Responding to Disasters in the Foreign Responding to Disasters in - PDF document

Responding to Disasters in the Foreign Responding to Disasters in the Foreign Service Setting Service Setting Samuel Thielman, M.D., Ph.D. RMO/P Frankfurt ATTACKS AGAINST U.S. DIPLOMATIC ATTACKS AGAINST U.S. DIPLOMATIC INSTALLATIONS INSTALLATIONS 1987- -1997 1997 1987 Bombings (both attempted and completed) 100 Fire Bombings (both attempted and completed) 51 Rocket Attacks (both attempted and completed) 26 Strafing 15 Grenade Attacks 11 Arson 7 Car Bomb 6 Takeovers 2 Armed Attack 1 Mine Attack 1 Kidnapping 1 1

Attac ks on U.S. Diplomatic Installations, 1900- - Attac ks on U.S. Diplomatic Installations, 1900 Attacks on U.S. Diplomatic Installations, 1900-1965 1965 1965 Deaths Destruction Injury Bombing No Lost Life Arson Destruction Assault 1900 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 Aftermath of Liberian Civil War Aftermath of Liberian Civil War Monrovia Mental Health Issues •Exposure to human remains •Extended exposure to extreme violence and threat of death •Isolation from social supports Outcome better than expected •Careful selection of personnel who remained at embassy during crisis •Group cohesiveness •No American deaths •Tangible benefit to Liberia because of strategy pursued by Mission 2

Psychological Response to Disasters Psychological Response to Disasters Disaster Response Organizational Response Individual response Timing of response Risk Factors Related to Characteristics of Risk Factors Related to Characteristics of Trauma Trauma Man-made traumas (terrorism, bombings) Traumas involving cruelty Grotesque or horrific deaths Exposure to dead bodies of social peers Exposure to bodies or injuries of acquaintances Exposure to deaths or injuries of children 3

Risk Factors Related to Prior Medical Risk Factors Related to Prior Medical History History Preexisting psychiatric disorder Acute stress disorder Bereavement Injury Intervention after Mass Violence Intervention after Mass Violence Psychological First Aid Critical Incident Stress Debriefing (no longer standard of care) 4

Managing Post Trauma Psychological Managing Post Trauma Psychological Issues Issues Nightmares Hyper-arousal Derealization Waves of emotions Harnessing Local Support/Usual Means of Harnessing Local Support/Usual Means of Support Support Most useful usual means of support Priority Varies depending on demographics Faith communities Prayer Family and Friends Fellow Survivors Individual counseling is not usually ranked high by survivors following a disaster 5

Traumatic Event Traumatic Event Definition is controversial Current definition in DSM: The person has been exposed to a traumatic event in which both of the following have been present: (1)the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2)(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. Trauma History Trauma History Focus on trauma literature dealing with disasters, other thypse of trauma may be different. 6

Risk factors Risk factors Nature and extent of disaster Prior exposure Prior psychiatric history “Constitution” Exposure to Trauma Exposure to Trauma in the General Exposure to Trauma in the General Population Population [Review: Surveys in US, Canada, and Mexico : 50 -90% adults had been exposed to a traumatic event.] Multiple trauma exposure is more common than not: 30% had a single trauma, 24% had two, 19% had three, 27% had four or more. 7

Common Reactions to Trauma Common Reactions to Trauma Denial of feelings Sense of pointlessness Increased anxiety & vulnerability Nightmares Sleep disturbances Intrusive images & thoughts Shame, regret, blame, anger, guilt & bitterness Sense of isolation & loneliness Posttraumatic Stress Disorder Posttraumatic Stress Disorder A. A traumatic event has occurred B. The traumatic event is persistently reexperienced C. Persistent symptoms of increased arousal (insomnia, irritability, forgetfulness, easily startled) D. There is persistant avoidance of things associated event and numbing of general responsiveness E. The disturbance has lasted for more than one month 8

Psychological First Aid Psychological First Aid nd ed. 2006) (Adapted fromAppendix A of Brymer, M et al, Psychological First (Adapted fromAppendix A of Brymer, M et al, Psychological First Aid: Field Operations Guide 2 Aid: Field Operations Guide 2 nd ed. 2006) 1. PREPARATION 2. ENTERING THE SETTING 3.PROVIDING SERVICES 4. GROUP SETTINGS 5. MAINTAIN A CALM PRESENCE 6. BE SENSITIVE TO CULTURE AND DIVERSITY 7. BE AWARE OF AT-RISK POPULATIONS Psychological First Aid Psychological First Aid Contact and Engagement 1. Introduce yourself/ask about immediate needs 2. Confidentiality 9

Psychological First Aid Psychological First Aid Safety and Comfort Assure secure area Attend to hunger, clothing, shelter Provide information about the respose Promote social engagement Help separated children Attend to children who are separated from their parents/caregivers Psychological First Aid Psychological First Aid Stabilization Orient Use appropriate medications 10

Psychological First Aid Psychological First Aid Information Gathering: Current Needs and Concerns 1 . Nature and severity of experiences during the disaster 2. Death of a loved one 3. Concerns about immediate post-disaster circumstances and ongoing threat 4. Separations from or concern about the safety of loved ones 5. Physical illness, mental health conditions, and need for medications 6. Losses (home, school, neighborhood, business, personal property, and pets) 7. Extreme feelings of guilt or shame 8. Thoughts about causing harm to self or others 9. Availability of social support 10. Prior alcohol or drug use 11. Prior exposure to trauma and death of loved ones 12. Specific youth, adult, and family concerns over developmental impact Psychological First Aid Psychological First Aid Practical Assistance 1. Offering practical assistance to children and adolescents : deal with boredom 2. Identify the most immediate needs 3. Clarify the need 4. Discuss an action plan 5. Act to address the need 11

Psychological First Aid Psychological First Aid Connection with Social Supports 1. Enhance access to primary support persons (family and significant others) 2. Encourage use of immediately available support persons 3. Discuss support-seeking and giving 4. Special considerations for children and adolescents 5. Modeling support Psychological First Aid Psychological First Aid Information on Coping 1. Provide basic information about stress reactions 2. Review common psychological reactions to traumatic experiences and losses Intrusive thoughts Avoidance and withdrawal Hyper-arousal Grief Sadness 12

Psychological First Aid Psychological First Aid Talking with children about body and emotional reactions Provide basic information on ways of coping Teach simple relaxation techniques Coping for families Assisting with developmental issues Assist with anger management Address highly negative emotions Help with sleep problems Address alcohol and substance use Psychological First Aid Psychological First Aid Linkage with Collaborative Services Provide direct link to additional needed services Referrals for children and adolescents Referrals for older adults Promote continuity in helping relationships 13

Leadership Management Leadership Management Engage leaders Offer informed and practical recommendations Encourage them to set an example in terms of respite and openness to support Help them identify and manage employees who impede mission effectiveness Make them succeed in managing the crisis Summary Summary The Foreign Service has unique issues that affect the disaster response Delivering mental health care during a crisis requires a departure from the usual mental health care delivery model Be aware of organizational factors that impact the medical response to disasters Psychological First Aid, with its practical approach, is the current standard of care for mental health care following a disaster. Attend to the needs of leaders 14