by Cynthia Cotter, Ph.D.
President, San Diego Psychological Association
Welcome to the second issue of The San Diego Psychologist for 2018!
This issue includes articles featuring the presentations from our 2018 SDPA Spring Workshop held this past May 19th, entitled Preparing for the Unthinkable: Mental Health Provider Roles in Disaster Recovery. This was the inaugural event of this title produced by the SDPA Disaster Psychology Committee co-chaired by Deborah Hopper, Ph.D. and Robert McGlenn, Ph.D.; it included remarkable national and local experts in disaster response and was hugely successful. The Committee is currently marketing the event to other organizations and is offering assistance to organizations so that more events of this type might be produced. If you are interested in these efforts, please contact the Disaster Psychology co-chairs. Special thanks to Mary Mulvihill, Ph.D. for being the guest editor of this important issue of The San Diego Psychologist.
We have recently launched our SDPA Fall Conference for this year, which will take place on October 27th, 2018; early bird registration extends to September 30th, so REGISTER NOW! The event entitled, Encountering Substance Use in Clinical Practice: Emerging Issues and Divergent Perspectives focuses on the very timely topic of problematic substance use. There has been a rapid increase in the use of prescription and non-prescription opioid drugs in the U.S. over the last two decades. Drug overdoses have become the leading cause of death of Americans under the age of 50, with two-thirds of those deaths from opioids. Behaviors related to alcohol abuse and alcoholism in the U.S. have also become much more serious. The speaker list for this year’s conference is sterling: Our keynote is George F. Koob, Ph.D., Director of the National Institute on Alcohol Abuse and Alcoholism. Beth D. Darnall, Ph.D., Clinical Professor, Department of Anesthesiology, Stanford University Medical School will present on the dual crises of pain and prescription opioids. We are excited to have investigative journalist Sam Quinones, author of Dreamland: The True Tale of America’s Opiate Epidemic speak on the sociocultural roots of the current opiate crisis. Other topics presented at the conference include marijuana post-legalization, addiction and personality, working with people of color in substance use treatment, support for families of substance users, and understanding relapse. Divergent perspectives on intervention/treatment are presented. There will also bespecial musical presentations. Please join us for our most exciting SDPA Fall Conference to date.
SDPA is pleased to announce that it will be a Platinum Sponsor for the 2018 NLPA (National Latina/o Psychological Association) Conference to be held from October 18th-21st 2018 at the Hyatt Regency La Jolla at Aventine. We are fortunate that this conference is local this year; please don’t miss the opportunity to attend this amazing national event.
If you are already an SDPA member, we are so happy for your participation. If you are not, there is no better time to become a member. Members receive many benefits and discounts, including lower registration fees to the 2018 SDPA Fall Conference. Join SDPA NOW! We hope to see you soon.
The San Diego Psychologist is grateful to Dr. Mary Mulvihill of the SDPA for guest editing this important issue based on the SDPA Spring Workshop entitled, “Preparing for the Unthinkable: Mental Health Provider Roles in Disaster Recovery.” She was responsible for curating the content, gathering and writing the transcripts, and doing the initial edits for this issue. She has written the Editorial for this issue.
The featured articles in this issue are not verbatim transcriptions of the authors’ presentations. The transcriptions have been edited for content, length, copy, and grammar for the purposes of this publication.
Please give us your feedback in the comments section of this or the other articles in this issue, and as always, thank you for reading.
Gauri Savla, Ph.D., Editor, The San Diego Psychologist
The San Diego community is on the leading edge of disaster response. In 1984, a McDonald’s restaurant in San Ysidro, a border town in San Diego was the scene of one of the earliest mass shooting incidents in our country’s recent history. Twenty-three people, including many children, were killed by an active shooter. This incident caught the Disaster Response community completely off guard, since mass shootings were rare at the time. After careful study of the emergency response to the event, ways to minimize casualties in similar events were devised in order to increase readiness. Some of the changes instituted included having SWAT teams carry their weapons with them in their vehicles for faster response, and developing robots to retrieve the wounded from the disaster site when unsafe for medics to do so. These “lessons learned” were applied nationwide to different extents, but particularly here in San Diego, where a shocked and saddened community took the need for improved disaster response seriously. Every disaster, although unwelcome and terrible, is an opportunity to study potential challenges and find ways to anticipate and solve them when the next disaster occurs.
The lessons learned from this and other incidents that followed have informed the “best practices” in the field of mental health disaster response field. The current issue of the San Diego Psychologist highlights the program from the SDPA 2018 Spring Workshop, Preparing for the Unthinkable: Mental Health Provider Roles in Disaster Recovery. The goal of the workshop (and this issue of The San Diego Psychologist) is to help you understand how the local San Diego County disaster response system works, where you fit in, and how you can help as mental health professionals.
The workshop was carefully planned and executed over 18 months by the Chair of the invaluable SDPA Disaster Psychology Committee, Dr. Deb Hopper and her team, which included SDPA members, Dr. Bob McGlenn, Dr. Glenn Lipson, Dr. Wendy Tayer, and Mr. Bo Robertson. Based on their knowledge of the field, they determined the agenda and assembled a first-rate team of speakers. They were also integral to the preparation of this issue of The San Diego Psychologist.
