Disaster Mental Health for Responders

1. Disaster Mental Health for Responders CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service Scientific and Training Symposium Vet Category Day New Orleans, LA 23 June 2011 Center for Global Health International Emergency and Refugee Health Branch Man reunited with his dog after 2011 Japanese earthquake. Credit: Friend Burst, 2011

2. Outline • Visual portrayal of disasters: impact on mental health • Types of disasters: • Natural versus complex humanitarian emergency • Settings • Trajectory of disasters • Deployment environments: • Organizational stress • Veterinarian stress • Individual stress • Examples from PHS deployments • Mitigation strategies: • Agency (OFRD) • Team • Individual

3. Reality of Disasters: Impact on our Senses

4. Japan Earthquake and Tsunami, 2011: Event and Consequences Credits: National Geographic, March 2011

5. Human and animal suffering Credit: Global Animal, Japan, 2011 Credit: AP, Japan, 2011 Credit: APF, Japan, 2011 Credit: Massoudi, CDC, Haiti, 2010

6. Victims Survivors! Credits: Massoudi, CDC, Haiti, 2010

7. Scenes of Destruction: Haiti Earthquake, 2010 Credits: Massoudi, CDC, Haiti, 2010

8. Scenes of Destruction: Hurricane Katrina, 2005 Credits: Bowers & Williams, CDC, New Orleans, LA, 2005

9. Complex Humanitarian Emergencies Credit: IERHB, CDC, Afghanistan, date unknown Credit: Lopes-Cardoza, CDC, unknown location & date Credit: Lopes-Cardoza, CDC, Mass Graves ,Kosovo, 1999

10. Types of Disasters/Emergencies Earthquake Flood Complex Humanitarian Disasters Hurricane Natural Disasters Tornado Drought/Famine War Civil Strife Internally Displaced Persons Refugees: cross international border

11. Settings and Timing of Disasters/Emergencies Timing Settings Acute Protracted Rural Urban Recovery/Rehabilitation Developed versus Developing Country Each type of situation, setting and the point of time in which you respond will have a different impact on responder mental health

12. Deployment Environments in General • Chaotic and often austere • Lack of familiar context: • Food • Environment, including climate • Community • Little privacy – work and sleep in same area • Overload of responsibility • Chronic sleep deprivation • Travel difficulties and delays • Security/safety is not assured • Work piles up at home agency, overwhelming upon return Credit: Williams, RDF 3, LSU Field House, Hurricane Gustav, 2008

13. Organizational Stress • Mission may be ambiguous or change mid-stream • Lack of efficient coordination: • Particularly in global responses • Limited resources: • Insufficient number of staff • Assigned personnel (i.e., Tier 3) may not professionally match gaps in team • Relief may be delayed secondary to bureaucracy: • Affected communities voice anger or feelings of entitlement • Conflict between individual values and organizational goals • Role confusion: mismatch of skills with tasks

14. Veterinarian Roles in Disaster Response • Pre-disaster planning • Surveillance and control of diseases and vectors • Animal safety and control • Animal health care • Zoonotic disease surveillance and public health assessments • Search and rescue • Assessment of disaster impact on animal populations • Information dissemination Credit: Peoplepets, Dog in Shelter, Japan, 2011

15. Organizational Stress: Veterinary Category • Deployment role may not match professional role: • PHS vets may work in non-clinical settings and have concerns about clinical care competencies • Frustrations with having to work through chain of command to make contact with local/state vet services • Frustration over challenges to providing adequate care for sheltered animals: • Lack of necessary cache for vets in RDFs, unlike National Veterinary Response Teams (NVRT) • Lack of trained assistants to help provide basic care • No control over animals that may arrive at shelters (i.e., degree of aggression) • Focus on companion and service animals: what happens when faced with herd management in agricultural-focused communities?

