Lessons Learned Since 9/11 about Post Disaster Intervention

Lessons Learned Since 9/11 about PostPost-Disaster
Intervention
Steven Marans, PhD, MSW
Childhood Violent Trauma Center, Yale University
Post Disaster Intervention: What Have We Learned
Since 911?
April Naturale, PhD
Disaster Mental Health Management
g
and Trainingg
Patricia Watson, PhD
National Center for PTSD
National Center for Child Traumatic Stress
Juliet Vogel, PhD
North Shore University Hospital
Patricia Watson, PhD
National Center for Child Traumatic Stress
Patricia.j.watson@dartmouth.edu
How Do We Know How to Respond
Following Disasters?
Assessment and Screening
• Cross-disaster comparisons difficult
• Groundbreaking work:
• Recipients of services
• Utilization of services over time
• Assessment and referral tool
• The numbers participating in post-disaster treatments
are often small relative to the numbers screened
• Those screened who did attend treatment show
substantial reduction in symptoms
First 2 Weeks
Five EmpiricallyEmpirically-Supported Early
Intervention Principles
Accepted:
• Primary goals should be to promote safety, attend to
practical needs, enhance coping, stabilize survivors,
and connect survivors with additional resources
• Psychological First Aid and outreach appear evidenceconsistent, non-harmful
Not universally accepted:
• CISD (given the negative findings and the findings re:
worsening of symptoms)
• CBT and EMDR may be contra-indicated, given that
they both encourage disclosure and emotional
processing, take energy and resources, and may
interrupt a necessary down-time
1
2 Weeks – 3 Months
Psychological First Aid Core Actions
1
Contact and Engagement
2
Safety and Comfort
3
Stabilization
4
5
Information Gathering
Practical Assistance
6
Connection with Social Supports
7
Information on Coping
8
Linkage with Collaborative Services
• CBT for PTSD or ASD has strongest empirical support
– Not recommended for routine use for all
– Determined by:
• the extent to which a sense of threat persists
g g in the intervention
• sufficient resources to engage
– Use empirically supported, flexible, modularized
approaches for the range of problems seen among
survivors
3 Months Onwards
Skills for Psychological Recovery (SPR)
• Good research support for
cognitive-behavioral approaches
for a wide range of problems and
after a broad range of disaster
types
• Empirically-derived skill sets
•
•
•
•
•
•
Information Gathering / Prioritizing
Problem-Solving
Positive Activities
Managing Distress
p Thinkingg
Helpful
Building Social Connections
• Further evaluation and research
would help clarify which
components of CBT are best
tolerated, work most quickly, and
are most efficacious
• 1-5 sessions, each “stand alone”
• But encouraging multiple visits
• Build skills, between-session tasks
• Flexible, tailored approach
Children and Adolescents
Immediate phase:
• Psychological First Aid (focused on
warmth, support, safety, education,
access to resources)
Later phases:
• Growing body of evidence supports CBT
interventions
• School based, group approaches may
be efficient and effective option
Innovations
•
•
•
•
•
•
Brief telephone interventions
Virtual reality strategies
Single-session simulations
Writing exercises
I
Internet-based
b
d iinterventions
i
School-based interventions
2
Expert Consensus Guidelines
Expert Consensus Guidelines
•Inter-Agency Standing Committee Guidelines (2007)
•The European Network for Traumatic Stress Guidelines
(TENTS, 2008)
1. Be proactive / prepared ahead of time, pragmatic,
flexible, and match services across the entire recovery
period for individuals and the community.
2. Promote sense of safety, connectedness, calming,
hope, and efficacy at every level of intervention.
3. Do no harm:
–
–
–
–
–
•The Disaster Mental Health Subcommittee (2009)
Expert Consensus Guidelines
4.
5.
6.
7.