The conference, held on May 19th, 2018 at West Auditorium at Scripps Mercy Hospital was a tremendous success, attended by 90 mental health professionals and graduate students. The dynamic speakers, all experts in the field of Disaster Response, were led by keynote speakers, Drs. Chip Schreiber and Melissa Brymer. All speakers had extensive, first-hand experience on the front lines of many recent local and national disasters.
Dr. Schreiber is one of the nation’s leading “second responders,” i.e., the mental health professionals participating in the recovery efforts on site. Dr. Brymer was the lead mental health professional in the 5-year post-Sandy Hook school shooting recovery effort, as well as many other school and workplace shootings across the country. She also worked with Dr. McGlenn as a second responder after the shooting at Santana High School in Santee, in 2001.
From our local resources, Ms. Crawford, head of San Diego County’s Emergency Response Command Center, is the one who takes command instantly when local disasters strike. She is capable and knowledgeable, and we were fortunate to hear her speak at the workshop. Dr. Lipson has extensive experience in our local Red Cross shelters and shared many tips about what to expect and what is most helpful in the immediate days after an event. Dr. Tayer applies the CBT model to explain why people do what they do when challenged by a disaster and the pitfalls of stress-induced, maladaptive thinking that one must be aware of. Dr. Hopper shared excellent, pragmatic tips on how to prepare for a disaster and cope when the “unthinkable” happens, both at home and work, including with our clients.
If you were not able to attend the event or if you just want to review some of the informative training provided, this issue of The San Diego Psychologist is for you. Through this issue, the experts in the mental health disaster preparedness field, will answer many of your questions about how you can prepare yourself, your family and your practice for the “unthinkable”.
We hope that you will be inspired to take a leadership role in your own community to help prepare and if needed, respond, when your mental health skills and expertise are called for.
Please refer to the list of Resources, compiled by the SDPA Disaster Psychology Committee, for additional, up-to-date disaster preparation and response information and the list of local mental health-related disaster response organizations, should you be inspired to consider the volunteering options available to mental health professionals.
Mental health professionals play a vital role Disaster Preparedness, Response and Recovery – be part of the solution!
Mary Mulvihill Ph.D.
SDSU Graduate School of Public Health
Guest Editor, Disaster Preparedness Issue of The San Diego Psychologist
Preparing for the Unthinkable: Mental Health Provider Roles in Disaster Recovery
Proceedings from the SDPA Spring 2018 Workshop
by Bob McGlenn, Ph.D.
Former Director of Santana Recovery Project and Trainer for National School Safety Center
The world is changing.
Thanks to global warming and climate change, in 2017, the United States suffered unprecedented damage from tornados and hail in the Midwest and freezing temperatures in the Southeast. These natural disasters, along with the three category 4+ hurricanes caused an estimated total damage estimated of 300 billion dollars. The California Wildfires caused losses of an estimated 65 billion dollars, not including the costs of land destroyed, homes lost, and human and animal death and injury.
Then there are the effects of “manmade” disasters, i.e., acts of terrorism, both foreign and domestic. In 2017, an attacker in New York City drove a vehicle into people on a bike path killing eight and injuring 12. In Sutherland, Texas a terrorist entered a church during Sunday worship and killed 27 and wounded 30. In Las Vegas, a gunman opened fire on thousands of concert-goers, killing 59 and physically wounding another 527; the psychological trauma suffered by thousands of survivors does not even feature in the toll of lives lost and maimed.
And that was just 2017. In 2018 so far, there has been an average of one school shooting a week. The most prominent being the Parkland shooting which killed 17, wounded 14, and started a movement.
Is this the “new normal”? Are we ready for it?
Do you know who IS ready? The first responders: the fire fighters, law enforcement officers, medical personnel, etc., are the ones who are ready. They learn from each event and then train and practice and prepare for what comes next. We rely on them to save us, rescue us, and guide us through the initial tragedy. They are the first responders. We rely on them being ready.
But what about the “second responders,” i.e., US, the mental health providers?
Yes, we mental health providers, are indeed the second responders. We are the practitioners who, when a disaster occurs, will be comforting the grieving, treating the traumatized, and creating order out of chaos. As second responders, we have a valuable role in the recovery of our community, short and longer term. We will be there after the first responders leave. It is our job to put the confused and emotional, metaphorical “Humpty Dumpty” back together.
Are we, the second responders, as prepared as the first responders? That is the question that the Disaster Psychology Committee of the San Diego Psychological Association asked itself over a year ago and concluded that no, we are not. The Disaster Preparedness Conference was first conceived in response to this insight into our lack of preparedness. It was designed to serve as an introduction to the preparation and training of second responders. In order to provide excellent, timely mental health disaster response intervention that might make a more lasting impact on recovery.
