Foundations of Psychosocial Support in Emergency Management

Transcription

1 Foundations of Psychosocial Support in Emergency Management Workshop Handbook March 2009 Dr Sarb Johal Emergency Management Team Ministry of Health New Zealand

2 Table of Contents Page No. Course Program 2 Theme, Purpose and Objectives 3 Section 1: Introduction to psychosocial support 4 Section 2: Psychosocial reactions to disasters 15 Section 3: Psychosocial Care: Individuals and Communities 26 Section 4: Self-Care, Staff, and Organisational Concerns 40 Resources 44 Acknowledgements This Foundations of Psychosocial Support in Disaster Management workshop originated from material developed for a collaborative initiative by the following partners: Greg Eustace, Queensland Health Sarb Johal, New Zealand Ministry of Health Garry Stevens, University of Western Sydney Athol Yates, Australian Homeland Security Research Centre Eustace, G., Johal, S, Stevens, G., and Yates, A. (2008) Foundations of Psychosocial Disaster Management Course Handbook, Australian Homeland Security Research Centre With grateful thanks for additional material: Christine Healy, Former Director, ACT Recovery Centre, Canberra, Australia David Johnston, Director, Joint Centre for Disaster Research Ben McFadgen, Ministry of Social Development, New Zealand Ljubica Mamula-Seadon, Ministry of Civil Defence & Emergency Management, New Zealand Garry Stevens, University of Western Sydney, Australia Anne Stevenson, Ministry of Social Development, New Zealand 1

3 Course program 9:00 am Arrival and coffee Introduction, definitions, and context How do disasters affect people? How do the effects show themselves in people and their communities? This section examines ordinary responses to extraordinary events Morning tea (provided) and networking How can individuals and communities be assisted to help cope with the effects of disasters? An overview of the psychosocial issues and techniques involved in support, including psychological first aid, and models for community recovery pm Activities Lunch (provided) Taking care of yourself, your staff, and your organisation with tips for communication with the public Time for feedback, questions & discussion 2pm Closing remarks 2

4 Workshop Theme What psychosocial support is, and what you and your service or organisation can do to contribute to community and organisational psychosocial response and recovery after emergency events. Purpose The purpose of the workshop is to educate participants about psychosocial and mental health concepts and practice, so they can: Identify the likely psychosocial and mental health issues arising from a disaster Better work with psychosocial and mental health practitioners Ensure mental health issues are better integrated into emergency / disaster management at an individual, organizational, community and / or national level. Objectives After participating in the workshop, participants will have developed, or added to, their awareness and knowledge about: People s reaction to emergency events Why psychosocial support is crucial What psychological first aid is How we can tell who might need further assistance Key challenges in operationalising psychosocial emergency management Where mental health services fit in Applying psychosocial support principles to protect emergency workers wellbeing Resources Workshops participants will be provided with a DVD comprising a suite of resources to help you pass on the concepts of psychosocial support within your own organisation, service or special interest group. The disc will include video clips explaining the key concepts of psychosocial support along with handbooks covering the workshop topics, and resources to deploy in case of urgent response. DVDs are free, plus all resources will be downloadable from the Ministry website. 3

5 Section 1: Introduction to Psychosocial Support The aim of this section is to introduce participants to the key elements of disasters from a psychosocial perspective. Definition of Disaster A disaster can be defined as, A serious disruption to community life that threatens or causes death or injury in that community and/or damage to property, the environment and/or economic activity that is beyond the day to day capacity of the prescribed statutory authorities and which requires special mobilisation and organisation of resources other than those normally available to those authorities. 1 Another definition is: an event when the consequences include many deaths or injuries, or extensive damage to property, infrastructure, or the environment 2 Key psychosocial definitions Psychosocial: The dynamic relationship that exists between psychological and social effects, each continually interacting with and influencing the other. Psychosocial recovery planning: Psychosocial recovery planning is focused on the social and psychological interventions that will help a community recover. 3 Definition of Psychosocial Disaster Management Psychosocial disaster management is an understanding of the potential mental health impacts that can occur on a large scale to affected populations. Raphael (2007) identified the key specific elements that are included in psychosocial disaster management as Resilience Social Processes Intervention strategies For many responders, the terms psychosocial and mental health are closely related and overlap. 1 Australian Emergency Management Glossary (1998), Commonwealth of Australia. 2 National Hazardscape Report (2007). Officials Committee for Domestic and External Security Coordination. Department of the Prime Minister and Cabinet. New Zealand. 3 Ministry of Health, (2007). Planning for Individual and Community Recovery in an Emergency Event: Principles for Psychosocial Support. National Health Emergency Plan. Wellington: Ministry of Health. 4

6 Introduction to Foundations of Psychosocial support Dr Sarb Johal Clinical Psychologist Emergency Management Team Ministry of Health, NZ Distress and suffering are not psychiatric illnesses What is psychosocial support? During and after emergencies or disasters there are a range of potential mental health impacts that can occur, on a large scale, to affected populations. Psychosocial support interventions aim to help people adjust to the new environments and revised social structures that arise after an emergency or traumatic event. It also aims to help people cope with their own potentially upsetting individual experiences. What is psychosocial support? Psychosocial support aims to improve well-being for individuals and communities across three different domains: Supporting human capacity to improve mental health and well -being Improving social ecology by focusing on the network of relationships linking individuals to each other, within and between communities Considering culture and values by being mindful of the value and meaning given to behaviour and experience as reflected by individuals and communities 5