16. Individual Stress During Deployment • Officers not prepared for stress of austere conditions over a 14-day or longer period • Lack of preparation for international deployments: • Limited understanding of how international disasters are managed • Inexperience with global travel • Unrealistic expectations • Visual impact of disaster on a daily basis, compounded with sheltered individuals needing to vent their feelings • No time to process impact of disaster during the deployment: • Some agencies refuse to allow time off after deployment

17. Common Stress Responses • Cognitive: • Memory loss, insomnia, reduced attention span, nightmares • Physiological: • Heart palpitations, dizziness, increased fatigue, tics, GI upset • Behavioral/Emotional: • Grief, guilt, sadness • Increased startle reactions • Crying easily • Social withdrawal: feeling numb and lack of reaction • Irritability, anger, increased conflicts with others

18. Examples of Stress-Inducing Deployment Situations • Lack of privacy: willingness to sleep on the ground in pup tents vs on cots in larger NDMS tents (Haiti) • Physical limitations not considered in austere conditions: • Need for CPAP machines and assistive devices • Failure to pay attention to basic public health preventive measures: • Did not use sunscreen or take prophylactic medications • Failure to drink enough fluids in situations of extreme heat/humidity • Multiple billeting changes: • Katrina: ~five moves in three weeks • Haiti: four different tent locations in five weeks

19. Deployment Examples: II • Limited dietary choices and food availability: • MREs x 3/day, no fresh fruit or dairy in Haiti • Inability to meet specific dietary requirements: • Kosher, vegan/vegetarian, gluten-free • Failure of contracted food service to provide meals at a time that was reasonable for those working night shift (Gustav) • Lack of contracted services to provide meals to sheltered patients requiring Preventive Medicine Branch staff to serve meals (Gustav) • Compounded stress of being co-deployed with Department of Defense: • Lack of familiarity with rank, military customs and etiquette • Perception that during deployments and trainings, officers asked to billet in circumstances not respectful of rank or perform functions for which enlisted would be expected to do

20. Deployment Examples: III • Hurricane Gustav: • Perceived lack of collaboration among co-located teams (RDF & DMAT) • Marked anger over lack of clinical staff • Team integrity fractured with team being split to three locations • Non-clinical officers: post-deployment nightmares seeing patient that had died being placed in a closet during the hurricane • Post-traumatic stress re-activated by working in shelter situation: • Brought back memories of being in a refugee camp as a child • Only one Mental Health (MH) provider for entire team – insufficient coverage for staff and patients • Shared shower space with shelter residents: • Perceived negative impact on ability to maintain professional relationship

21. Life as a Responder: Sleeping Home Sweet Home Group Sleeping Sleeping on Ship Preparations for Sleeping on Ship Credits: Williams & CDC staff, 2005, 2008, 2010

22. Life as a Responder: Bathrooms and Shared Living Haiti Response Credits: Williams, CDC, Haiti, 2010

23. Mitigation Strategies: Agency • Agency (OFRD): • Improve travel clearance process • Work with PHS MH providers to develop training for officers in recognizing and mitigating signs of team and individual stress during deployment: • Screen officers pre-deployment for suitability, especially for global deployments • Develop Standard Operating Procedures for managing stress that becomes disruptive to a team’s ability to function • Work with HHS to improve global preparation pre-deployment • Train ‘resiliency’ officers to work with MH providers

24. Mitigation Strategies: Team • Team: • Develop team goals that stress the concepts of resiliency and team support • Ensure that all officers have access to team MH providers in safe and private area • Implement rotational schedules for time off and rest period • Develop an area for ‘rest & relaxation’ during duty hours that is not accessible to shelter residents • Promote feeling of safety with initiating ‘buddy’ system for accountability Credit: Williams, CDC, “Club Fed”, Hurricane Gustav, LA, 2008

25. Mitigation Strategies: Individual • Individual: • Know your individual stressors and plan ahead: • Exercise if possible, include comfort snack foods, bring novels and headlamps for reading, keep packing organized, write in a journal, eat well • Maintain contact with family and friends • Alert team lead when you have reached your limit and need time alone • Try to find humor on a daily basis (individually and with team) • Meditate, use yoga or deep breathing exercises, attend spiritual services

26. BBQ beats MRE’s any day! Much needed and earned rest! Credits: Williams, CDC, Hurricane Frances, FL, 2005 Credits: Williams, CDC, Hurricane Gustav, LA, 2008 Celebrating Louisiana style! Credits: Williams, CDC, Hurricane Gustav, LA, 2008

27. Thank you to the various officers with whom I have had the honor and pleasure to serve during a myriad of disaster responses. Center for Global Health International Emergency and Refugee Health Branch