The American Red Cross Disaster Mental Health System PsySTART Model.
In the absence of rapid triage and coordination between systems, those with the greatest needs may not be located until clinical levels of distress and impairment have become entrenched.5,59 As large numbers of children move across different systems of care, inconsistent approaches to the definition and assessment of “acute need” may further hamper critical provision of psychological assistance and definitive care. For example, following the 1994 Northridge earthquake in California, many children at high risk due to intense event exposures remained undetected until months and, sometimes years later.67 These included children injured and/or trapped inside structures. Evidence from New York City also found that only 27% of children with severe or very severe posttraumatic reactions received any mental health care 4–5 months after the U.S. terrorist attacks of September 11, 2001.68 Acute-phase triage and incident management are critical because there is meta-analytic evidence that certain types of acute-phase interventions, applied early after the traumatic event, might afford a unique window of opportunity to interrupt the trajectory of risk, disorder, and impairment for those at high risk who are already symptomatic.69,70 There are also limited data for the efficacy of an evidence-based acute intervention for children.71
Disaster mental health workers and other responders should apply timely, evidence-based care to individuals at risk. Optimally, there should be a seamless system of triage, needs assessment, clinical care, and long-term surveillance for disaster-related mental and behavioral health5 matching acute and long-term evidence-based interventions for the subset of persons that require them. One approach involves partnerships among many entities including public health authorities, public information officers, emergency medical services, primary and advanced medical and behavioral healthcare facilities, medical examiner and mortuary services, faith-based communities, schools, businesses, and nongovernmental relief organizations. These “disaster systems of care” are positioned to significantly mitigate adverse outcomes and move populations toward improved mental health preparedness, response, and recovery19 if appropriate preparedness and coordination has begun pre-event.5 This requires dynamic and continuous coordination, communication, and resource (goods and services) delivery targeted to those at highest risk of adverse outcomes. A paradigm shift in disaster recovery planning is needed to manage the continuum of risk and adverse outcomes over the extended course of recovery. The emerging incident management model PsySTART for disaster mental and behavioral health is composed of three major components. This enables a common operational picture and real-time situational awareness for participating entities and jurisdictions.5 The components are: 1) community-based “disaster systems of care”; 2) a common system for incident-specific rapid triage; and 3) a mobile-optimized web application for real-time triage linkage across diverse disasters and systems of care. In the PsySTART model, each participating system of care uses the same triage risk factors, which are based on objective evidence-informed exposure risks (not symptoms) for adverse post-disaster mental health outcomes. In field applications, the triage information were found to positively predict PTSD and depression among exposed children in the Indian Ocean tsunami63 and the Laguna Beach, California wildfires.72 PsySTART was also used in the federal response to the American Samoa Catastrophic Earthquake and Tsunami64 and by the American Red Cross in 18,000 triaged disaster mental health contacts within the first three weeks after Superstorm Sandy.73 This rapid mental health triage system flexibly incorporates event- and hazard-specific exposure factors such as decontamination, mass prophylaxis or vaccination, shelter in place, quarantine, and/or evacuation in more complex public health emergencies. The triage data are used to inform incident managers of resources needs, match high-risk adults and children to available screening and clinical resources, and provide estimates of burden. In this way, stratified rapid triage data correspond to the concept of disaster medical triage and connect level of need with appropriate level of evidence-informed intervention throughout an extensive period of community recovery.5,30
Preventing and Managing Psychological Injuries
Estimates of Disaster-Related Behavioral Health Casualties
In catastrophic events, rates of disorder in the vulnerable child population are extremely high. For example, in a large earthquake in Armenia in villages with nearly 50% pediatric mortality, the surviving children exhibited comorbid psychiatric disorders approaching 90%.74 Adults are also at risk. In a study published in 2006, 64% of the 5,383 survivors who were in collapsed and damaged buildings during the September 11, 2001, terrorist attacks reported new-onset depression, anxiety, or emotional problems after the event.75 Estimates of mental health disorders within months post-event revealed an incidence of approximately 100,000 new cases in school-aged children alone.76 As another example, approximately half of those most severely impacted by Hurricane Katrina in the United States had clinically significant levels of distress, leading to federal funding requests for “specialized/enhanced services” beyond typically funded crisis counseling programs.