There here are some fundamental questions that we were unable to answer on the day of the conference and will not answer in this issue either: It is not a question of IF a disaster such as a major earthquake, wild fire or terrorist attack occurs in San Diego, WHEN it will occur and WHAT will it be.
The topics covered in the Workshop are listed below.
Lessons from the Field: Toward the Way Forward in Mental Health Disaster Response by Merritt “Chip” Schreiber, Ph.D.
Responding to the Needs of Children and Families after Mass Violence and Disasters by Melissa Brymer, Ph.D., Psy.D.
Disaster Preparedness 101 (Part 2): How to Get Ready at Home and in Your Practice in Four Simple Steps by Deborah Hopper, Ph.D.
Kindness: Poem by Naomi Shihab Nye
***Editor’s Note: The featured articles are not verbatim transcriptions of the authors’ presentations at the SDPA Workshop on “Preparing for the Unthinkable: Mental Health Provider Roles in Disaster Recovery.” The transcriptions have been edited for content, length, copy, and grammar for the purposes of this publication.***
Dr. McGlenn is a clinical and school psychologist who, in addition to maintaining a private practice since 1977, has experience in a variety of mental health areas. He has worked as a school psychologist at both the elementary and secondary levels, trained and supervised doctoral level interns at area psychiatric hospitals and community based clinics, and consulted with a residential treatment center for severely disturbed adolescents. Dr. McGlenn designed and directed the implementation of the crisis response plan to the Santana and Granite Hills High School shootings in March 2001. He served as Coordinator of the Santana Recovery Project, which provided services and treatment to those traumatized by the event. Since the incident he has spoken to numerous groups concerning school safety, treatment, and violence prevention and has worked for the National School Safety Center as a trainer for the Community Oriented Policing Services (COPS) program and as a consultant to the Department of Homeland Security. In 2009, he released his first book, Winning at the Card Game of Life.
by Holly Crawford
Ms. Crawford, San Diego County Disaster Manager, explained her critical role of coordination and communication when disaster strikes, a complex effort often overlooked by the public. Two critical components of her job are (1) to provide accurate, consistent information to the public about what is happening/what to do, and (2) to conduct the planning & management of the evolving needs during a disaster. This includes such practical considerations as how many shelters are needed & where, whether facilities for large animals are required, etc. This crisis leadership requires good situational awareness, necessary to make & act on decisions even if information is limited, as it often is during a developing emergency. Ms. Crawford is an experienced County employee, with an incisive mind, the ability to think on her feet and a “can do” attitude, which give her excellent credibility in taking command of an emerging disaster situation.
Fires comprise our number one local disaster risk. San Diego County is rather advanced with respect to disaster preparation, thanks in part to the terrible Cedar Fire in 2003. A silver lining to this event was that needed changes to local disaster response were identified, based on the problems encountered. Some of the same issues that San Diego faced during the Cedar Fire were faced by Sonoma/Napa during their recent fires, since they had not experienced a large scale fire for a long time. These disaster system management changes included having all ER personnel use the same radio frequency, development of the “reverse 911” notification system for evacuations, increased fire-fighting air assets, and training of County employees to immediately staff shelters. An emergency chaplaincy program is now run out of Rock Church, to provide spiritual support. Also, more effort is now directed to individuals with special access and functional needs, such as those with disabilities. San Diego is also now the site of the Regional Terrorism Threat Center.
The challenge in past disasters has been primarily how to get information to and from the public during the event. However, with social media being the primary source of information these days, the challenge has to do with how we can sift through a massive amount of information of varying accuracy efficiently. Since San Diego has minimal notable weather events, most of us do not follow the weather channels commonly used in other cities to keep the community informed. During disasters, the 911 system typically gets overwhelmed mainly by “missing person” inquiries, so there is an effort underway to shift this function to the 211 system. Simply by employing an “out of state” and a “local” central contact for your family, you may be able to avoid contributing to this traffic jam by having your own points of contact to reconvene your loved ones in a disaster.
For personal notification, the Wireless Emergency Alert system is built into your phone’s chip, so you will get automatic bulletins from extreme weather and other emergency alerts in your area (National Weather Service), AMBER alerts (in cases of child abduction, sent by the National Center for Missing and Exploited Children), and Presidential alerts in a national emergency. For specific local Information, the SD Emergency App can be downloaded to your phone to provide guidance for disaster preparation, response, and convenient, pop-up disaster notifications.
It is also critical to register your mobile phone with the County for emergency notifications (reverse 911). Your residential landline is automatically enrolled, if you still have one, but no mobile phones unless you request it. Register your mobile phone for the SD County Emergency notification system by going to the Alert San Diego website online. This is important, as you never know where you will be when disaster strikes. Finally, make sure you have a phone which does not require electrical power or cell phone towers, (which may go down during a disaster), to operate. Everyone needs to own one phone which plugs directly into the phone cable socket, which can be obtained at Goodwill for a few dollars.
