational

37. Stakeholders/ Shareholders Organization Continuity Planning All Members Of An Organization Leadership Families Human Continuity Planning Community Organizational Culture Flynn & Lane, “Integrating Organizational and Behavioral Health Principles to Promote Resilience in Extreme Events” in International Terrorism and Threats to Security: Managerial and Organizational Challenges. C. Cooper, R. Burke (eds.) Edward Elgar Publishing, 2008.

38. BOTTOM LINE: Without: Caring/Supportive Organizational Culture Sound Leadership Stakeholder Support The House of Cards Comes Down!

39. Mental Health and Mass Violence: Evidence Based Early Psychological Intervention for Victims/ Survivors of Mass Violence— A workshop to Reach Consensus on Best Practices (NIMH, 2002)

41. Roles beyond direct psychosocial interventions

42. Making It Happen Examine organizational culture Assure integration of human factors in continuity of business/operations planning Implement an all-hazards approach integrated with other community stakeholders

43. Making It Happen Include realistic behavioral health scenarios in drills/exercises Expand internal/external assistance/consultation Don’t Forget Families

44. Segments of Opportunities/Responsibilities toProtect Worker Health and Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

45. Be candid about expectations Be clear about risk/benefits Appreciate need to fill diverse roles Match more than technical skills (e.g., info needed to make decisions, comfort w/ chaos, risk taking, etc. Know your skills, temperament, needs Are you really prepared for the risks?? What are your motives? How will this work impact family and others? Health status Hiring/ Selection Individual Organizational

46. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

47. Pre-event training/preparedness Organizational Stress In The Workplace--Before Planning/negotiating workload shifts Having fewer people to do the work Disasters never come at “good” times Planning and preparedness takes resources away from ongoing work

48. Pre-event training/preparedness Organizational Provide a shared sacrifice, mutually supportive, values driven work culture Evaluate policies and procedures View stress management as a job skill Involve all impacted workers in planning

49. Pre-event training/preparedness Organizational Prepare workers for new roles/experiences (training, orientation, clarity, go-kits, etc.) Address stigma and fitness for duty/security clearance, etc. up front Integrate EAP, healthcare, supervision, and organizational policy Is the program prepared to deal with adverse physical and psychosocial sequelae during and following deployment?

50. Pre-event training/preparedness Individual Self-care Anticipate issues Knowing your strengths and vulnerabilities Get physically, emotionally, and vocationally prepared Train for disaster role

51. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

52. Nature Of The Stressors Environmental factors Job role stressors Personal stressors Event

53. Environmental Factors Event Dislocation to new place Climate (cold, hot, wet, smoke, etc.) Living conditions Sensory impact (e.g., sights, smells, sounds)

54. Promote risk And crisis communication Monitor stress Promote communication w/ families Provide/model leadership Implement plan Provide stress mediators Assure intervention without stigma Practice psychological first-aid Integrate physical and psychological safety Practice self-care Use buddy system Be assertive regarding needs Event Organizational Individual

55. Event Stress In The Workplace--During Managing changed/ expanded workloads/ reporting relationships Keeping up with the work Politics/criticism Potential loss of expertise Uncertain duration (or repeat) of deployment Perception (“He’s out doing interesting things while we are stuck here doing his job!”)

56. Event Organizational Strategies For The Workplace--During Contact/support/assist workers during deployment Provide positive reinforcement Range of interventions at any given time Interventions that are phase appropriate

57. Event Individual Personal Stressors Overwork/fatigue Change in eating/drinking patterns Factors adversely impacting health Interpersonal conflict Highly emotional experiences Existential conflict Role conflict

58. Event Individual Strategies For Individuals--During Private time Talk to somebody who understands Have a trusted monitor/self-monitor Limit alcohol Have an end point Reasonable work hours Rest/sleep Diet Exercise Real or symbolic contact with home

59. Event Individual Strategies For Individuals--During Self-care Use the buddy system Advocate for your needs Record your experiences your reactions Reduce stressful stimuli as much as possible Seek help if needed

60. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

61. Facilitate range of interventions Monitor ongoing stressors Support work groups Foster appropriate referrals Reinforce positive organizational culture Maintain reasonable expectations View return to home/work as a process not an event Rest, monitor physical and psychological health Seek help as needed/appropriate Immediate Aftermath Organizational Individual

62. Organizational Immediate Aftermath Stress In The Workplace--After Working slowly Missing deadlines Calling in sick frequently Absenteeism Irritability and anger Difficulty concentrating and making decisions Appearing numb or emotionless Withdrawal from work activity Overworking Forgetting directives, procedures, and requests Difficulty with work transitions or changes in routines Perception (“nobody knows what I went through”)