7 Principles of psychosocial support and recovery National Health Emergency Plan Planning for Individual and Community Recovery in an Emergency Event: Principles for psychosocial support (2007) Expect psychosocial reactions within an appropriate range for most, although some people may exhibit short - term reactions Most people will recover from an emergency event with time and basic support Principles of psychosocial support and recovery There is a relationship between the psychosocial element of recovery and other elements of recovery, e.g. economic infrastructure Psychosocial support in an emergency event should be geared toward meeting basic support needs Principles of psychosocial support and recovery Self - help to more intensive forms of support should be operationalised through a well - supported triage process, immediately post - event and onwards Those at high - risk in an emergency event can be identified and offered follow - up services provided by trained and approved community - level providers 6

8 Principles of psychosocial support and recovery Outreach, screening and intervention programmes for trauma or related problems should conform to current professional practice and ethical standards Operational effectiveness in psychosocial recovery from an emergency event stems from effective readiness phase actions Principles of psychosocial support and recovery Cooperative relationships across agencies, sound planning and agreement on psychosocial response and recovery functions is vital Delivering psychosocial support IASC Guidelines, 2008 Human rights and equity Participation Do no harm Building on available resources and capacities Integrated support systems Multi - layered supports Challenge in matching service delivery to need assessment is key 7

9 The IASC Guidelines released in June 2008, Mental Health and Psychosocial Support in Emergency Settings: Checklist for Field Use identifies a number of core principles that should guide psychosocial interventions: Human rights and equity Psychosocial workers should promote the human rights of all affected persons and protect individuals and groups who are at heightened risk of human rights violations. Psychosocial workers should also promote equity and non-discrimination. Participation Psychosocial work should maximise the participation of local affected populations in the humanitarian response. In most emergency situations, significant numbers of people are resilient enough to participate in relief and reconstruction efforts. Do no harm Work in the realm of mental health and psychosocial support has the potential to cause harm because it deals with highly sensitive issues. Psychosocial workers may reduce the risk of harm in various ways, such as: Participating in coordination groups to learn from others and to minimise duplication and gaps in response; Designing interventions on the basis of sufficient information and evidencebased guidelines; Committing to evaluation, openness to scrutiny and external review; Developing cultural sensitivity and competence in the areas in which they intervene/work; and Developing an understanding of, and consistently reflecting on, universal human rights, power relations between outsiders and emergency-affected people, and the value of participatory approaches. 8

10 Building on available resources and capacities All affected groups have assets or resources that support mental health and psychosocial well-being. A key principle, even in the early stages of an emergency, is building local capacities, supporting self-help and strengthening the resources already present. Externally driven and implemented programmes often lead to inappropriate mental health and psychosocial support and frequently have limited sustainability. Where possible, it is important to build both government and civil society capacities. Integrated support systems Activities and programming should be integrated as far as possible. The proliferation of stand-alone services, such as those dealing only with rape survivors or only with people with a specific diagnosis, can create a highly fragmented care system. Multi-layered supports In emergencies, people are affected in different ways and require different kinds of supports. A key to organising mental health and psychosocial support is to develop a layered system of complementary supports that meets the needs of different groups. All layers of the pyramid are important and should ideally be implemented concurrently. 9

11 Psychosocial Intervention Pyramid adapted from IASC Guidelines, 2008 EXAMPLE AGENCIES THAT DELIVER Specialised psychological or social support Health and Welfare Agencies, e.g. MSD Child, Youth and Family, Local DHB / PHOs, local counseling networks Emotional support Livelihood support Basic Mental Health care Health and Welfare Agencies, e.g. MSD, Te Puni Kokiri, Victim Support, Local DHB / PHOs, local counseling networks Family contact tracing Family reunification Assisted mourning, Communal healing Child Support Food Water Shelter Accommodation Welfare Agencies, e.g. MSD - Child, Youth and Family, Work and Income, Red Cross, Te Puni Kokiri, Victim Support, Salvation Army Territorial authorities, Welfare Agencies, e.g. Work and Income, Salvation Army, Red Cross, Housing New Zealand Matching the level of psychosocial care to assessed need The well being of all people should be protected through the re-establishment of security, adequate governance and services that meet basic physical needs. Psychosocial agency intervention activities could include: Advocating that these services are put in place with responsible workers and volunteers Recording their impact upon mental health and psychosocial well-being Influencing workers and volunteers to deliver them in safe, dignified and socioculturally appropriate ways that promote mental health and psychosocial wellbeing. 10

