For Mental Health and Substance Abuse Professionals and Facilities
- Upon successful completion of this course, the learner will be able to:
- Discuss the repercussion natural disasters have and how they affect mental health and the health care system
- Discuss man-made disasters and bioterrorism
- Explain the importance of planning emergency preparedness
- Discuss the impact of disasters on responders
Are we ready? It doesn’t seem prudent to ask “if disaster strikes,” but “when.”
The recent events of terror, storm destruction, and wildfires have punctuated the importance of educating all healthcare providers on emergency preparedness and bioterrorism. No longer can we rely on only the professionals responding on the front lines to have the necessary skills to care for victims of disasters. Natural or man-made disasters can occur at any time and in any place, often without warning. Emergency preparedness is a critical competency that is needed by all members of the health care team.
Emergencies and Disasters
Many different types of situations require emergency preparedness. A key component to understanding preparedness is to differentiate between emergencies and disasters.
An emergency is any natural or man-made situation that requires a rapid response that can be managed by a community’s existing resources.
A disaster is any event (natural or man-made) that causes damage, injury, and loss of life that overwhelms a community’s existing resources. Outside resources are needed. A mass casualty incident occurs when injuries/loss of life exceed the community’s or facility’s ability to provide care without outside resources.
The better prepared we are, the less likely an emergency will become a disaster. Emergency preparedness has many benefits, such as:
Being prepared can reduce fear, anxiety, and losses that accompany disasters.
People also can reduce the impact of disasters (floodproofing, elevating a home or moving a home out of harm’s way, and securing items that could shake loose in an earthquake) and sometimes avoid the danger completely.
People who live through a disaster can experience emotional distress. Feelings of anxiety, constant worrying, trouble sleeping, and other depression-like symptoms are common responses to disasters before, during, and after the event. Many people can “bounce back” from disasters with help from family and the community, but others may need additional support to cope and move forward on the path of recovery. Anyone can be at risk, including survivors living in the impacted areas and first responders and recovery workers.
Natural disasters are large-scale geological or meteorological events that have the potential to cause loss of life or property. These types of disasters include:
- Tornadoes and Severe Storms
- Hurricanes and Tropical Storms
Severe storms and floods are the most common types of natural disasters reported in the United States. These meteorological events are occasionally preceded by presidential “emergency declarations” requiring state and local planning before the event, such as evacuations and protection of public assets. Disaster Distress Helpline staff are available to speak to those who call or text before, during, and after a natural disaster.
Examples of man-made disasters include industrial accidents, shootings, acts of terrorism, and incidents of mass violence. As with natural disasters, these types of traumatic events may also cause loss of life and property. They may also prompt evacuations from certain areas and overwhelm behavioral health resources in the affected communities.
In the aftermath of the tragic loss of life that occurred on September 11, 2001, the feelings of loss of security and well-being—arguably the most crucial ingredients for leading a happy, healthy life—dramatically affected the citizens of the United States. Disaster Distress Helpline staff are also trained to respond to calls or texts related to these types of disasters.
Incidents of Mass Violence
Incidents of mass violence are human-caused tragedies that can impact whole communities and the country at large. These types of disasters, including shootings and acts of terrorism, often occur without warning and can happen anywhere, as shown by the Sandy Hook Elementary School tragedy of 2012 and September 11, 2001.
These violent acts typically target defenseless citizens with the intent to harm or kill. They can instill feelings of confusion, fear, and helplessness in survivors. Incidents of mass violence disturb our collective sense of order and safety and may even impact those with no personal connections to the event.
Because of the unpredictable nature of these types of disasters, it’s normal for people to experience emotional distress. Feelings such as overwhelming anxiety, trouble sleeping, and other depression-like symptoms are common responses to incidents of mass violence. Other signs of emotional distress related to incidents of mass violence may include:
- Feeling numb or like nothing matters
- Feeling helpless or hopeless
- Worrying a lot of the time; feeling guilty but not sure why
- Feeling like you have to keep busy.
- Excessive smoking, drinking, or using drugs (including prescription medication)
Symptoms of distress may appear before, during, and after such an event and may manifest in the hours, days, weeks, months, or even years after they occur. These are just a few warning signs of disaster-related distress. Learn more about warning signs and risk factors for emotional distress related to incidents of mass violence and other disasters.
Other Incidents of Mass Trauma
Infectious disease outbreaks, incidents of community unrest, and other types of traumatic events can also bring out strong emotions in people.