Ms. Crawford is Director of the County of San Diego Office of Emergency Services, which is responsible for alerting and notifying appropriate agencies when disaster strikes, coordinating all agencies that respond, ensuring resources are available and mobilized, and developing plans for disaster mitigation, preparedness, response and recovery. Ms. Crawford led the Emergency Operations Center during the December 2017 Lilac fire, the May 2014 San Diego County fires, the Joint Information Center during the September 2011 blackout, and she directed the communications team who responded to H1N1 in 2009 and the San Diego County measles outbreak in 2008. Crawford also played a leadership role in the Emergency Operations Center during the 2007 federally declared wild land fire disaster.
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by Merritt “Chip” Schreiber, Ph.D.
Dr. Schreiber, a child psychologist and expert on disaster response, discussed current issues in disaster response from a national perspective, based on his work as the CPA Disaster Response Network Coordinator (DRN) and a Red Cross volunteer, and his vast experience deploying to major national disasters for many years. The CPA DRN is based on the local jurisdiction of the 57 counties in California. He drew attention to the DRN member from San Diego, Dr. Deborah Hopper, who is the current Chair of the SDPA Disaster Psychology Committee.
Dr. Schreiber noted a number of concerns for the direction of the disaster response field related to mental health (second responders). Often, disaster response operations tend to be “one size fits all,” when in reality, individuals vary in their needs, based on many factors. It is still not completely clear where mental health professionals fit in with disaster response, per se. The focus remains on acute response, rather than prevention or the aftermath.
Dr. Schreiber pointed out that as clinicians, we tend to focus on individuals rather than populations. Disaster work is optimized by a clear understanding of population groups in the ways in which people respond to disasters. Certain subgroups of the population tend to respond differently to disasters than others, e.g., those who have faced disasters in the past. 30-40% of disaster victims can develop new mental health disorders after experiencing such an event. Yet, many people are resilient and able to return to their baseline functioning after enduring “transitory distress.” Symptoms may resemble post-traumatic stress disorder, but much of the symptomatology is sub-clinical. People tend to fear disaster recurrence, which may trigger symptoms again, but this fear tends to fade over time.
When disaster strikes, a large number of mental health providers and volunteers of varying motive and skill simply show up, and they need to be coordinated. There are increasing efforts to automate this process online. The response to the recent Hurricane Harvey was so large, that it crashed the online mental health volunteer system. Over 5,000 volunteers deployed to this event, even though the site was quickly taken down when capacity was reached. Dr. Schreiber, due to his experience, is often responsible for the assessment and coordination of mental health volunteers on site. It is necessary to appropriately “vet” these individuals before sending them into the field to manage the affected public. Once selected, volunteers may need guidance or targeted training. Much of what has been learned about disaster response and its aftermath comes from a 12-year follow up study after 9/11, conducted by the National Institute for Occupational Safety and Health (NIOSH) within the Centers for Disease Control and Prevention..
There are two main pathways after a disaster: (1) the Acute Disaster Response and (2) the Later Response, both significant to recovery. The severity of the disaster is also important. Extreme, widespread disasters are a great equalizer since most people are greatly challenged simply due to local conditions. In a more moderate intensity disaster, individuals with prior trauma, depression, mental health issues or recent stress may be particularly at risk.
Following the disaster, anyone exposed to an event is now considered vulnerable in future disasters, since experiencing the event will comprise a new mental health risk factor. He noted that most mental health providers are trained to “chase tears” during a disaster, but the most helpful effort may actually be to identify those survivors who are at highest risk and steer them toward the appropriate services. He labeled this phenomenon “triage vs. secondary assessment.” The interventions for these high risk individuals may vary greatly, depending on their needs. Generally, only 25% of those affected receive timely care, a statistic that can be improved with targeted training.
Dr. Schreiber noted that American disaster response teams have not learned from their international colleagues who seem to do a better job connecting victims with appropriate resources. He perceives a huge gap in the US between provider capability and awareness that further mental health intervention is available and may be helpful post-disaster. With low awareness and few referrals for follow-up services, mental health care services for many people after disasters is inadequate. He emphasized the need for systematic secondary screening of victims and the “alignment of intervention intensity” to relative risk and resilience among population groups, thereby countering the “one size fits all” approach. He called for the development of strategies to treat population groups for the identified reactive pathways after a disaster to further extend secondary prevention efforts.
Another important element is to protect volunteers (and first responders) from undue exposure to traumatic scenes. Repetitive, sensational media coverage is a hazard for disaster workers as it may detract from efficacy on the job. Dr. Schreiber stated that he avoids consuming any disaster-related media while deployed, in order to preserve his energy and focus for what he must do at the scene. Obviously, one will invariably be exposed to incidental trauma while on site, but the policy of limiting one’s media consumption will serve to minimize the emotional repercussions of this work. Although the majority of first responders are resilient during/after the disaster, approximately 10% may develop adverse mental health sequelae. Some of them may have had predisposing risk factors, such as recent emotional stress or depression.