12 The next layer of support represents the emergency response for the smaller number of people who are able to maintain their psychosocial well-being if they receive support in accessing key community and family supports. Useful responses in this layer of intervention include: Family contact tracing and re-unification Assisted mourning and communal healing ceremonies Mass communication on constructive coping methods etc. The third layer represents the still smaller group of people who additionally require more focused individual, family / whanau or group interventions by trained and supervised workers (who may not have had years of training in supervised care). For example, survivors of gender-based violence may need a mixture of emotional and livelihood support from community workers. This layer also includes psychological first aid and basic mental health care by primary health care workers. The top layer of the intervention pyramid represents the additional support needed for the small percentage of the population whose suffering, despite the supports already mentioned, is intolerable and who may have significant difficulties in basic daily functioning. This assistance should include psychological and / or psychiatric supports for people with sever mental health difficulties whenever their needs exceed the capabilities of primary health services. The Intervention Pyramid Matching level of psychosocial care to assessed need 1. Basic services and security The well being of all people should be protected through the re-establishment of security, adequate governance and services that meet basic physical needs. These needs include: Food, Water, Shelter, Accommodation etc. 11

13 Related psychosocial agency activities could include: Advocating that these services are put in place with responsible workers and volunteers Recording the impact of basic services and security upon mental health and psychosocial well-being Influencing workers and volunteers to deliver the services in a safe, dignified and socio-culturally appropriate way that promotes mental health and psychosocial well-being. The agencies that deliver these services are: Territorial authorities, Welfare Agencies, e.g. Work and Income, Salvation Army, Red Cross and Housing New Zealand. 2. Community and family supports The next layer of support represents the emergency response for the smaller number of people who are able to maintain their psychosocial well-being if they receive support in accessing key community and family supports. Useful responses in this layer of intervention include: Family contact tracing and re-unification Assisted mourning and communal healing ceremonies Mass communication on constructive coping methods Supportive parenting programmes and advice Direct child support Formal and non-formal educational activities Activation of social networks, e.g. women s groups or youth clubs The welfare agencies that can assist in delivering this sort of support are MSD - Child, Youth and Family, Work and Income; Red Cross, Te Puni Kokiri, Victim Support, Salvation Army etc. 12

14 3. Focused, non-specialised supports The third layer represents the still smaller group of people who additionally require more focused individual, family / whanau or group interventions by trained and supervised workers (who may not have had years of training in supervised care). For example, survivors of gender-based violence may need a mixture of emotional and livelihood support from community workers. This layer also includes psychological first aid and basic mental health care by primary health care workers. Health and welfare agencies that can assist in delivering emotional support, livelihood support and basic mental health care services include: MSD, Te Puni Kokiri, Victim Support, Local DHB and local counseling networks etc. 4. Specialised services The top layer of the intervention pyramid represents the additional support needed for the small percentage of the population who suffering, despite the supports already mentioned, is intolerable and who may have significant difficulties in basic daily functioning. This assistance should include psychological and / or psychiatric supports for people with severe mental health difficulties whenever their needs exceed the capabilities of primary health services. Health and welfare agencies that deliver these specialist services include MSD, Child, Youth and Family, local DHBs (Adult Mental Health Services and CAMHS) and counseling networks. 13

15 However Mid and long - term effects of large - scale disasters can include: Alcoholism Suicide Cardiovascular and other stress - related physical diseases Family and vocational problems And these may be NEW problems for these people _ Greater degree of disturbance if: 1. There is a change in the entire physical and organisational structure of a community 2. The trauma consists of more than the impact of the physical event and persists for a long time 3. There are additional subsequent traumas and disruptions that require further coping (Green, 1982) _ 14

16 Section 2: Psychosocial reactions to disasters Individual reactions For the great majority of survivors of catastrophic events, reactions will be transient, meaning a normal response to an abnormal event. In some people, resilience and positive outcomes may emerge. Groves (2007) indicated that some people involved in disaster events may experience reactions such as: Emotional responses: shock anger, irritability, and helplessness. Physical: fatigue, sleep disturbance, hyper-arousal, somatic anxiety. Cognitive: concentration, memory, intrusive thoughts, Resilience Altruism Common responses Most people will experience some psychosocial reaction, usually within a manageable range. Some may exhibit more extreme reactions in the short, medium or long term. Most people will be affected in some way by the experience of an emergency event, either directly or indirectly. However, research indicates that most people who experience an emergency event tend to recover with time. Consequently, a sensible working principle in the phase immediately following such an event is to expect a manageable trajectory of recovery for those involved, although it must be emphasised that the post-emergency life circumstances will not be as they were before the emergency event. 15

17 Following an emergency event there is a range of common transitory reactions, as outlined in Table 1. Table 1: Survivor responses in emergency situations Physical Faintness and dizziness Hot or cold sensations Tightness in throat and chest Agitation, nervousness, hyper-arousal Fatigue and exhaustion Gastrointestinal distress and nausea Appetite decrease or increase Headaches Exacerbation of pre-existing conditions Emotional Shock, disbelief Anxiety, fear, worry about safety Numbness Sadness, grief Longing and pining for deceased Helplessness Powerlessness and vulnerability Dissociation (disconnected, dream-like) Anger, rage, desire for revenge Irritability, short temper Hopelessness and despair Blame of self and others Survivor guilt Unpredictable mood swings Re-experiencing pain associated with previous trauma Source: US Department of Health and Human Services Behavioural Sleep disturbances and nightmares Jumpiness easily startled Hyper-vigilance scanning for danger Crying and tearfulness Conflicts with family and co-workers Avoidance of reminders of trauma Inability to express feelings Isolation or withdrawal from others Increased use of alcohol or drugs Cognitive Confusion and disorientation Poor concentration and memory problems Impaired thinking and decision-making Complete or partial amnesia Repeated flashbacks, intrusive thoughts and images Obsessive self-criticism and self-doubt Preoccupation with protecting loved ones Questioning of spiritual or religious beliefs 16

