Transcript presentation

Disaster Mental Health for Responders
CAPT Holly Ann Williams
Nurse Epidemiologist/Anthropologist
CDC
Operations Section Chief
USPHS Rapid Deployment Force 3
2011 U.S. Public Health Service Scientific and
Training Symposium
Vet Category Day
New Orleans, LA
23 June 2011
Man reunited with his dog after 2011 Japanese earthquake.
Credit: Friend Burst, 2011
Center for Global Health
International Emergency and Refugee Health Branch
Outline
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Visual portrayal of disasters: impact on mental health
Types of disasters:
 Natural versus complex humanitarian emergency
 Settings
 Trajectory of disasters
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Deployment environments:
 Organizational stress
• Veterinarian stress
 Individual stress
 Examples from PHS deployments
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Mitigation strategies:
 Agency (OFRD)
 Team
 Individual
Reality of Disasters: Impact on
our Senses
Japan Earthquake
and Tsunami,
2011: Event and
Consequences
Credits: National Geographic, March 2011
Human and animal
suffering
Credit: AP, Japan, 2011
Credit: Global Animal, Japan,
2011
Credit: Massoudi, CDC, Haiti, 2010
Credit: APF, Japan, 2011
Victims
Survivors!
Credits: Massoudi, CDC, Haiti, 2010
Scenes of Destruction: Haiti Earthquake, 2010
Credits: Massoudi, CDC, Haiti, 2010
Scenes of Destruction: Hurricane Katrina, 2005
Credits: Bowers & Williams, CDC, New Orleans, LA, 2005
Complex Humanitarian Emergencies
Credit: IERHB, CDC, Afghanistan, date unknown
Credit: Lopes-Cardoza, CDC,
unknown location & date
Credit: Lopes-Cardoza, CDC, Mass Graves ,Kosovo, 1999
Types of Disasters/Emergencies
Complex Humanitarian
Disasters
War
Internally Displaced
Persons
Natural Disasters
Civil Strife
Refugees: cross
international
border
Earthquake
Flood
Hurricane
Tornado
Drought/Famine
Settings and Timing of Disasters/Emergencies
Timing
Settings
Rural
Urban
Developed versus Developing
Country
Acute
Protracted
Recovery/Rehabilitation
Each type of situation, setting and the point of
time in which you respond will have a different
impact on responder mental health
Deployment Environments in General
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Chaotic and often austere
Lack of familiar context:
 Food
 Environment, including climate
 Community
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Little privacy – work and sleep
in same area
Overload of responsibility
Chronic sleep deprivation
Travel difficulties and delays
Security/safety is not assured
Work piles up at home agency,
overwhelming upon return
Credit: Williams, RDF 3, LSU Field House, Hurricane
Gustav, 2008
Organizational Stress
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Mission may be ambiguous or change mid-stream
Lack of efficient coordination:
 Particularly in global responses
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Limited resources:
 Insufficient number of staff
 Assigned personnel (i.e., Tier 3) may not professionally match
gaps in team
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Relief may be delayed secondary to bureaucracy:
 Affected communities voice anger or feelings of entitlement
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Conflict between individual values and
organizational goals
Role confusion: mismatch of skills with tasks
Veterinarian Roles in Disaster Response
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Pre-disaster planning
Surveillance and control of
diseases and vectors
Animal safety and control
Animal health care
Zoonotic disease
surveillance and public
health assessments
Search and rescue
Assessment of disaster
impact on animal
populations
Information dissemination
Credit: Peoplepets, Dog in Shelter, Japan, 2011
Organizational Stress: Veterinary Category
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Deployment role may not match professional role:
 PHS vets may work in non-clinical settings and have concerns
about clinical care competencies
 Frustrations with having to work through chain of command
to make contact with local/state vet services
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Frustration over challenges to providing adequate
care for sheltered animals:
 Lack of necessary cache for vets in RDFs, unlike National
Veterinary Response Teams (NVRT)
 Lack of trained assistants to help provide basic care
 No control over animals that may arrive at shelters (i.e.,
degree of aggression)
 Focus on companion and service animals: what happens
when faced with herd management in agricultural-focused
communities?