As Dr. Schreiber summarized, recovery intervention efforts do work and are worth undertaking. After 9/11, there was a $100 million effort to conduct crisis counseling, which was unprecedented. From a Public Health perspective, even if individuals are only slightly impaired, and their work, only mildly affected, when this impact is multiplied across the population affected by a large scale disaster, the economic loss and human suffering is substantial and significant. Unfortunately, no matter how much care is taken, we are bound to miss many people after a disaster who need and might benefit from intervention. Identifying and reaching everyone who needs assistance after a disaster is one of the biggest challenges going forward.
Dr. Schreiber is a Professor of Clinical Pediatrics in the Department of Pediatrics at Harbor UCLA Medical Center and the David Geffen School of Medicine at UCLA. He serves as subject matter expert for the US Department of Homeland Security Interagency Advisory Board on first responder issues in terrorism and disaster response. Dr. Schreiber’s current work is focused on the development models of “stepped continuum of mental health care” in mass casualty disasters, terrorism and injury trauma for both adults and children in a public health context and enhancing disaster medical responder resilience to large and small events.
Dr. Schreiber created the PsySTART Rapid Mental Health Triage and Incident Management System for rapid identification of at risk victims and emergency responders in mass casualty events. He is the founder of the Psychological First Aid program provided to family members and friends by each other called “Listen, Protect and Connect.” He has also developed the “Anticipate, Plan and Deter,” a disaster responder resilience system, currently in use in various counties in California and several other states. He was appointed by the US Secretary of Health to the Emergency Public Information Advisory Committee (EPIC) as the sole behavioral health subject matter expert. Dr. Schreiber serves as mental health team lead for NDMS/DMAT CA-1 and is regional disaster mental health advisor for the American Red Cross in Southern California. He is a member of the California Disaster Mental Health Coalition and Chair, Disaster Response Network for the California Psychological Association. He is a member of the California Department of Health, Emergency Preparedness Office Advisory Committee.
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by Melissa Brymer, Ph.D., Psy.D.
Dr. Brymer is the head of the National Child Traumatic Stress Network, which promotes best practices for pediatric trauma recovery. The nationwide network comprises 87 sites, including Rady Children’s Hospital in San Diego. Between natural disasters, violence & terrorism, there have been many such events in recent years which have exposed children to extreme events, including mass violence. The technical definition of mass violence is “an intentional violent crime which causes physical and psychological injury with at least four casualties, which increase the burden of victim assistance & compensation.” School shootings and mass casualty events may not necessarily be the same thing (although colloquially, they are often conflated as such). Dr. Brymer pointed out that only eight of the last 22 school shootings met the full definition of a mass casualty event. For example, there are many school shootings where, thankfully, no one is injured.
Dr. Brymer discussed some recent mass casualty events to illustrate how each event is unique and presents different challenges for recovery. Each event has the potential to change perceptions & beliefs of professionals involved in the disaster field as well. For example, after Sandy Hook, it was realized that elementary schools are not necessarily safer or immune to violent events. After Parkland, we now appreciate that students exposed to a school shooting can be fierce and effective advocates for better safety, and that this may help them heal. It is necessary for the mental health responder to know something about the community history, the unique features of each event, and relevant cultural traditions/rituals, to be able to identify those individuals at highest risk, and interventions which might be effective.
The first example discussed was the shooting at Sandy Hook Elementary School, where the perpetrator was an ex-student, during what appeared to be the most positive part of his life adjustment. He returned to where he felt comfortable to enact his violence. The doors were securely locked, but he shot off the lock. Although no one knows how this happened, since no one realized the school even had an intercom system that could even be used, this system was accidentaly turned on at the start of the attack. This exposed all the children to the horrific sounds of the violent attack, extending the trauma well beyond the affected classrooms.
Another example discussed was the Festival 91 Harvest Concert in Las Vegas, which was unique since its impact was not confined to Las Vegas, where the attack took place. In fact, 62% of ticketholders were from California, and quickly scattered after the event, without access to organized intervention. The sheer size of this event (59 killed and 527 injured)was unprecedented. There are still so many questions unanswered about the perpetrator, which is unusual. No motive has been put forth to explain his actions, posing a challenge for assembling a coherent narrative, essential for healing. Many “first responders” in this event turned out to be taxi drivers or random passersby who were not formally trained EMTs, thus putting them at risk. Dr. Brymer noted that it is important to remember that first responders and providers have their own grief after the event, not just victims’ families and survivors. Memorials and community support provide valuable support to all individuals affected in the community.In this event, the tragic loss of the Sandy Hook principal, vice principal, and school psychologist, wiped out the administrative “brain” of the school, so survivors had to cope with the loss of people they loved and with the loss of their institutional memory which helped the school function smoothly. Since children/teachers were relocated to another town while the school site was investigated, then razed to the ground and rebuilt, the school community members were “refugees,” in that they could not follow their usual, convenient routine for four years. Familiar routines are helpful to children’s coping with a trauma. For example, the UN supplies a “School in a Box” to refugee sites, so disaster responders can get children in shelters and refugee camps into positive, structured educational routines as soon as possible.