The outbreak of Ebola affecting several countries in West Africa, even with limited reported cases in the United States, may lead to feelings of anxiety and confusion, even to the point where it can interfere with one’s routine. Community upheaval, such as that seen in Ferguson, Mo., can also impact emotional health. News reports and the 24-hour news cycle can make people even more anxious when these kinds of events occur.
There are also many situations other than natural disasters and man-made intentional threats that can lead to a disaster, such as chemical spills, radiological dispersion device events, explosions, and hazardous material incidents that can be accidental but cause serious disasters.
Three basic groups of biological agents could likely be used as weapons: bacteria, viruses, and toxins. Biological agents can be dispersed by spraying them into the air, person-to-person contact, infecting animals that carry the disease to humans, and contaminating food and water.
A biological attack may or may not be immediately obvious. In most cases, local health care workers will report a pattern of unusual illness, or there will be a wave of sick people seeking emergency medical attention. The public would be alerted through an emergency radio, TV broadcast, or some other signal used in the community.
In the event of a biological attack, public health officials may not immediately be able to provide information on what you should do. It will take time to determine exactly what the illness is, how it should be treated, and who is in danger.
During a bioterrorism event, wear a face mask to reduce inhaling or spreading germs.
If you have been exposed to a biological agent, remove and bag your clothes and personal items. Follow official instructions for the disposal of contaminated items. Wash with soap and water and put on clean clothes.
The basic public health procedures and medical protocols for handling exposure to biological agents are the same as for any infectious disease. You need to pay attention to official instructions via radio, television, and emergency alert systems.
Healthcare Facility Preparations
When disaster strikes, healthcare facilities, and their staff play an essential role in the response efforts. It is, therefore, vital to address emergency preparedness before help is needed.
The design, preparation, and implementation of an emergency plan that includes all the procedures, strategies, organizational structures, potential hazards, personal protection equipment, and all the potential actions that can be completed in case there is an emergency is a foundation for a safe facility. The next important step is to provide training to all workers independently of the activity they do. An emergency plan should incorporate:
- Facility Risk Assessment – This multidisciplinary process should include representatives from all services involved in an emergency.
- Hazard Vulnerability Analysis – The Joint Commission on Accreditation of Healthcare Organizations requires member hospitals to complete an annual Hazard Vulnerability Analysis (HVA) to provide a foundation for emergency planning efforts.
- Training – Everyone working at a healthcare facility needs to be adequately trained to react to disaster situations.
- Command and Coordination – Emergencies are typically chaotic and confusing, but that doesn’t mean the response should match. Individual roles and responsibilities during the disaster should be clearly defined.
- Evacuation – When conditions are severe and force evacuation of the facility’s patients and staff, the safety of patients and the possibility of continuing their care rely entirely on a facility’s preparedness. Security and communication are vital in a successful evacuation.
In consideration of the above areas, the comprehensive plan for dealing with emergency events should include:
- Specific instructions to building occupants
- Actions to be taken by facility management
- First responder notification procedures
- Evacuation procedures
- Rescue and medical duties for those employees who are trained to perform them
- Names or job titles of persons who can be contacted for further information or explanation of duties under the plan
As the emergency plan is created and put into place, other items to ensure are in place and well maintained include:
- Portable fire extinguishers
- Fire detection systems
- Employee alarm systems
- Fire prevention plans
- Maintenance, safeguards, and operational features for exit routes like a sign
- Automated External Defibrillators
- First Aid kits
- Personal protective equipment
Who is at Risk for Emotional Distress?
People at risk for emotional distress after a disaster or traumatic event include:
- Survivors. Injured victims, as well as bystanders near the event, are especially at risk for emotional distress.
- Friends and loved ones. It’s normal for friends and family members located outside the impacted area to feel anxious about people who are in direct proximity to an incident of mass violence.
- First responders and recovery workers. These individuals may experience prolonged separation from loved ones and show signs of mental fatigue during the incident.
- Community members. People who live in the area surrounding the event may experience emotional distress.
If a terror alert, lockdown notice, or other warning is issued via television, radio, social media, or text alert systems, the risk for emotional distress becomes greater. It’s normal to feel unprepared, overwhelmed, or confused, particularly if you are not at home. You may also feel isolated if you are separated from friends or family members.
Remember, too, that the anniversary of a disaster or tragic event can renew feelings of fear, anxiety, and sadness in disaster survivors. Certain sounds, such as sirens, or large crowds, can also trigger emotional distress. These and other environmental sensations can take people back to the event or cause them to fear it’s about to happen again. These “trigger events” can happen at any time.