63. Immediate Aftermath Organizational Strategies For The Workplace--After Meet/talk with returning workers Acknowledge roles/contribution of other workers Understand and implement psychological first aid Be flexible/compassionate Informally appraise returning workers Screening/referral/monitoring Focus on function

64. Debriefing? Rebriefing!

65. Guide For Interventions A major new article: Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence Psychiatry, 70(4) Authors: Steven Hobfoll plus 19 others Very diverse/credible authors The Five Elements: Provide a sense of safety Calming Sense of self- and community efficacy Connectedness Hope

66. Immediate Aftermath Individual After Disaster Work…First Things First Rest/sleep Time with friends and families Attention to health concerns Completing undone daily personal tasks (e.g., pay bills, mow lawns, shop for groceries, etc.) Initial reflection upon what the experience has meant personally and professionally

67. Immediate Aftermath Individual Strategies For Individuals--After Advocate/negotiate for your reentry needs Be tolerant and understanding of others Talk about your experience if that is helpful Show appreciation to others Resume normal routine as quickly as possible Use the experience to help change your life in positive ways Get help if needed

68. Segments of Opportunities/Responsibilities ToProtect Worker Health And Promote Resilience Organizational Organizational Organizational CONOPS Hiring/ Selection Pre-event training/preparedness Individual Individual Individual Organizational Organizational Organizational Event Long-term Aftermath Immediate Aftermath Individual Individual Individual

69. Reinforce organizational culture Manage conflicts among organizational, work group, individual needs Support ongoing interventions as needed Reevaluate CONOPS Modify plans Long-term Aftermath Individual Organizational Implement lessons in both work and personal life Seek help if needed Provide feedback to organizations Continue/ enhance personal/organizational readiness

70. Stress In The Family Before During After

71. Examples Of Family Members Spouses Children Parents Partners Close friends

72. Stress In The Family--Before Anger about deployment Anger about remaining family member’s added responsibility Fear on every side Strong emotions resulting from uncertainty about initiation, nature, and duration of deployment Denial

73. Stress In The Family--During Fatigue and frustration over added responsibilities Fear for safety of loved ones Discomfort with new roles Disappointment over missed events/obligations/landmarks

74. Stress In The Family--After Reasserting old roles Fatigue on all sides Conflicting expectations Balancing work/family reentry Stress reactions on all sides

75. Strategies For Families-Before Discuss potential of work in disasters, terrorism, WMD/bio events with loved ones Seek agreement/consensus on acceptable risk level, conditions of deployment, etc. Consider the potential of adverse medical and psychosocial consequences Have a family disaster/deployment plan

76. Strategies For Families-During Maintain contact Seek/utilize social support Maintain structure/routine Self-care

77. Strategies For Families--After: Remember… Homecoming is more than an event; it is a process of reconnection for family and loved one. While coming home represents a return to safety, security, and return to “normal”, the routines at home are markedly different than life in a disaster zone.

78. Strategies For Families: Remember… In loved one’s absence family members have assumed many roles and functions that may have to now be renegotiated. Be patient during this period. Go slowly. Returning loves one and families need time—Time together if possible before exposure to the demands of the larger community—friends, extended family and coworkers.

79. Strategies For Families Talking about disaster experiences is a personal and delicate subject. Listening rather than asking questions is the guiding rule. Caution: In the disaster environment, it is common to talk about things that may be upsetting to people not directly involved (e.g., dead bodies, graphic images, etc.). Extreme care should be taken by returning family members to assure that relating experiences does not unnecessarily upset or traumatize others…especially children.

80. Special Considerations… Worker is also a victim Greatly intensified stressors Special work and family needs Potential family/coworker contamination Credible education/information Available monitoring, assessment, and treatment Cultural considerations Culture impacts how we experience crisis, expression of emotion, help seeking, understanding…learn it, make it central to preparedness and response

82. Have you matched the potential risks with personal characteristics (e.g., physical/mental health, family obligations)?

84. Does an adequate and appropriate menu of interventions exist for workers, families, co-workers/supervisors?

86. Are you adequately prepared for stresses/disruptions in family roles?

87. Have you candidly assessed family vulnerabilities?

90. Does your role match your skills, temperament, assets, obligations?

91. Are you adequately trained/prepared?

94. Contact Information: BRIAN W. FLYNN, ED.D. P.O. Box 1205 Severna Park, MD 21146 Phone: 410-987-4682 Email: Brianwflynn@aol.com