To illustrate a different type of event, the San Bernadino workplace shooting incident was also discussed. This incident occurred at a holiday party/meeting of the County Public Health Department. One of the victims’ co-workers and his wife were the perpetrators; one the perpetrators being someone they had worked alongside for five years and thought they knew compounded the confusion and grief caused by the incident. The victims’ County EMT co-workers were the first responders, called upon to help their colleagues. The Public Health Department’s work unit moved to a temporary location while their former office was remodeled so that the perpetrator’s familiar cubicle was not part of their environment as before. This physical disruption adds to the coping burden for survivors.
Dr. Brymer then presented the Five Steps for Mental Health Disaster Recovery, according to the current National Child Traumatic Stress Network (NCTSN) model, developed out their extensive experience with traumatic events.
In this model, the general approach to disaster response always starts with Re-establishing Safety. Besides the direct risk from the violent event, there may be new safety risks or severe adversities after the event (for example, in shelters or getting to them). Both victim/survivor specific and community-wide safety measures are often needed. Extra law enforcement brought on to the scene must be encouraged to approach the survivors with sensitivity, as their presence may feel intrusive to some vulnerable groups. For example, after Sandy Hook, implementing a large police presence on a daily basis among elementary school age children involved thinking through how not to frighten them further. As it happened, someone donated hundreds of small rubber ducks, so these were handed out by law enforcement on site for comfort, as part of their routine function to make them less scary.
Once people are safe, Calming Efforts are needed. Many individuals may be shocked or acutely bereaved. Parents and teachers need information about how to help children cope. Resources and information on post-traumatic grief are often helpful. Posters and signs from “kindred spirits” who have gone through similar tragic events are often very meaningful to current survivors. This helps them feel they are not alone and there is another community which understands some of what they are going through. The Sandy Hook Community received over 500,000 letters of support, which showed them how much people cared. However, managing this logistically and respectfully was a challenge in itself. In the end, the letters were organized into a “digital library” with open access. The actual letters were then burned in a ritual, and the remains compressed into bricks, which formed the foundation of their new school.
Survivors need opportunities and interventions that help them Build their Self-efficacy, which may have been damaged during a sudden harmful event that left them feeling helpless. Providing resources and information so that people can make good decisions is a basic step in this process. Allowing survivors to give their input into decisions that need to be made is also important. Community town hall meetings, mourning rituals, and religious services can provide opportunities for meaningful decisions to be made by the community. These efforts also provide community recognition and validation of the seriousness of the tragedy and its aftermath. This collective healing can be very empowering, thus enhancing recovery.
Facilitating Helpful Connections is the next step in the recovery process. People do not heal after a traumatic event in isolation. Identifying those individuals with low social support, who may be isolated, or have special needs is critical. Being with people they love and connecting meaningfully with those who understand is the most healing environment for recovery. Social media can be helpful, but care must be taken; a strange and distressing modern phenomenon is the “truther” movement, that is, after an event, there are people communicating online who claim the event did not happen or was staged by actors, which is potentially harmful and invalidating. Survivors and their families are also usually targeted by trolls with aggressive and frightening threats. The members of the notorious Westboro Baptist Church may show up, for example to the school’s graduation, to heckle survivors with hate speech. This is a new and troubling phenomenon, for which awareness and prevention may help in advising survivors and in organizing post disaster events to prevent survivors from further harm.
Finally, Fostering Hope is important. With acceptance that their lives are forever changed, survivors and their families must find a way to go on with the new reality. In this way forward, they benefit from memorializing their loved ones in creative ways, which add meaning to their lives and the lives of others. For example, after Sandy Hook, many parents created non-profit organizations which aim to contribute potential solutions to or prevention of school-based violence in their child’s memory. Safe & Sound Schools is an organization devoted to safe school environmental designs run by two Sandy Hook mothers. Dylan’s Wings of Change is dedicated to supporting children with autism, and The Avielle Foundation is run by two neuroscientist parents to find new information about the brain & violent behavior; both organizations are named after children who were murdered at Sandy Hook. Love Wins: An Ana Grace Project, Jesse Lewis: Choose Love Movement and Sandy Hook Promise are other organizations created in the aftermath, which augment healing for those involved and contributing, strengthening the community.
With the lessons learned from each event, the NTCSN has been working on modernizing disaster mental health response. Particularly problematic for healing post-disaster is the tendency for a “let’s move on” attitude, which undermines how long grief and trauma recovery take. It is difficult to have the necessary patience in our “hurry up” culture. Profound grief and anger are difficult to sit with. Even clinicians may avoid contact with this, and seek to move on. It takes significant effort to create a cohesive, stable community over time, in which survivors can take the time they need to fully recover. Survivors must also be protected from intrusive media interviews, where they are urged to recount the event over and over again.