18 Psychosocial responses to traumatic events Dr Sarb Johal Clinical Psychologist Emergency Management Team Ministry of Health, NZ Overview Hazards & disasters types, exposure and vulnerabilities Reactions & mental health impacts Special needs groups T y p e N a t u r a l T e c h n o l o g i c a l M a l i c i o u s D i s a s t e r M e n t a l H e a l t h E f f e c t s ( f r o m U W S, ) E x p o s u r e W a r n i n g? I n t e n s i t y P r o x i m i t y D u r a t i o n I n t e n t P e r s o n a l & S o c i a l R i s k R e s i l i e n c e 17

19 The NZ Hazardscape Hazard the potential for an event to impact on individuals and communities and the social, cultural, economic and environmental resources supporting them When an event actually affects people, their activities, or the built and natural environment, consequences range from nuisance through to disaster Disaster an event when the consequences include many deaths or injuries, or extensive damage to property, infrastructure, or the environment (from Nationa l Hazardscape Report, 2007) The NZ Hazardscape Earthquakes Volcanoes Landslides Tsunamis Coastal Hazards Floods Severe Winds Snow Droughts Wildfires Animal and plant pests and disease Infectious human disease pandemics Infrastructure failures Hazardous substance incidents Major transport accidents Terrorism Food safety Types of major incidents Forewarned: anticipation, anxiety, planning war some natural disasters (flood, cyclone, bird flu) Unexpected: shock, fear, uncertainty, confusion natural disasters man-made- made disasters - e.g. transport accidents terrorism ( conventional( conventional, CBRN) 18

20 Types of Disasters Modified from Beaton (2002) Unintentional Intentional Natural Floods, Cyclones, Earthquakes, etc. Act of God Cultural / Religious Technological Biological e.g., Bhopal, Haz- - Epidemic e.g., Mat, Nuclear 1918 Power plant Influenza accident Pandemic (Three Mile Island) Chemical, Nuclear, Radiological, Explosion, Acts of Terrorism Bioterrorism Anthrax, U.S Exposures & mental health outcomes Norris, 2002 & studies, 85,000 disaster victims More severe mental health impacts More severe events Greater losses - deaths, destruction resource loss Natural disaster similar to technological disaster Terrorism more than both (2:1 ratio) Disasters: Mental health impacts Key Stressors Severity, Proximity, Injury Life threat Deaths Type - Dose response effect - II thought I was going to die - multiple, mutilating - Intentional (Norris, 2005) Reactive processes Anxiety, fear, shock, somatic, organic Anxiety, fear, shock, somatic, organic (heart rate) 1. Hyper-arousal: - Scanning for threat 2. Intrusive thoughts / re-experiencing - experiencing 3. Avoidance re events Dissociation Numbing t r a u m a t i c s t r e s s A c u t e S t r e s s D i s o r d e r 19

21 Impact of various disaster types Personal threat Traumatic stress reactions Loss of loved one Grief/depressive reactions Separation from family Anxiety reactions Specific triggers Terror reactions Traumatic Stress Risk & Morbidity Possible MH effects conditions: ASD, PTSD, Anxiety & Depressive disorders Social & Work function, presentism,, alcohol / drugs issues 75% with ASD ( ( 30 days) PTSD (Bryant, 2008) PTSD : 3.5% Population 20% + High Exposure/Violence Resilience most common Expect recovery Bereavement & traumatic stress reactions Cognitive Emotions Bereavement Focus: images of lost person Yearning Separation anxiety Anger (external) Sadness Post traumatic stress Focus: injury, death Helpless, horror, blame Anxiety threat, safety Fear Anger, irritability Arousal Scan for person Focus on further threat Triggers person Triggers startle defence 20

22 Fight or Flight Response: Effects of Stress Hormones (adapted from Stevens, UWS, 2008) Physio- logical Arousal S N S P N S SNS: Adrenaline Heart Rate Respiration Survival actions (training) Perceptions sharpen * Memory consolidation (learning) * De-arousal - system delayed Trauma memories * (Highly vivid + high arousal) Reasons: Prolonged exposure Low cortisol Psychological debriefing Y e h u d a ( ) Time Terrorism Bushfires 21

23 Resilience and Recovery Recovery implies a trajectory in which normal functioning gives way to clinical level of symptoms, e.g. PTSD or depression Resilience ability to maintain a relatively stable equilibrium stable in terms of psychological and physical functioning, though some transient disturbance Resilience is more than an absence of symptoms Capacity for generative and positive experiences Evidence bases does not really distinguish between these two groups of people can lead to confusion Though PTSD is a genuine risk, resilience is common Bonanno (2004) Prototypical patterns of disruption in normal functioning after interpersonal loss or potentially traumatict events 22