Most people who experience disasters can recover quickly, but others may need additional support to move forward on the path of recovery. Finding ways to manage stress is the best way to prevent negative emotions from becoming behavioral health issues.
The following factors might be important to assess when working with a trauma-affected person as they may impact how the person is going to deal with the disaster, crisis, or traumatic event.
• Cultural values and beliefs
• Spiritual/religious beliefs and values
• Physical well-being
• Psychological well-being
• Relational history
• Family/family history
• Living environment
• Poverty and low socioeconomic status
• Poor coping abilities and strategies
• Difficulty learning from previous experiences
• Low self-esteem
• Unstable work history
• Lack of finances
• Chemical dependency
• Chronic mental health issues (e.g., obsessive-compulsive disorders, anxiety disorders, PTSD, depression, etc.)
• Past and/or present legal problems
• All or nothing thinking
• Negative perception of other people’s responses
• Negative perceptions of symptoms
• Exaggeration of the future probability of a critical incident
• Catastrophic attribution of responsibility
• Family transitions(e.g., marriage, divorce, death, the birth of a child, a child leaving home, etc.)
• Work stress (e.g., work hours, unreasonable expectations, lack of resources, etc.)
• Previous critical incidents in a short time frame
• Resource deterioration
• Relocation and displacement
• Social support deterioration
• Marital distress
• Loss of home, property, and finances
• Alienation and mistrust
• Avoidance coping
• Family support
• Peer support
• Initially available and accessible resources
• Educational materials, such as information about normal reactions after a critical incident
• Intervention services, such as psychological debriefing, as long as it is not used as a blanket intervention, but only after careful initial screening
The primary purpose of crisis counseling is to help an individual to restore some sense of control and mastery after a crisis event or disaster. It is not unusual that in a crisis or disaster event, an individual’s normal coping capacities are taxed. Individuals can become emotionally overwhelmed and have difficulty problem-solving and other coping skills. Also, the individual’s basic beliefs (western phenomenon) about themselves (I can keep myself safe), others (humans are generally good [generally challenged in human-generated disasters such as terrorism, war, etc.]) and the world (is generally a safe place) might have been violated.
Crisis counseling has limited goals of ensuring safety and promoting overall stability. The goal is to provide emotional support and concrete feedback/assistance for the individual. Crisis counseling helps problem-solve and assists individuals in obtaining available resources.
Important aspects of crisis counseling:
- Establish rapport
- Tell their story
- Identify the major problem(s)
- Assess for safety issues
- Deal with feelings
- Explore alternatives
- Develop an action plan
- If appropriate, make referrals (ongoing services or crisis services)
Crisis counselors can help survivors and their families understand that it is often difficult to make good decisions about how to deal with stress after a disaster. Crisis counselors can ask survivors and their families: How did you deal with stress before the disaster? What worked for you? (What did not work in the past?), and/or What can you do today to deal with your stress?
Sometimes survivors and their families are aware that the stressors of the disaster can affect their ability to sleep, concentrate, and/or complete their daily activities/responsibilities. Survivors should be informed that there are inefficient coping skills that some people use after a disaster that are NOT helpful, such as:
• Not getting enough rest
• Binge eating
• Avoiding eating/starving
• Drinking alcohol / using drugs/smoking
• Excessive television watching
• Sexual acting out
• Aggressive behavior
• Other risky behaviors
When crisis counselors present different options on how to deal with post-disaster stress, counselors mustn’t present the information as “boilerplate advice,” as this might be rejected by the survivor and his/her family.
Depending on the disaster, suggestions for positive effective stress management might vary. For example, it might not be safe to encourage a survivor to go for a walk or bike ride, as this activity may be hazardous to the person. Counselors also need to ensure that stress management skills are culturally sensitive and appropriate. More general suggestions might be:
• Good self-care (sleeping, eating, rest)
• Use of a support system (family, friends, etc.)
• Set realistic short-term goals
• Maintain a normal (or new) schedule or routine
• Make to-do lists and prioritize them
• Set appropriate limits for yourself
• Be aware of your feelings. If you are
overwhelmed, reach out to someone
• If possible, decrease environmental stressors
• Reach out to others – do not isolate – ask for help if you need help
• Continue spiritual and religious practices as these can serve as a source of comfort
• Identify what works best for you in dealing with stress. Focus on what has worked well for you in the past
• Keep active. If appropriate, exercise
• Breathe deeply (stressed people often do not inhale or exhale deeply, and keep the body
tense). Deep breathing can help the body relax
• Avoid overexposure to the disaster coverage by the media (e.g., limit watching TV coverage of the disaster efforts, radio coverage, etc.)