Many challenges remain. For mental health providers, shielding oneself from media coverage about the event is widely understood now to be essential in order to have the energy to effectively treat the survivors, but increasingly hard to do with the proliferation of media into many aspects of our life. A particular challenge is how to include the injured and/or hospitalized survivors in the community support events and grief rituals, such as memorials, when they cannot physically participate. When they recover from their injuries, they may find that the community has already moved on. A recent investigation showed that six years after the incident, the majority of the injured children never went back to school, thus missing out on the organized longer term “postvention”/recovery efforts and may be lost to follow-up. More research is needed to develop interventions which fit their needs.
A lesson learned from the school shooting in Chardon, Ohio in 2012 was that many first responders never get to learn the outcome of those they helped during the acute emergency, which can create an information gap that is hard to heal with. Sometimes rescuer/survivor reunions can be very helpful and healing. Other groups in disaster response often overlooked for trauma recovery intervention include law enforcement, members of the media, local funeral directors and any community organization which has been involved in the response in any way. NAMI has a good program available for law enforcement, Preparing for the Unimaginable.
The ABCs of second responder self-care during and after a disaster are
Awareness (that one has been affected and how)
Balance (restoring energy, rest, play & joy)
Connection (seeking out support resources & community)
Care must always be taken to restore oneself as needed when participating in disaster response.
There are a number of free online resources which can help mental health providers become more informed and prepared to offer post-disaster support. The NCTSN website, NCTSN.org, is the starting place for many resources. At https://learn.nctsn.org/, there is a course and an app for Psychological First Aid, courses in Trauma Focused CBT, Psychological Recovery Skills, Traumatic Grief, and links to many other web-based resources. Some of these online courses are CE approved.
For parents, UCLA has created Helping Kids Cope, a parent-focused app which covers eight different types of disasters and how to help kids through them. It is important to remember that notable events such as sudden evacuations, parental panic, or periods of time without any power can be frightening for children, although these may be taken in stride by adults. To address this, graphically appealing children’s stories about some unlucky mice who cope with various disasters have been developed. These are posted online at the NCTSN center website in English and Spanish.
Dr. Brymer is the Director of Terrorism and Disaster Programs of the UCLA and Duke University and the National Center for Child Traumatic Stress Network. In this capacity she has been involved with the development of acute interventions, assessment, and educational materials in the area of terrorism, disasters, and school crises. Dr. Brymer is one of the primary authors of the NCTSN/NCPTSD Psychological First Aid and Skills for Psychological Recovery interventions and has served as a consultant for many Federal, state, and local agencies across the country and internationally after disasters, terrorism, school shootings, and other mass violence tragedies. She is the lead advisor to the Newtown Public Schools, and has established many long-term public disaster mental health programs for children and families. As Principal Investigator for the National of Institute of Justice project, “Examining the Short and Long-term Impact of School Shootings and Mass Violence in Communities,” Dr. Brymer is identifying ways in which victims and other individuals are impacted by such incidents and what services need to be brought in to promote healing. She is a consultant for the US Department of Education and a subject matter expert for the Disaster Mental Health Subcommittee of the National Bio-Defense Science Board, the Office of the Assistant Secretary for Preparedness and Response (DHHS/ASPR), and for Substance Abuse Mental Health Services Administration (SAMHSA).
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Common Challenges in Emergency Shelters
by Glenn Lipson, Ph.D.
Dr. Lipson has been involved with disaster response deployment via the Red Cross in San Diego for a number of years. He discussed his extensive experience with local Red Cross Disaster shelters, which tend to be the primary sites of psychological first aid.
The work of a mental health provider in such settings is challenging; the work conditions are often harsh, uncomfortable for all, and focus on general, basic needs, rather than preferences or individual needs. Survivors in shelters may be wet, dirty, hungry, thirsty, and sleep deprived. The most basic comforts, such as being able to take a shower or maintain cleanliness are a challenge. Meeting these, however, may make a huge difference to the survivors. Simple acts of kindness that let people know that they are being helped by good people they can depend on are vital to the recovery process. A major initial focus for many survivors is to try to assemble a coherent narrative of what happened, which requires filing in information gaps and understanding the sequence of events. Very often, responders and volunteers don’t yet have this information either, which can provoke a lot of frustration among survivors.
Survivors of Hurricane Maria in Puerto Rico
One of the biggest (and often unexpected) challenges is coping with and helping survivors cope with a high level of anger directed toward the first and second responders. This is especially true when the disaster is “manmade” rather than a natural disaster. Many mental health providers do not have experience dealing with such high levels of anger. The extreme situation can stir up complex issues that cannot be easily or quickly handled. Dr. Lipson stressed how important it can be to acknowledge that as a mental health provider, he may not have the information the survivors are seeking about the situation or the immediate solution for their needs. Mental health providers are often not briefed in the acute phase, so that first responders can focus on those directly in harm’s way. Dr. Lipson reminds us that letting survivors know proactively that those on scene don’t have this information, and explaining the complexity of the situation may help mitigate anger directed at second responders.