Psychological impact and resulting levels of psychiatric disorders vary as a function of event characteristics, such as terrorism (biological, explosive, chemical, nuclear, or radiation), which can cause mass casualties and societal disruption.1 Weapons that involve sustained health risk over time can induce particularly pernicious mental and behavioral health morbidity on a population scale. Planning for mental and behavioral healthcare needs must anticipate demand surges during acute-phase distress and the behavioral reactive phase. This is followed by an extended trajectory of needs continuing and emerging throughout the duration of recovery, especially after mass casualty events.5,30 A unique approach to modeling a continuum of population-level mental health effects was performed for an exercise in Southern California termed the “Shakeout Scenario.” In this scenario, a mock 7.8 magnitude earthquake strikes eight counties and a population of 21 million in Southern California. Using the Psy-START triage model based on incident-specific features such as death, injuries, and home loss, investigators estimated the number of distressed, but resilient persons to be approximately 8 million, and a new incidence of mental health disorders requiring professional assessment and care for approximately 200,000 persons.77
In the United States, the approach of using incident-specific features to estimate the continuum of mental health impacts based on PsySTART triage has been further developed into a national model for planning for the mental health response at the local or state level focused on the needs of children and families.65 In this model, PsySTART triage is used to estimate impacts for children and then convert them into estimates of service delivery requirements. This metric reveals a “gap” which then becomes the focus of local preparedness efforts. It is also used for triggers for “crisis standards of care,” which are operationalized into a floating triage algorithm78 such that those at higher risk are prioritized for care in a rational and ethical alignment of resources. In 2012, the National Children’s Disaster Mental Health Concept of Operations model was extended to include a novel triage-driven disaster mental health incident action plan for coordination of response-phase operations.65
Basic Disaster Mental and Behavioral Health Intervention
Much of the initial on-site disaster mental health response focuses on 1) dampening anxiety and arousal by providing safety, comfort, and consolation; 2) assisting those directly affected to function effectively (reality testing and concrete problem solving); and 3) providing clear guidance and information to meet basic individual and family needs (e.g., safety, medical attention, water, food, shelter, clothing, essential medication, supervision of children and other dependents, and reunification of families).58,79 An extensive literature review, including the findings of two consensus development workshops, defined key components of early intervention for survivors of mass violence.79–81 Key components of this early intervention include: assess needs; monitor the recovery environment; and provide outreach, screening, triage, and treatment services for survivors. The goal is to foster resilience, effective coping, and recovery.82
Early Intervention
From a population health perspective, the following groups stand to benefit from early intervention: 1) persons with direct disaster exposure; 2) persons demonstrating extreme acute stress reactions, extreme cognitive impairment, or prolonged and intense distressful emotions; and 3) persons having a prolonged inability to sleep.1,4,19,79,80 Risk factors in the early disaster aftermath include loss of personal and financial resources, loss of social support, displacement, loss of home, and proliferation of secondary stressors. Also at increased risk for psychiatric outcomes following disasters are persons living in poverty; low visibility groups (homeless, migrant, impaired mobility, institutionalized); and persons with trauma, psychiatric, or illicit substance use history. The goal is to deliver a compendium of pragmatically oriented interventions as soon as possible for individuals experiencing acute stress reactions or who appear unable to regain function.80,82 At-risk persons should be connected early with evidence-based interventions such as acute prolonged exposure cognitive-behavioral therapy (CBT) for adults, or trauma-focused CBT for children. There is evidence of benefit to both adults and children when these interventions are provided early (∼30 days). In addition to decreasing morbidity in high-risk and symptomatic individuals, overall cost of care is reduced.69–71 In general, interventions are designed to aid adaptive coping and restore problem-solving capabilities as quickly as possible. During the 1980s and early 1990s, critical incident stress debriefing surged in popularity and was widely adopted by disaster response personnel. During this period, critical incident stress debriefing was applied indiscriminately to disaster survivors; however, the technique was found to have equivocal effects and in some applications, to have the potential to cause harm. This led to consensus recommendations to abandon this approach.80–82
