DISASTER HEATLH FOR THE COMMUNITY RESPONSE TEAM Andrea Allen PhD Susan Schmitz MA James M. Shultz PhD
DISASTER HEATLHFOR THE
COMMUNITY RESPONSE TEAM
Andrea Allen PhDSusan Schmitz MA
James M. Shultz PhD
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2007.
A disaster is characterized asan encounter between
forces of harmand a human population
in harm’s way,influenced by the ecological context,
that creates demandsthat exceed the coping capacity
of the affected community.
DISASTER DEFINITION
Individual/Family Context
Community Context
Societal/Structural Context
Individual/Family Context
Community Context
Societal/Structural Context
Resilience Factors
Risk Factors
DISASTER ECOLOGY
MODEL
Forces of Harm
Affected Population
Disaster Impact
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2006.
Widespread and Pervasive
Spectrum of Severity
Range of Duration
Disaster-related4321
PSYCHOSOCIAL CONSEQUENCES OF DISASTER
psychological “footprint”
medical “footprint”
Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003
PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1
In a disaster,the size of thepsychological“footprint”
greatlyexceeds thesize of the
medical“footprint.”
psychological “footprint”
medical “footprint”
Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003
PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1
psychological “footprint”
medical “footprint”
Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003
PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1
MIAMI
PSYCHOSOCIAL CONSEQUENCES:SPECTRUM OF SEVERITY 2
Fear and Distress Response
Disaster Impact
BehaviorChange
PsychiatricIllness
Source: Butler AS, Panzer AM, Goldfrank LR. Preparing for the psychological consequences of terrorism: A public health
approach. Washington, D.C.: National Academies Press, 2003.
PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2007.
ExposureForcesof Harm
AffectedPopulation
Time from Impact
Disaster Impact
Loss
Change
PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2007.
ExposureForcesof Harm
AffectedPopulation
Time from Impact
Disaster Impact
Loss
Change
PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2007.
ExposureForcesof Harm
AffectedPopulation
Time from Impact
Disaster Impact
Loss
Change
PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3
Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)
Textbook of Disaster Psychiatry, Cambridge University Press, 2007.
ExposureForcesof Harm
AffectedPopulation
Time from Impact
Disaster Impact
Loss
Change
ComplexEmergencies
PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4
Human-Generated DisastersNatural Disasters
Hurricanes, Storms
IntentionalMass Violence
Terrorism
Non-intentional
TechnologicalFloods, Mudslides
Wildfires, ExtremeHeat, Cold
Earthquakes,Tsunamis, Landslides
Pandemics
ComplexEmergencies
PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4
Human-Generated DisastersNatural Disasters
Hurricanes, Storms
IntentionalMass Violence
Terrorism
Non-intentional
TechnologicalFloods, Mudslides
Wildfires, ExtremeHeat, Cold
Pandemics
EarthquakesTsunamis, Landslides
ComplexEmergencies
PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4
Human-Generated DisastersNatural Disasters
Hurricanes, Storms
IntentionalMass Violence
Terrorism
Non-intentional
TechnologicalFloods, Mudslides
Wildfires, ExtremeHeat, Cold
Pandemics
EarthquakesTsunamis, Landslides
ComplexEmergencies
PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4
Human-Generated DisastersNatural Disasters
Hurricanes, Storms
IntentionalMass Violence
Terrorism
Non-intentional
TechnologicalFloods, Mudslides
Wildfires, ExtremeHeat, Cold
EarthquakesTsunamis, Landslides
Pandemics
CATASTROPHE
Extreme exposure during impact
Extreme hardship in the aftermath
Separation or loss of loved one
Loss of place or territory4321
Violation of meaning, justice, order5
PSYCHOSOCIAL CONSEQUENCES: MECHANISMS
Num
ber o
f Sur
vivo
rs w
ith P
sych
olog
ical
Rea
ctio
ns
Time from Impact
Mild Reactions
Moderate Reactions
PROFILE OF DISASTER STRESS & DISTRESS
Severe Reactions
Time from Impact
Mild Reactions
Moderate Reactions
Severe Reactions
WIDESPREAD
SPECTRUMOF SEVERITY
RANGE OFDURATION
Num
ber o
f Sur
vivo
rs w
ith P
sych
olog
ical
Rea
ctio
ns
SAFETY FUNCTION ACTIONis a framework
for achieving and maintaininga high level of
DISASTER HEALTHand well-being
SFA FRAMEWORK
Achieve and maintaina high level of
DISASTER HEALTHand well-being.
SAFETY FUNCTION ACTION GOAL
Homeland Security Presidential Directive 21 (HSPD 21)“National Strategy for Public Health and Medical Preparedness.”
HSPD 21 proposes a new fieldof “disaster health”
to bring together medical,public health, public safety, and
behavioral health aspects ofdisaster preparedness and response.
HSPD-21: DISASTER HEALTH
DISASTER HEALTHMaximal SAFETY,
optimal FUNCTION,and effective ACTION
in preparedness for, and response to, emergencies, disasters,
and extreme events.