Given the high levels of confusion and uncertainty, survivors are often looking to place blame for the incident or lack of adequate/immediate resolution, which can lead to further challenges. Certain sub-groups (e.g., immigrants, Muslims) may be scapegoated as “causing” the disaster, which can then fester over the years among individuals and across communities. When an individual becomes stuck in the anger, he or she cannot move forward through recovery. Dr. Lipson referred to the work of the Buddhist monk, Thích Nhất Hạnh, in which he counseled the application of mindfulness, acceptance, and mindful processing of anger to generate calm. The reality at hand can then be investigated and good decisions made to respond effectively to the current situation. Personal or sub-group blame must be shifted to “situational” blame to promote healthy recovery.
This kind of emergency shelter work can be very meaningful and gratifying for the provider, albeit unpredictable and sometimes intense. For mental health providers, fostering compassion and promoting self-soothing, while appreciating that past trauma may be activated, is helpful.
Dr. Lipson shared the helpful acronym, HEAL, which stands for Hear (listen, validate), Engage (be present in the moment), Accept (no platitudes, sorrow, anger is ok), and Laugh.
Many absurd and ridiculous situations arise in shelters, so imparting and encouraging humor and laughter can help ease tensions. Simple kindnesses and comforts, including listening to music or using art to express one’s losses can also be helpful coping strategies. Dr. Lipson recounted one of his experiences working in a shelter, wherein the environment became soothing with the arrival of a musical group and the resulting respite felt by the survivors.
Dr. Lipson recommends taking courses on Psychological First Aid to gain the specific skills useful in supporting recent disaster victims. One example of a good reference for this protocol can be found in the Field Operations Guide developed by the VA. https://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp
There are several apps that one can download on their mobile device that can help with psychological first aid (list compiled by Wendy Tayer, Ph.D.). The following are a few examples:
- Insight Timer
- Breathe 2 Relax
- Help Kids Cope by the National Child Traumatic Stress Network
- Psychological First Aid (PFA Mobile)
- Virtual Hope Box
- Stress Less Cards
Extreme circumstances and traumatic loss often compel application of a spiritual perspective. Dr. Robert Jay Lifton, a psychiatrist famous for his research on the psychological causes and effects of war and political violence has coined the term, “death imprint,” to describe the phenomenon of coming so close to near-fatality that the experience leaves a deep mark on the psyche. The “death imprint” may affect not only direct victims of the disaster, but also their loved ones, and the first and second responders involved in recovery. Personal meaning may vary, but there is a general sense of a changed sense of self and relationships with self and other. Grief may be a big part of this shift, since loved ones, homes, pets, and essential personal items may have been lost. Through kindness and the creation of a safe “ “holding environment” “ in which to process the event, a person must come to terms with why they experienced the traumatizing event via cognitive, emotional, and sometimes spiritual processes.
Consider, for example, a carpenter, who has lost his tools that enable him to work, ones which took a lifetime to accumulate and are not fully replaceable. The meaning of these lost tools is not just “stuff”; the impact of any loss is unique to each individual, depending on the significance, and should not be prejudged by the mental health provider involved in the recovery process. Values clarification, resulting in a change of priorities, may be a part of the “post traumatic growth” after a disaster; this process benefits the survivor over time, and can help him or her become stronger and more resilient than they were before the event.
Vicarious trauma is a real risk for secondary responders in disaster recovery, given their exposure to people’s raw anger, shock, fear, and horror, as they are encountered in shelters and on scene, further amplified by the survivors’ repeated recounting of their stories as they process their experiences. This risk may be further exacerbated by sleep deprivation in both survivors and responders. If responders do not process their own disaster-related trauma, they are at risk for a delayed post-traumatic emotional response and maladaptive coping behaviors such as substance use as a form of self-medication. Dr. Lipson led the audience through a guided imagery exercise, of victims in a shelter imagining gentle rain washing away the imprint of their trauma, i.e., the sights, sounds, smells, loss. This can also be a soothing self-care activity for providers, and can be shared with other survivors.
Overall, disaster recovery work is not for the faint of heart, but can be very rewarding and meaningful. Each mental health provider has to determine his or her comfort level with traumatic exposure, assess their own recent emotional challenges, consider their own health and hardiness, the time they have to devote, and whether they can manage being away from family, pets, work, and clients, both on short notice and for varying lengths of time. It is imperative that clients of mental health providers who expect to deploy from time to time in local or national disasters be advised in their informed consent that their regular therapy may be interrupted on short notice should their providers be summoned in the wake of a disaster. As difficult as it is, the rewards of being able to make a positive impact after a disaster, and to use one’s professional skills and expertise to make a significant difference in a survivor’s outcome are incredibly gratifying.
Dr. Lipson is a Forensic Psychologist and an internationally-recognized expert in in the prevention, intervention, and prosecution of violent crimes. As an expert witness, speaker, trainer, and advisor, he has testified at court martials, regulatory hearings and submitted briefs through counsel to the United States Supreme Court. Dr. Lipson co-authored the Risk Assessment Guidelines for Evaluating – Violence (RAGE-V) for the Association of Threat Assessment Professionals, and is one of the founding members of the San Diego District Attorney cyber assessment team which created protocols to integrate digital data to assist in the prevention, intervention, and prosecution of crimes.
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