Psychological First Aid
Psychological First Aid (PFA) is currently the most widely accepted intervention for populations following disaster. PFA is based on a core set of principles: 1) promote a sense of safety; 2) promote calming; 3) promote self and community efficacy; 4) promote social connectedness; and 5) instill hope.83 The core principles of PFA have been operationalized into a set of core actions summarized in Table 9.3.84 PFA is intended to restore and maintain individual and community function, reduce health-risk behaviors in the population, and prevent or minimize psychiatric illness following disaster. While users must undergo a brief training, use of PFA does not require a licensed mental health provider or formal mental health training. National and international organizations endorse either PFA, or interventions based on its principles.85,86 The American Red Cross also includes a version of PFA for use by all of its disaster relief workers as a key element of its disaster response strategy.66 In Los Angeles and New York, “Listen, Protect and Connect,” a “Neighbor-to-Neighbor” simplified version of PFA designed for family members (including parents with children), schools, the faith-based community, neighbors, and coworkers to use with each other, has been implemented as part of a broader all-hazard, community resilience initiative.87,88 Both the American Red Cross and “Listen, Protect and Connect” PFA include PsySTART rapid mental health triage as a core competency. Application of this model to non–mental health medical reserve corps members revealed improvements in their awareness about the psychological impact of disasters and in their comfort level in providing PFA.89
| Contact and Engagement |
| Safety and Comfort |
| Stabilization |
| Information Gathering: Needs and Current Concerns |
| Practical Assistance |
| Connection with Social Supports |
| Information on Coping |
| Linkage with Collaborative Service |
Promoting a sense of safety and promoting calm (PFA principles 1 and 2) mitigate the physiological and psychological reactions to life-threatening events. Recommendations include reducing exposure to further trauma by discouraging repeated retelling or witnessing media coverage of events. Promoting calm facilitates the transition out of intense emotions experienced immediately after a disaster and reduces the development of avoidant behaviors. Techniques such as therapeutic grounding, breathing retraining, or deep-muscle relaxation are appropriate.83 Promotion of self- and community efficacy (PFA principle 3) involves restoring a sense of control over outcomes in both individuals and communities. Individuals and communities can manage uncomfortable post-disaster emotions by successfully solving problems, facilitating the transition from “victim” to “survivor.”83 Promoting social connectedness (PFA principle 4) enhances and sustains attachments between affected individuals and within affected communities. This provides survivors with better access to the knowledge necessary for recovery and allows for collaborative problem solving. It also offers emotional understanding and acceptance.83 Instilling hope (PFA principle 5) is the process of restoring a positive outlook against a worldview shattered by overwhelming events. At the individual level it requires countering catastrophic thoughts while promoting realistic benefit-finding.83 Affected individuals gain the most when they identify a realistic outcome, even if the situation is worse than their pre-disaster circumstances. At the population level, psychological benefits accrue in a systemic manner by bridging together primary care and mental health systems (i.e., “disaster systems of care”) and improving access to the broad range of human service needs (e.g., housing, employment, schooling, and child care). Such approaches, although not mental health interventions by mental health providers, may be the most effective for providing PFA and improving coping at the population level.