Maximize local participation, resources and capacities
Integrate programs and services
Use a stepped care approach
Provide multi-layered supports, both individual and
community level (work with media, facilitate communal,
cultural, memorial, spiritual healing)
Expert Consensus Guidelines
Provide a spectrum of services, including:
a) Provision of basic needs
b) Assessment at the individual and community level
c) Psychological first aid / resilience-enhancing support
d) Outreach and information dissemination
e) Technical assistance, consultation and training
f) Treatment for individuals with continuing distress or
decrements in functioning
Summary
Advances:
• Clarification of risk, protective, and resilience factors
• Identification of varying outcome trajectories
• Understanding of coping strategies
p
knowledge
g about timingg of interventions
• Improved
• Interventions for cultural, ethnic, and minority groups
• Improving training
• Development of metrics and methodologies
Consider human rights and cultural sensitivity
Stay updated on the evidence base
Match interventions to information and resources
Participate in coordination groups
Commit to evaluation
Recommendations
•
•
•
•
•
•
•
Systematic prospective longitudinal research
Factors related to adaptive recovery
Theoretical models
More sensitive statistical analyses and methods
More structured and systematic evaluation of services
Wide range of individual and group outcomes
Increased delivery of evidence-based interventions and
evidence-informed services
• Research to guide services that are acceptable and
feasible for both recipients and providers
• Focus on family and community resilience
3
CVTC Responds Acutely to 9/11
9/11 and Beyond
Steven Marans,
Marans MSW,
MSW PhD
Harris Professor of Child Psychiatry
Professor of Psychiatry
Director Childhood Violent Trauma Center
Yale University School of Medicine
In the Aftermath
• Developing guidelines for parents, teachers & health care
providers re helping children re terrorist attacks
– Work with Congresswoman Rosa DeLauro to distribute
materials through members of Congress
– Development of materials for anthrax scares
• Interviews with news media about affected children
Consulting with Agencies (cont’d)
• Application of training for schools on disaster preparation &
response developed in New Haven to all of NYC over 2
years
• Preparing for casualties that never came
• Consulting with providers in NYC, DC, CT
• Organizing responses with CT, Yale colleagues,
Steven Southwick & Julian Ford (UConn)
– Availability at train station
– Develop state-wide training for mental health &
others re preparedness & response
• Consulting with CEO’s of companies in WTC
Consulting with Agencies
• NYC Board of Education & State mental health
authorities along with Bob Pynoos, Marlene Wong &
other NCTSN members
• Attempted to help ongoing & coordinate with Mental
g
in NYC & Federal Agencies
g
re
Health agencies
response to affected children
– Pre-existing limited resources & coordination
– Work with CDC & Christian Haven per needs
assessment & follow-up
– Creating competition when cooperation is paramount
Recommendations
• Need for integration of behavioral health perspectives
• Consultation with members of Congress, DOE & Justice
• Need for integrated treatment informed training for federal,
state & local leadership, 1st responders, medical personnel,
educators, mental health providers, & others
• Member of Federal Commission under Secretary Tommy
Thompson re children & disaster
• Funding allocated to states would need to include
provision/requirements for above training & integration
4
Recommendations
• Attention to needs of first responders & families if we
expect them to respond effectively
• Need for behavioral health screenings as part of medical
assessment of victims
• Availability of school based, clinic based, etc. trauma
informed interventions
– Necessity of needs assessment & longitudinal follow-up
for children & families at greatest risk for long-term posttraumatic difficulties
*The worst time to develop new collaborations is in the middle
of a crisis
Decade following 9/11
• Birth of NCTSN led to development and proliferation of
interventions with proven effectiveness in helping
traumatized children & families
• Increased knowledge about roles/contributors of various
professionals – mental health, first responders,
p
p
courts,
education, medical personnel, social service, political leaders
in promoting recovery
Decade following 9/11
Forward
• Learned about the limitation of continuing to operate in
silos & the necessity of applying the wealth of what we have
• Recognized the necessity to establish policies that address
the needs of all citizens when the ability to optimally
navigate life & the world are undermined by traumatic
events
• There is much more work that needs to be done as
we celebrate & capitalize on the achievements &
contributions of NCTSN members over this past
decade.
Acknowledgments
Lessons Learned from Intervention after 9/11
In the Metropolitan New York Area
A View from Long Island
Juliet M. Vogel, Ph.D.
Division of Trauma Psychiatry
North Shore-LIJ Health System
Manhasset, NY
• People
– Sandra Kaplan, MD
– Victor Fornari, MD
– Alan Cohen, MD
– Peter D’Amico, Ph.D.
– The Staff of the North Shore LIJ CATS and Red Cross Programs
– Our NCTSN and CATS Program collaborators
– The families, individuals and community groups with whom we had the
privilege of working
• Support
– Project Liberty
– Nassau County SERV grant
– NCTSN
– Child and Adolescent Trauma Treatment and Services Consortium
(CATS)
sponsored by NY Office of Mental Health and SAMHSA
- Red Cross September 11th Youth Resilience and Recovery Program
grant
- New Yorkers for Children grant
5
Overview: Importance of…
1. Identifying local impact
2. Pre-disaster planning/relationships
3. Cooperative/collaborative efforts among providers
a. Working in teams
b Collaboration
b.