Individual Stress During Deployment
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Officers not prepared for stress of austere conditions
over a 14-day or longer period
Lack of preparation for international deployments:
 Limited understanding of how international disasters are
managed
 Inexperience with global travel
 Unrealistic expectations
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Visual impact of disaster on a daily basis,
compounded with sheltered individuals needing to
vent their feelings
No time to process impact of disaster during the
deployment:
 Some agencies refuse to allow time off after deployment
Common Stress Responses
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Cognitive:
 Memory loss, insomnia, reduced attention span, nightmares
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Physiological:
 Heart palpitations, dizziness, increased fatigue, tics, GI upset
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Behavioral/Emotional:
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Grief, guilt, sadness
Increased startle reactions
Crying easily
Social withdrawal: feeling numb and lack of reaction
Irritability, anger, increased conflicts with others
Examples of Stress-Inducing Deployment
Situations
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Lack of privacy: willingness to sleep on the ground
in pup tents vs on cots in larger NDMS tents (Haiti)
Physical limitations not considered in austere
conditions:
 Need for CPAP machines and assistive devices
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Failure to pay attention to basic public health
preventive measures:
 Did not use sunscreen or take prophylactic medications
 Failure to drink enough fluids in situations of extreme
heat/humidity
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Multiple billeting changes:
 Katrina: ~five moves in three weeks
 Haiti: four different tent locations in five weeks
Deployment Examples: II
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Limited dietary choices and food availability:
 MREs x 3/day, no fresh fruit or dairy in Haiti
 Inability to meet specific dietary requirements:
• Kosher, vegan/vegetarian, gluten-free
 Failure of contracted food service to provide meals at a time
that was reasonable for those working night shift (Gustav)
 Lack of contracted services to provide meals to sheltered
patients requiring Preventive Medicine Branch staff to serve
meals (Gustav)
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Compounded stress of being co-deployed with
Department of Defense:
 Lack of familiarity with rank, military customs and etiquette
 Perception that during deployments and trainings, officers
asked to billet in circumstances not respectful of rank or
perform functions for which enlisted would be expected to do
Deployment Examples: III
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Hurricane Gustav:
 Perceived lack of collaboration among co-located teams (RDF &
DMAT)
 Marked anger over lack of clinical staff
 Team integrity fractured with team being split to three locations
 Non-clinical officers: post-deployment nightmares seeing
patient that had died being placed in a closet during the
hurricane
 Post-traumatic stress re-activated by working in shelter situation:
• Brought back memories of being in a refugee camp as a child
 Only one Mental Health (MH) provider for entire team –
insufficient coverage for staff and patients
 Shared shower space with shelter residents:
• Perceived negative impact on ability to maintain professional
relationship
Life as a Responder: Sleeping
Home Sweet Home
Group Sleeping
Sleeping on Ship
Preparations for Sleeping on
Ship
Credits: Williams & CDC staff, 2005, 2008, 2010
Life as a Responder: Bathrooms and
Shared Living
Haiti
Response
Credits: Williams, CDC, Haiti, 2010
Mitigation Strategies: Agency
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Agency (OFRD):
 Improve travel clearance process
 Work with PHS MH providers to develop training for officers in
recognizing and mitigating signs of team and individual
stress during deployment:
• Screen officers pre-deployment for suitability, especially for
global deployments
 Develop Standard Operating Procedures for managing stress
that becomes disruptive to a team’s ability to function
 Work with HHS to improve global preparation predeployment
 Train ‘resiliency’ officers to work with MH providers
Mitigation Strategies: Team
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Team:
 Develop team goals that stress
the concepts of resiliency and
team support
 Ensure that all officers have access
to team MH providers in safe and
private area
 Implement rotational schedules
for time off and rest period
 Develop an area for ‘rest &
relaxation’ during duty hours that
is not accessible to shelter
residents
 Promote feeling of safety with
initiating ‘buddy’ system for
accountability
Credit: Williams, CDC, “Club Fed”, Hurricane Gustav,
LA, 2008
Mitigation Strategies: Individual
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Individual:
 Know your individual stressors and plan ahead:
• Exercise if possible, include comfort snack foods, bring novels and
headlamps for reading, keep packing organized, write in a journal,
eat well
 Maintain contact with family and friends
 Alert team lead when you have reached your limit and need
time alone
 Try to find humor on a daily basis (individually and with team)
 Meditate, use yoga or deep breathing exercises, attend spiritual
services
Much needed and earned rest!
Credits: Williams, CDC, Hurricane Gustav, LA, 2008
BBQ beats MRE’s any day!
Credits: Williams, CDC, Hurricane Frances, FL, 2005
Celebrating Louisiana style!
Credits: Williams, CDC, Hurricane Gustav, LA, 2008
Thank you to the various officers with
whom I have had the honor and pleasure
to serve during a myriad of disaster
responses.
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
Center for Global Health
International Emergency and Refugee Health Branch