PFA research reports positive provider perceptions of efficacy,90 but, at the time of this writing, controlled trials of interventions in a real-world disaster setting are lacking. Mental health practitioners cite providing safety and comfort, making contact and engaging with survivors, and providing practical assistance as the most beneficial interventions.91
World Health Organization Guidelines
In 2013, the World Health Organization (WHO) published guidelines for the management of acute stress in adults and children resulting from traumatic exposure.92 Among the specific recommendations, WHO emphasizes basic principles such as communication and social support, and recommends that PFA be available to anyone recently exposed to a potentially traumatic event. For adults experiencing acute symptoms, WHO recommends acute trauma-focused CBT and avoidance of medications such as benzodiazepines and antidepressants in the first month. For those experiencing insomnia, relaxation and sleep hygiene techniques are advised for both children and adults. For children experiencing enuresis, WHO endorses non-punitive psychoeducation for children and parenting skills enhancement for adults. For those children and adults who develop PTSD more than a month after exposure, WHO advocates individual or group CBT with a trauma focus, eye movement desensitization and reprocessing, and stress management. Antidepressant medication should be considered for those who develop moderate to severe depression.
Behavioral Preparedness for Disaster Responders
Responder Resilience
Disaster responders represent a diverse collection of professional and volunteer workers that bring unique strengths and vulnerabilities. Resilience is common, even in the face of severe adversity.93 Resilience is not a fixed attribute; instead, resilience is a process that evolves with changing disaster circumstances and experiences (see Chapter 6). Responders as a population may be self-selected for resilient psychological traits, but are vulnerable due to the duration and intensity of their exposure to disaster stressors. The disaster experience may be transformative, enabling more constructive ways of managing adversity and stress.94 Responder resilience refers to the capacity of emergency personnel to rapidly adjust to the stresses of deployment, successfully respond to adverse cultural and situational challenges, and reintegrate into routine work in a healthy and adaptive fashion.
Responding optimally to mass trauma and mass casualty incidents requires an organizational culture that prioritizes both physical health and psychological well-being. Psychological preparedness improves disaster response for those who respond to incidents of all magnitudes. Enhancing resilience skills in the workforce will diminish the likelihood 1) that critical infrastructure personnel refuse to work during a disaster;49 2) that workers resign, requiring massive retraining and rehabilitation; and 3) of lost productivity, thus dampening the economy in a potentially cascading fashion. In the face of all-hazard planning and the need to maintain critical infrastructure and key resources, responder health, safety, and resilience must be integrated into organizational culture for public safety, health, and security. Emergency response personnel are often required to work extended hours in high-risk environments, where alertness and attention to detail are an absolute requirement for safe work practices. Hazards and risks to responders can be directly related to the reason for the deployment (e.g., infectious disease outbreak) or incidental to the deployment (endemic diseases, lack of medical facilities, and physical security hazards). Risk of psychological effects from exposure to these hazards must be assessed and appropriate control measures taken to reduce them.
Promoting Resiliency in Emergency Responders
Organizational policy can prevent or mitigate injuries and illnesses from environmental, occupational, and operational threats including psychological and traumatic stress. Disaster events in the United States over the last decade led to the creation of the National Planning Frameworks, promoting inter-agency coordination.95 As part of this coordination, the National Institute for Occupational Safety and Health (NIOSH) created a recommended framework for health surveillance of emergency responders, to include psychological health.96,97 This comprehensive plan identifies actions to be taken before, during, and after deployment. Before deployment, organizations should ensure personnel complete multiple requirements to foster a state of readiness. These include rostering and credentials verification to perform work assigned and health screening for both medical and behavioral fitness for deployment. In addition, pre-deployment training on safe work practices, use of appropriate personal protective equipment, and self-care (psychological, social, and behavioral), and other specialized training are needed to fulfill job-related responsibilities. During deployment, just-in-time briefings should be used to provide information about anticipated hazard exposure, including psychological and emotional hazards from response activities. Health monitoring of individual exposures and population surveillance for patterns of injury and disability, and communication of this information back to disaster workers are vital activities to maintain a resilient and ready workforce. At the conclusion of deployment, organizations should again screen responders for physical and psychological health during their outprocessing, and establish mechanisms to continue to follow workers post-event. This screening should include particular attention to those workers with the most hazardous exposures and those showing signs of adverse reactions at outprocessing.98