These stress management techniques should be presented with care and an understanding that some of the suggestions might not be helpful or possible. In addition, counselors should explore with the survivor and his/her family other stress management techniques that might work specifically for them.
As an important health care team member, the mental health professional plays a vital role in responding to the disaster. These professionals, whether social workers, counselors, o therapists, have the knowledge and skills to manage acute and chronic stress disorders and depression.
An important component of comprehensive emergency preparedness planning includes surge capacity. Surge capacity is defined as the health care facility’s ability to expand beyond normal capabilities to care for an influx of patients. According to the Agency for Healthcare Research and Quality (AHRQ), planning for a surge includes beds, staffing, supplies, and equipment. A major concern for mental health professionals is the potential surge in patients requiring post-traumatic event counseling in the aftermath of a disaster. These professionals should be encouraged to be actively involved in community preparedness. These professionals can effectively function as disaster response team members in a disaster.
Psychological Impact of Disaster Response
All health care team members need to be aware of the psychological impact of disasters on not only the public they serve but also on themselves. Efforts are more commonly directed toward the immediate physical health and community infrastructure risks during and in the aftermath of disasters. This focus overshadows the short and long-term mental health consequences of disasters and the extent to which mental health plays a role in the impact of a disaster.
The consequences can also have a devastating impact on emergency response workers. Mass violence or disaster exposes victims and professionals alike to physical and mental trauma that may result from exposure to severely injured children, adults, dead bodies or body parts, or the loss of colleagues.
Emergency responders must be educated and supported to deal with their vulnerabilities and fears and must not become victims themselves. Mental health concerns exist in most preparedness, response, and recovery aspects.
Traumatic incidents can produce unusually strong emotional reactions that may interfere with the ability of professionals to function during the disaster or in the aftermath.
Psychological Response Stages of Disaster
The survivor realizes they made it through the disaster/trauma. This is the stage where physical/physiological needs are assessed and present danger re-evaluated. Emergency management services may have been offered. The survivors are assisted in safety/resource stabilization efforts.
Losses become apparent over the following days, weeks, and months post-disaster/trauma. The consequences of the trauma are appraised. This is sometimes called the “second disaster” stage, where disillusionment is felt.
At this stage, more than a year has passed since the trauma, and the survivor’s focus has changed. They may no longer be provided with community-based resources for recovery. In many cases, their life has been stabilized. However, this is also the time when some victims (approx. 25%) recognize that they are not recovering from the emotional impact of the trauma/disaster. Not all of those in need will reach out for assistance. This is where good community-based service follow-up becomes important.
Early Post-Disaster Interventions
These are very different than the types of services offered weeks, months, or years after a disaster and very much in line with moving toward a resource base to enhance recovery. Emotional recovery support programs include:
- Interventions need to fit the recovery phase.
- Establish a “community reach-out” plan to recognize individual needs before escalating. Interventions are tailored to the individual.
- Utilize a wide-range toolkit for recovery:
- Psychoeducation – tell survivors what they might experience and how to get assistance, and normalize trauma response.
- Build skills for recovery using identified community resources and social buffer building.
- Get the community involved in assisting survivors, their families, and friends.
- Use direct Critical Incident Debriefing methods for groups and individuals where appropriate.
- Actively manage the care of individuals who are under your attention. For example, this would mean you make sure you follow up if a survivor you spoke with requested a referral for an individual trauma counselor.
- Community organization through the Emergency Site Management System, if necessary or at a lesser scale advocating for the utilization of appropriate community resources.
Disasters impact entire communities. The immediate effects include loss of life and damage to property and infrastructure, with the survivors, some of whom may have been injured in the disaster, traumatized by the experience, uncertain of the future, and less able to provide for their welfare, at least in the short term. They are likely left without adequate shelter, food, water, and other necessities to sustain life. Rapid action is required to prevent further loss of life.
Emergency preparedness and effective response to mass casualty incidents will require a comprehensive and coordinated approach to ensure effective disaster response. Mental health professionals are integral members of the healthcare team and possess valuable skills that can and should be utilized in both disaster planning and response efforts.
Locate your facility disaster plan and familiarize yourself with it. Be an active participant in facility and community disaster drills. Keep your clinical skills up to date and your Basic Life Support skills current.
In today’s world, all healthcare providers need to be prepared and ready to respond.
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