DISASTER HEALTH: DEFINITION
Maximal
SAFETYOptimal
FUNCTIONEffective
ACTION
SAFETY FUNCTION ACTION3 KEYS TO DISASTER HEALTH
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
6 STRATEGIES3 KEYS TO DISASTER HEALTH
SAFETY FUNCTION ACTION3 KEYS AND SIX STRATEGIES
Maximal
SAFETYOptimal
FUNCTIONEffective
ACTION
ACTIONADVISEACTIVATE
ADVISEACTIVATE
FUNCTIONCOMFORTCONNECT
COMFORTCONNECT
SAFETYSAFEGUARDSUSTAIN
SAFEGUARDSUSTAIN
RESPONDSKILLS SET
PREPARESKILLS SET
STRATEGIES FORRESPONDERS
STRATEGIES FORSURVIVORS
SAFETY FUNCTION ACTIONPARALLEL STRATEGIES
ACTION
ADVISE
ACTIVATE
FUNCTION
COMFORT
CONNECT
SAFETY
SAFEGUARD
SUSTAIN
RESPONDSKILL SET
PREPARESKILL SET
1 GOAL Achieve and maintain a high level ofDISASTER HEALTH and well-being.
3 KEYS TODISASTER HEALTH
6 STRATEGIES
2 SKILL SETS
SAFETY FUNCTION ACTION BUILDING BLOCKS
DISASTERHEALTH
DEFINITION
Maximal SAFETY , optimal FUNCTION,and effective ACTION in response to
emergencies, disasters, and extreme events.
PREPARESKILLS
SET
SFA Strategiesfor
Responders
SAFEGUARDResponders
SUSTAINResponders
COMFORTResponders
CONNECTResponders
ADVISEResponders
ACTIVATEResponders
SAFEGUARDSurvivors
SUSTAINSurvivors
COMFORTSurvivors
CONNECTSurvivors
ADVISESurvivors
ACTIVATESurvivors
PLAN for the
DISASTERROLE
SFAOverview
2Disaster
Health
RESPONDSKILLS
SET
SFA Strategiesfor
Survivors
SAFETY FUNCTION ACTION PATHWAY
1 3 4 5 6
PRACTICEfor the
DISASTERROLE
PRIORITIZESTRESS
MANAGE-MENT
APPROACHSURVIVORS
PresenceEmpathyRespect
Communi-cation
ATTEND toSURVIVORS
SpecialNeeds
CulturalIssues
APPRAISESURVIVORSIdentify Issues
CustomizeSFA Tactics
Refer toServices
SAFETY FUNCTION ACTIONTRAINING MODULE GUIDEBOOK
SAFETY FUNCTION ACTIONLAMINATED SHEET
SAFETY FUNCTION ACTIONFLIPBOOK
SAFETY FUNCTION ACTION FRAMEWORK
FIVE ESSENTIALELEMENTS
SAFETYSAFEGUARD
SafetySUSTAIN
FUNCTIONCOMFORT CalmingCONNECT Connectedness
ACTIONADVISE Self-EfficacyACTIVATE Efficacy & Hope
Source: Hobfoll, et al. Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 2007:70;283-315.
FIVE ESSENTIAL ELEMENTS
Primary focus on responders
One framework for responders and survivors
Operates 360o throughout the disaster cycle
43
2
1
5
Structured for evaluation
6
SAFETY FUNCTION ACTIONDISTINCTION
Incorporates resilience training for respondersand psychological support for survivors
First course focusing on DISASTER HEALTH
Public health, medical preparedness, andbehavioral health integration
7
PSYCHOLOGICALSUPPORT
FOR RESPONDERS
• Preparedness– Disaster plans– “Disaster ready lifestyle”
• Recognition– Educate about disasters
• Expectability of psychological reactions• Understanding of disaster health concept• Effective stress management and coping skills
PREVENTION
Physical Body reactionsEmotional Feelings
Cognitive Thinking/decision-makingBehavioral ActionsSpiritual Beliefs and valuesSocial Interactions
Dimensions of the Stress Response
PREPARESKILLS
SET
PLAN for the
DISASTERROLE
PRACTICEfor the
DISASTERROLE
PRIORITIZESTRESS
MANAGE-MENT
SAFETY FUNCTION ACTION FRAMEWORK
RESPONDERS-PREPARE SKILLS SET
PLAN for the DISASTER ROLE
PRACTICE for the DISASTER ROLE
PRIORITIZE STRESS MANAGEMENT
Plan and Prepare:Florida Demographics
• 3rd largest state in the nation– Overall population: 18.5 million
• 7th fastest growing state– 3+ million new residents in past 10 years
• Vast number of foreign-born individuals– 16.7% of the population– Accounts for 61% of state’s population increase
• 1.2 million people live in rural FL• 700,000+ illegal immigrants in FL (many are
migrant workers)
US Census Bureau (2010). Florida Quick Facts. http://quickfacts.census.gov/qfd/states/12000.html. Accessed May 2010.
US Immigration Support (2010). Immigration to Florida. http://www.usimmigrationsupport.org/florida.html. Accessed May 2010.