24 Response Trajectories & PTSD Symptoms after Sept 11 Bonanno, Rennicke & Dekel (2005) Time and Progress: The phases of response to disaster (Raphael, 1986) 23

25 Recovery phase The recovery phase is the prolonged period of return to community and individual adjustment or equilibrium. It commences as rescue is completed and individuals and communities face the task of bringing their lives and activities back to normal. Much will depend on the extent of devastation and destruction that has occurred as well as injuries and lives lost (Raphael, 1993). This period usually begins in the weeks post-impact. It may be associated with a honeymoon phase deriving from the altruistic and therapeutic community response in the period immediately following the disaster. A disillusionment phase may soon follow when a disaster is off the front pages, organised support starts to be withdrawn, and the realities of losses, bureaucratic constraints, and the changes wrought by the disaster must now be faced and resolved. 4 Phases During the emergency the surrounding community responds, everyone is supportive, the honeymoon phase follows and many promises are made. It is as though everyone wants to make up for what has happened and return things to the way they were before the disaster. Of course this is not possible. The extent of costs, the problem of who will pay, the time that will be required, the ongoing problems that will continue, all start to impact on those affected, bringing chronic stress which is often more difficult to deal with than the original acute experience. This period is often called the phase of disillusionment, or if it becomes entrenched and severe, the second disaster. 4 Raphael, B. (1986). When disaster strikes: How individuals and communities cope with catastrophe. New York: Basic Books. 24

26 Special Needs Groups Pre-event event risk factors: Prior trauma Female Family history Personality Low education Culturally and linguistically diverse Displaced e.g. refugees Others Others e.g. children, responders - anxiety / depression - negative emotions - resource access - inclusion Post-event risk factors: Resource loss Further life events Poor social support - resource spiral Further life events - cumulative? Flowerdale, Victoria Theage.com.au Section 3 Psychosocial Care: Individuals and Communities 25

27 Psychosocial care: individuals and communities Dr Sarb Johal Clinical Psychologist Emergency Management Team Ministry of Health, NZ Overview The impact on individuals Psychological First Aid The process of helping Helping particular groups of people Community level interventions Ordinary reactions to extraordinary events Most people will experience some psychosocial reaction Initially, typically shock and denial Gives way to: Intense and sometimes unpredictable feelings Thoughts and behaviours are affected repeated, vivid memories of the event, physical symptoms such as sweating or rapid heartbeat. Difficulty concentrating or making decisions, sleeping and eating disrupted Recurring emotional reactions are common - anniversaries, aftershocks, sounds of sirens can trigger upsetting memories and fear of repeat Physical symptoms headaches, nausea, chest pain and exacerbation of pre - existing conditions Survivor s Guilt a normal response. Difficult to be grateful to be alive and concurrently feel intense sorrow for those who did not survive 26

28 Most people will recover from an emergency with time and basic psychosocial support Time helps but recovery may not be a simple linear path and some need greater assistance Psychological First Aid Core competencies 1. Contact and Engagement 2. Safety and Comfort 3. Stabilisation (if needed) 4. Information Gathering 5. Practical Assistance 6. Connection with Social Supports 7. Information on Coping 8. Linkage with Collaborative Services Psychological First Aid Psychological first aid seeks to reduce distress and provide basic needs following a traumatic event, such as comfort, information, support and immediate practical and emotional assistance. There are eight core components of psychological first aid: 1. Contact and Engagement: To respond to contacts initiated by survivors, or initiate contacts in a non-intrusive, compassionate, and helpful manner. 2. Safety and Comfort: To enhance immediate and ongoing safety, and provide physical and emotional comfort. 3. Stabilization (if needed): To calm and orient emotionally overwhelmed or disoriented survivors. 4. Information Gathering: Current Needs and Concerns: To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions. 5. Practical Assistance: To offer practical help to survivors in addressing immediate needs and concerns. 6. Connection with Social Supports: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources. 7. Information on Coping: To provide information about stress reactions and coping to reduce distress and promote adaptive functioning. 8. Linkage with Collaborative Services: To link survivors with available services needed at the time or in the future. 27

29 Who will need most help? People reporting symptoms like restlessness, panic, sleep problems, nightmares, frequent recollection of traumatic events and emotional upset Those who remain isolated / withdrawn most of the time and show little interest in the activities going on around them Those showing reluctance to communicate when approached Those who have significant losses like death of family members How can you help? Not a one - time activity think of it as an emotional contract, a continuous and time - taking activity. Practical help Helping people pack up, spending time playing with children so adults can get on with tasks Listen you don t have to come up with solutions or answers immediately listening helps Show by words and actions that you care. Small, kind deeds mean a lot Keep helping revisit people, keep in touch A balance of empathy and structure Jing Guerrero International Federation of Social Workers Engagement is so important: Briefing and debriefing sessions for the 11 - man humanitarian contingent for Aceh were conducted. Being apprehensive of the language barrier, I couldn t help imagine how difficult it would be to provide psychosocial intervention when communication skills were impaired. I repeatedly thought about what to do to understand the residents there. In the meantime, we practiced saying some common phrases like apa kabar or how are you, selamat pagi or good morning, or terima kasi or thank you to name a few. Psychosocial support as a process 28