A similar approach, specifically designed and operationalized for disaster health workers, called “Anticipate, Plan and Deter” has been deployed in California for Los Angeles and Alameda County Emergency Medical Services providers as part of an overall evidence-based platform for community-wide disaster mental health for citizens and responders.99 The “Anticipate, Plan and Deter” responder resilience model entails pre-event stress inoculation, basic PFA training for all responders using the “Listen, Protect and Connect” model and acute phase response, including responder self-triage and use of the novel, Internet-based intervention “Bounce Back Now.”100 Optimally, the individual responder has existing emergency plans and systems to manage concerns about the safety and welfare of loved ones. This avoids fractured attention on the job and decreases the likelihood of accidents, improper work practices, and poor decision making. Training and maintenance programs can be instituted for peer support, team building, and crisis leadership, with skill building to improve stress, anger, and grief management.48
Recommendations for Further Research
Despite continued progress, several areas of disaster behavioral health require research attention. Quantifying the psychological, behavioral, and social consequences and management strategies for disasters and mass violence is critical. Continued efforts are needed to:
further refine and test emerging rapid mental and behavioral health triage and assessment tools for population-based, facility-based, and clinical contact surveys, including assessment for mass casualty settings;
integrate psychological and behavioral elements into population-based surveillance systems; and
leverage modifiable risk factors to help design effective prevention and intervention programs.
Despite the knowledge that early intervention mitigates risk for extended traumatic stress syndromes, the field has been hampered by misapplication and misrepresentation of early intervention strategies. Prospective research to quantify the outcomes of PFA is essentially nonexistent and urgently needed.88 Applied research is needed to test promising early interventions for those directly impacted by disasters and mass violence. Such studies should include:
quantitative study and comparison among the various models of Psychological First Aid;
further development and validation of acute phase, evidence-based interventions, including interventions for young children; and
determination of optimal timing of strategies to implement interventions.
Research is also needed to evaluate the effectiveness of efforts to increase preparedness and adherence to behavioral aspects of public health emergency response strategies. These include compliance with incident-specific disaster response strategies, such as sheltering and evacuation. More research and program evaluation efforts are needed to understand the key ingredients of resilience of professionals performing emergency response, disaster recovery, and remediation work. Finally, research is needed to evaluate the value of organizational approaches such as Emergency Responder Health Monitoring and Surveillance and “Anticipate, Plan and Deter” in enhancing resilience among disaster response professionals.
Conclusion
Planning for the behavioral and mental health needs of disaster-exposed individuals, families, communities, and responders is an essential public health and medical activity. Without it, available resources, monitoring efforts, and healthcare services may be overwhelmed. Although “panic” is ill-defined, anxiety, fear for one’s children, and the absence of feeling safe can create personal and community confusion and disillusionment with leadership that has substantial real world consequences. Planning must address the range and trajectory of responses from distress to persisting illness, as well as numerous behavioral impacts (e.g., changes in travel, reverse quarantine). Communities receiving disaster victims must anticipate the need for additional mental health services, both for displaced persons with existing psychiatric conditions and for those with new disorders. Disaster mental health Concepts of Operations (such as the National Children’s Disaster Mental Health CONOPS project) include triage, protection from secondary stressors, restoration of families and social networks, and a continuum of care from PFA acute and long-term evidence-based interventions. Novel Internet-based interventions are the primary cutting-edge, population-level interventions for codifying the behavioral and mental health consequences of disaster. Public messaging and leadership presence are critical to convey and implement the principles of mental health interventions. At appropriate times, grief counseling – an important task in advancing communities to recovery – becomes the focus of all community leaders. First responders represent a high-risk group and benefit from planned behavioral health support and surveillance to promote their resilience and readiness. Addressing knowledge gaps in disaster mental health, applying scientifically supported interventions, and tracking the trajectory of unresolved needs are important objectives.
References
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