Plan and Prepare:Characteristics of Rural Communities
• High levels of:– Poverty (17.8% poverty rate in rural areas vs.
13% poverty rate in urban areas)– Unemployment– Health related problems
• A usually homogeneous community with pockets of minorities
• Large percentage of population is involved with organized religion
SAMHSA (1999). Disaster Mental Health: Crisis Counseling Program for the Rural Community.
Plan and Prepare: Rural Populations Post-Disaster
• Accessing population– Agricultural considerations (i.e. free time)– Migration– Living situation
• Cultural values– Individualism and independence– Stigma of mental health services– Religion
Plan and Prepare: Cross-Cultural Issues
• Recognizing ethnicity– Avoiding labels
• Language barriers• Migration history
– Reasons for migrating– Experiences in homeland, during migration,
and in current location• Level of acculturation• Social support networks
Association of Reproductive Health Professionals (2008). Cross-Cultural Communication with Immigrant and Refugee Patients. http://www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/Cross-Cultural. Accessed May 2010.
Plan and Prepare:Co-occurring Issues Post-Disaster
• Poverty• Housing• Lack of understanding and/or language• Immigration status• Transient population = lowered social network• Transient population = lack of stable access to
social services• Compounding health issues• Mental health symptoms• Slavery and abuse
Immigration, Children, and Disasters
• Prior to the 2010 earthquake in Haiti– 6% of children in Florida are foreign-born– 28% of children in Florida have immigrant
parents• Following the 2010 earthquake in Haiti
SAFETY
FUNCTION
ACTION
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
STRATEGIES FORRESPONDERS
STRATEGIES FORSURVIVORS
SAFETY FUNCTION ACTIONPARALLEL STRATEGIES
DISASTERSTRESSORS:
HAITI’S YOUTH
STRESSORS FOR CHILDREN
INTENSE EXPOSURE
STRESSORS FOR CHILDREN
INTENSE EXPOSURE
LACK OF SURVIVAL NEEDS
STRESSORS FOR CHILDREN
LACK OF BASIC SUPPLIES
STRESSORS FOR CHILDREN
PERSONAL INJURY
STRESSORS FOR CHILDREN
STRESSORS FOR CHILDREN
INJURY TO CAREGIVERS
STRESSORS FOR CHILDREN
SEPARATION OR LOSS OF CAREGIVERS
STRESSORS FOR CHILDREN
FUNCTIONALLY-IMPAIRED CAREGIVERS
STRESSORS FOR CHILDREN
DISPLACEMENT / POST-IMPACT HARDSHIPS
INTENSE EXPOSURE
LOSS OF A LOVED ONE
DISRUPTION OF SURVIVAL NEEDS
DISRUPTION OF ESSENTIAL SERVICES4321
PRIOR TRAUMA5
SEVERE PSYCHOLOGICAL REACTIONS
MAJOR LIFE STRESSORS6
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
6 STRATEGIES3 KEYS TO DISASTER HEALTH
SAFETY FUNCTION ACTION3 KEYS AND SIX STRATEGIES
Maximal
SAFETYOptimal
FUNCTIONEffective
ACTION
SAFETY FUNCTION ACTION
Maximal
SAFETYOptimal
FUNCTIONEffective
ACTION
SAFETY FUNCTION ACTION
SAFEGUARD
SAFETY FUNCTION ACTION
SAFEGUARD
SAFETY FUNCTION ACTION
SUSTAIN
SAFETY FUNCTION ACTION
SUSTAIN
SAFETY FUNCTION ACTION
COMFORT
SAFETY FUNCTION ACTION
CONNECT
SAFETY FUNCTION ACTION
CONNECT
SAFETY FUNCTION ACTION
ADVISE
SAFETY FUNCTION ACTION
ACTIVATE
SAFETY FUNCTION ACTION
ACTIVATE
• Classified according to– Timing
• When to intervene– Is the survivor receptive for services?– Does the intervention drain already minimal resources?
– Intention• Early post-disaster
– Re-establish sense of safety and security• Intermediate post-disaster
– Increase coping skills• Long-term post-disaster
– Address symptoms of PTSD, Major Depressive Episode, Complicated Grief, Anxiety
– Build Resiliency
POST-DISASTER INTERVENTIONS
• Expert panel consensus in 2001 suggests move towards– Flexible– Non-prescriptive– Multi-faceted approach
• Focus on– Securing basic needs– Applying principles of psychological first aid– Conducting needs assessment– Monitoring rescue and recovery– Providing outreach and information– Fostering resilience and recovery– Conducting triage and referral– Providing psychiatric treatment for subset of survivors (NIMH,
2002)
EMPIRICALLY-INFORMED EARLY INTERVENTION
SAFETY
FUNCTION
ACTION
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
SUSTAINSAFEGUARD
CONNECTCOMFORT
ACTIVATEADVISE
STRATEGIES FORRESPONDERS
STRATEGIES FORSURVIVORS
SAFETY FUNCTION ACTIONPARALLEL STRATEGIES