30 That night we conducted our first psychosocial processing on Ibu. She narrated that her husband, a high ranking official in Banda Aceh, perished together with her mother in the Tsunami. Until that time, their bodies were not recovered from the rubbles. It was a story of a wealthy family, whose grand mansion, along with bars of gold and everything in it, perished in minutes. Nothing was left of her except herself and her four children. Their life was their consolation. But they were so helpless. Ibu was not able to work for a living. She has never done so. The four children, although adults, were not raised to be independent for they were living luxuriously. For several nights, this family underwent psychosocial processing and crisis management from us. Gradually, although feelings of hopelessness and helplessness were still there, recovery was noted and the family started to talk about what they can do for their emotional and financial recovery. We became friends that Ibu would cook Indonesian food for us. Do no harm The primary overriding requirement is to do no harm Evidence - based practice is crucial Psychological debriefing or critical incident debriefing are NOT recommended and should not be offered on a routine basis Do not push disaster affected individuals and communities to conform to your way of going about things. Try to be a part of their distress Do not force them to do things or talk Children & Adolescents Risk & Protective Factors: Infants & Children - Cognitively protected - Concrete - Care giver defines threat - Loss of caregiver function - Care need signals When will the waves stop Distress Management Attachment needs, routines Crying, naughty, withdrawn 29

31 When helping a child Anxiety and fear following a disaster can be especially troubling for surviving children May see regressive behaviour, such as thumb - sucking or bed -wetting Fear of sleeping alone School performance may suffer More tantrums or withdrawal and becoming solitary Children Helpful strategies Preschool (1-5) Expression through play re-enactment Verbal assurance, physical comfort Allow short term changes in sleep arrangements e.g. light on, door open, staying with child until asleep Early childhood (5-11) Limit television of event Play sessions / discussions with adults and peers Est. routines, relax expectations Rehearse future safety measures Community - Priority re-opening of schools (( W o o d ii n g & R a p h a e l, , S A M H S A,, )) When helping a child Ensure the child is safe and being looked after by a caring and responsible adult As far as possible, do not institutionalise or adopt the child out Be sensitive to know i ng that a chi l d often finds a toy or object or photograph comforting and that they may choose to wear or carry it around with them constantly Ensure regular monitoring of children who have been orphaned where are they sleeping, what do they do during the day, do they feel safe? Arrange informal gatherings for children close - by to their families or new home bases so children have the opportunity to play and talk together Listen to children s stories Encourage young people to take up a useful role of their choice to help in the healing process 30

32 Activity suggestions 1. Facilitate expression through drawing, writing, group discussions, or using puppets or stories 2. Goal oriented activity such activities help foster confidence and directed behaviour Try collage making, or involving children in small repairs Adolescents Abstract thinking Worry, guilt Coping styles, locus of control Adapt, role? Able to articulate distress, needs Helpful strategies Resume routines Enlist - structured, undemanding responsibilities Individual attention and consideration When helping an adult Allow crying and sharing of grief Encourage the establishment of social support groups Facilitate return to normal daily routine activities Educate information about the disaster, caring for oneself and the community, health practices, reconstruction ) Encourage gainful employment in reconstructive tasks Discourage the spreading of any rumours take the initiative in ensuring good information resources are developed and disseminated 31

33 When helping an adult Activity suggestions Group Mourning let people come together and mourn the losses as a community Group Discussion - open communication and encourage people to talk and express their pain and loss. This will help to build solidarity and lessen the feeling of I am the only sufferer Cultural community activities such as songs, participation in rituals etc Encourage relaxation and exercise When helping older adults Ensure medical aid and physical well -being Guard against extreme feelings of hopelessness and helplessness Encourage healthy grief reactions Allow elders to talk about their fears and anxieties Encourage group meetings with other older survivors Encourage participation in community decision - making and care When do you need to seek further assistance / refer on? Extreme agitation, particularly if it leads to act i ons that are life threatening to the self or others Overt psychiatric disturbance requiring care i n its own right, for example, psychotic decompensation Prolonged denial of reality. Some shutting out of what has happened is natural in i tially but some are likely to need specialist care Persons d i stressed by overwhelming bouts of anxiety, dread, or panic when the danger has long since passed Depression and prolonged low self-esteem Although suicide is not that common after disaster, one should be alert to the possibility that feelings of hopelessness may be associated with this level of despair Body complaints particularly mild, ill - defined and chronic complaints such as l i stlessness and headaches, often accompanied by irritability and sleep disturbance Disturbed interpersonal relationships Post Traumatic Stress Disorder 32

34 Summary 1. Adaptation, resilience are the norm 2. Convey positive expectations 3. Support optimal de-arousal- arousal 4. Longer-term - mental health effects for some The Canberra bushfire event: 18 January 2003 A devastating firestorm Four people died, 3 badly burned 500 homes destroyed Extensive damage to neighbourhoods, gardens, businesses Death and injury to livestock and pets 5,000 people fled in fear for their lives and the lives of loved ones Little warning Severe psychological exposure (threat to life, injury and extreme loss) Recovery Services model Evacuation Centres in ACT colleges Bushfire Recovery Task Force ACT Bushfire Recovery Centre Early days outreach teams included counselors Recovery Centre staffed with personal support workers (k/a Recovery Workers), counselors and community organisations Counselors there from the beginning 33

35 Recovery Workers Social workers, youth and community workers, community nurses Organised in geographical teams Caseload of affected households Assess social, emotional, financial, practical needs Linked to all services/grants available; strong advocates/brokers Advised Task Force on emerging needs Counselors Mental Health Practitioners Provided by ACT Health (Community Care and Mental Health); then Relationships Australia A specialist children s counselor Initially provided personal support and psychological first aid in evacuation centres Later, applied their therapeutic skills Recovery Workers and Counselors the partnership Recovery workers normalized the effects of disaster When those effects impinged on daily functioning, recovery worker sought client consent to consult a counselor Recovery Worker consulted with counselor; or Recovery Worker referred to counselor and they worked jointly with client; or Counselor worked with client alone Strong word of mouth referral system - clients recommended a counselor to their friends/loved ones 34

36 Early presenting conditions Everyone in the family feeling out of whack Sleep disturbance, loss of appetite, mood disturbance Anxiety, sadness, feeling flat Grief for lost homes and neighbourhoods Anger at lack of warning Children clingy; obsessive play about fire Children reflecting their parents anger Intrusive thoughts, visual and auditory flashbacks of the fire Relationship issues What happened on the day e.g. you should have.. Caught in crisis, personal guilt and regret Stress around crucial decisions e.g. rebuild or move elsewhere; multiple household moves; putting off retirement to recoup financial losses Psychological education Recovery Centre invited psychologist to address large community meetings What people can expect to be experiencing short and long term For some a turning point for understanding feelings and experiences still quoted Parenting After Disaster as a means to engage 35

37 Outreach Many showing significant emotional distress Did not believe they needed help Felt they were better off than most Felt overwhelmed and isolated Felt numb for a while Did not realise they were in need of assistance Recovery Workers case workers and community workers In partnership with affected communities, Recovery Workers organised events / opportunities for people to catch up and share Slicing the community Analysed the community in different ways Streets, neighbourhoods, suburbs, schools Age and interest groups Children, over 70s Parents who had babies just before, during and just after the disaster Outreach events Regeneration Walk Parties in the Park Children s Art and Writing Competition Children s camp Boat cruise for over 70s Parenting after Disaster Rural men s BBQs Role of the counselor at these events Moved amongst the crowd, picking up signs of people needing follow up Often directed by family and friends to certain distressed people Engaged, built trust, created comfort in making contact with the counselor 36

38 Effective Counselors Flexible and robust Comfortable working outside the office Psychological first aid and psycho - education on a park bench or holding a drink at a BBQ Happy to follow up quickly No waiting lists Happy to work alongside volunteers, other professions Key success factor 1 Counseling was an integrated part of the recovery service from the very beginning Disaster recovery counseling committee part of the Community Recovery Committee Counselors part of exercises in peace time Counselors were in the recovery service from Day One, providing psychological first aid, practical support Key success factors 2 & 3 The organisational issues were sorted out early A unique organisation was established for the event (the Task Force) Counselors were part of that organisation Task Force met regularly with the donor organisations (ACT Mental Health and Relationships Australia) re staffing, issues and resourcing Outreach was used as a key strategy Outreach was active, creative and done in partnership with the community As a result, many hard to reach were engaged in counseling 37

39 Lessons from Matata Small coastal community in Bay of Plenty Population 759 NZDep2006 = 9 18 May 2005, 124mm fell in 90mins 300mm rain in 24 hour period Severe flooding caused major debris avalanche through town Closure of main road and railway, 27 houses destroyed Damage to 87 other properties Evacuation of 538 people 750,000m 3 debris deposited Disruption to water, electricity, stormwater and septic tank systems Immediate response Recovery structure set up within week of event Based on experiences of 2004 BoP floods and MCDEM Guidelines One - stop shop welfare advice centre operating from Matata Community Resource Centre for 1 month Included MSD, WDC, and VS Other supports could be accessed directly if required, e.g. Community MH and IRD However: Response was efficient but focused on physical recovery and reducing further exposure to hazard Emotional needs were not being addressed Perception developed amongst residents that their needs were being ignored Responding to the Community Sept 2006 Community did not support proposed mitigation works Increased rates of $3K - $7K per year WINZ Social Development Regional Manager organised community planning day in October 2006 Based on feedback, developed work programme See Kellie Spee s report for more detail GNS Science report 2008/12, March

40 Success factors in disaster recovery 1. Initiatives supported by community and they take a lead role in implementing them 2. Use established community and social structures 3. Treat problems proactively and early 4. Provide emotional and mental health follow - up 6-9 months after the disaster to the community 5. Provide occasions for recognition of the disaster and suffering 6. Community rallying together after the disaster 7. Community reference / working group 8. Support from family / whanau & friends 9. Formal disaster recovery plan Barriers to disaster recovery 1. Limited knowledge and understanding of disaster and their likely impacts 2. High levels of trauma in the community 3. Inappropriate responses 4. Lack of skilled and trained people within organisations that are responsible for responding to disasters 5. Restricted leadership 6. Limited involvement of mental health services and / or professional organisations 7. Incomplete holistic response 8. No allocated funding base and lack of clarity about whose responsibility long - term psychological disaster recovery is 9. Limited operational / implementation guidelines for holistic disaster recovery 39

41 Section 4 Self-Care, Staff, and Organisational Concerns Taking care of staff and yourself Dr Sarb Johal Clinical Psychologist Emergency Management Team Ministry of Health, NZ sarb@equanimity.co.nz _ Intervening agencies bring additional human capacity and physical resources but also their own culture and values own social and organisational networks. The degree of fit between the intervening agency and affected communities is important as a key concept The fit between your understanding and others in your organisation is another challenge The process engaged in by communities impacted by emergencies is often referred to as recovery and restoration restoring previous human capability, social ecology, culture and values and physical resources Best conceived as transformation where social structures, relationships between groups, cultural rights and values are all subject to readjustment. _ What happens when organisations don t fit together? 7 July Assistance Centre one stop shop Run by bereavement counseling service, but rift occurred with NHS Screening Team Not smooth for the client August 2005 NHS mass screening unit NHS Trauma Response (London Bombings) Screening Team Purpose screen for indicative symptoms of psychiatric disorder such as PTSD or clinical depressions then assess, monitor and refer as necessary 2 centres in operation _ 40

42 Two centres shared vision? From Aug 05 Nov 05 Assistance Centre routinely directed all people to Screening Team Bereavement Service took over contract in Nov 05 Number of people directed to Screening Team dropped dramatically Evaluator questioned this Concluded it was due to compassionate concern for service users, esp. as those previously directed to screening service had been disappointed they had not been offered treatment for their symptoms Centre believed counseling should be for all? _ Staff and Self Care Some challenges 3 factors seem to predict impact on workers: Level of exposure to trauma Environment factors, including working conditions and management practices Individual factors, such as worker perceptions, personal coping and stress reduction practices, personality and applicable training and expertise Effects can include compassion fatigue, vicarious traumatisation and empathetic strain - burnout SARS tells us that the stigma in being involved in an emergency response can be lasting _ Some solutions A clear organisational structure with defined roles and responsibilities has been shown to reduce psychosocial effects Educate workers about normal stress reactions and importance of stress management helps workers to anticipate and manage their own response Consistent adherence to occupational safety controls, for example, workers should do no more than 12 - hour shifts and should be rotated through high -, mid - and low - stress tasks If you re in a leadership role demonstrate leadership through using this information and applying it to yourself _ 41

43 Seek professional help or a supportive group when: You feel persistently uncomfortable You believe that improvement is impossible or the situation is hopeless When there are obvious changes in speech, appearance or behaviour including memory confusion or hallucinations or delusions When you are so emotional you cannot communicate effectively There is ongoing physical and emotional deterioration You only discuss physical complaints There is increased drug or alcohol intake There are threats of self - harm or harm to others There is aggression and / or abuse If the situation seems horrible or unbearable Or, if you re unsure _ Some tips on communicating with the public _ Threat Perception Decision Pathways (thanks to Stevens, UWS, 2008) Risk Comm. Cue (threat) Cognitive Evaluation Feeling State Decision Adapted from Lowenstein 2001 Behaviour Outcome (incl. emotions) _ Low threat pathway High threat pathway 42

44 Threat Perception Threat Altered Decision Pathways Frontal Cortex & Amygdala - Analytic vs. Experiential Processing Risk as Feelings Goal: Minimise extreme feeling states ( De( De-arousal- arousal ) Rationale: Outcomes: Threat processing Trauma memories Stress / Performance curve (performance band ) Concentration, Problem solving Task Performance Co-operation - operation _ Risk Communication Goals: Message Decision-relevant - information & reduce stress Acute Simple, repeat often What do I do now Message relative to action Manage risks well to have credible message Co-ordinated, - consistent Two-way - citizens as risk management partners (Fischoff, 2006) Messenger Leadership Trusted source Emergency service workers most trusted (Lemyre,, 2005) _ Coordination and Operationalisation Leadership and coordination across agencies at National, Regional and local levels is crucial to prepare for response and recovery How well do you know who you will be working with? Liaising with? Drill. Drill some more. And then do it again. Are you aware of a Psychosocial and Mental Health Disaster Plan in your organisation or area? What can you be doing to prepare? Prov id i ng psycholog i cal and counsel li ng serv i ces Ma inta in i ng core psychosocia l, menta l health and commun i ty hea l th services Prov is i on of consu ltat i on and assistance w i th cris i s counsel li ng services for affected persons Prov id i ng psychosoc ia l expert i se at a s i te and i n Emergency Co -ord inat i on Centre i n the event of a pro l onged event Prov id i ng adv i ce and support w i th D i saster V i ctim Ident if icat i on and the menta l hea l th aspects of hand l ing relatives and friends of the deceased Prov id i ng adv i ce and support serv i ces i n the event of evacuat i on of a community Deve l oping pub lic informat i on mater ia l for uti l isation by psycho logica l and counse lli ng serv ices _ 43