C ll b
i across iinstitutions
i i
4. One size does not fit all
5. Collaboration around resilience building
6. Honoring both resilience and needs over time
Demographics of Metropolitan NYC WTC Deaths
(NYC Dept of health records as of Oct 2002)
Location of residence
Percent of Total Deaths
New York City
43%
Long Island (Nassau/Suffolk)
14%
(approx. 34% emergency/rescue workers;
66% building occupants)
Other New York State
8%
New York State Total
65%
Lessons Learned #2
The Importance of Planning!
Lesson #1: Trying to Understand the Disaster Experience:
The View from Long Island
Manhattan
Queens
Staten
Island
Suffolk
Nassau
Brooklyn
Demographics of Metropolitan NYC WTC Deaths
by County
(NYC Dept of Health records as of Oct 2002)
County
Manhattan (NYC)
Bronx (NYC)
Brooklyn (NYC)
Queens (NYC)
Staten Island (NYC)
Nassau (LI)
Suffolk (LI)
Number of deaths
340
93
293
258
195
243
143
Lesson #2: The Importance of Planning
and Relationships (Cont.)
Nassau County
• During acute response phase: working with
schools
– Importance of pre-existing relationships
– Importance
p
of collaboration around disaster p
plans
BEFORE the event
– 9/12/01 Meeting with over 100 school district
representatives; follow-up meetings & SERV grant
– Built on prior relationships
•NSUH/ Mental Health Association/BOCES
•School districts re preparedness
Manhattan and Queens
- Range of efforts, including activation of schoolagency relationships
6
Lesson #3: The Importance of Collaboration:
Two levels
Lesson #3b (cont): The Power of Collaboration :
Toward the Child and Adolescent Trauma Treatment and
Services Consortium (CATS)
• 10/13/2001 Meeting
– Included hospitals serving Ground Zero schools, other key medical
centers including NSLIJ
– NY Office of Mental Health (Peter Jensen, MD)
– Expertise from beginning leadership of NCTSN
a. Working in teams: An important part of self-care
b. The power of collaboration across programs and
institutions
• Follow up: key ingredients
– Collaboration:
• conference calls re joint efforts (OMH sponsored)
• Willingness to “buy into” shared assessment, trainings, maybe
shared protocols
– Expertise: Shared + NCTSN begins and has impact
– Funding helps:
• If you cooperate, there may be funding
Toward a Consortium
The Child and Adolescent Trauma Treatment
and Services Consortium (CATS)
Lesson #4: One size does not fit all
a: Model of continuum of care evolves
• An RFP: NYS Office of Mental Health/SAMHSA
– collaboration of academic medical centers, community
organizations
– Continuum of services: relationship with FEMA crisis
counseling
• From the ivory tower to the streets --and schools of New
York…
and Long Island
• Community outreach and psychoeducation
• Crisis counseling
• Liberty Enhanced: brief CBT skills interventions
• CATS: evaluation pus full trauma treatment
b: Working with individual differences even within a
family!
History
Project Liberty – 2001
• FEMA awarded the State 22M for crisis services and
outreach; largely adult focused, some child services.
Project Liberty – 2002
• FEMA awarded
d d 132M to
t continue
ti
crisis
i i services
i
and
d
outreach, and provide brief interventions for adults
and children.
History
CATS 2002-2005
• SAMHSA awarded 3M to the State for trauma
treatments and services specific to children and
adolescents, including an evaluation.
• RFP process; consortium created to develop common
screening and assessment protocol, and core
evidence-based treatments
• 9 funded programs (45 sites)
• CATS was “in the field” 2003-2005, demonstrated
effectiveness
7
Lesson #5 : Collaboration around Resilience
Building
Example: working with the North Shore LIJ Health System’s Center
for Emergency Medical Services
– Crisis Intervention week of 9/11
– Request for assistance from their peer support team;
– Collaboration on identifying needs:
• backup for their peer support team
• Staff psychoeducation
• How to address needs of children
– Collaborating on creating parenting guide: Strategies to
Manage Challenges for EMS Families (2008)
(http://www.nctsn.org/products/strategies-managechallenges-ems-families-2008)
Lesson #6: Planning for the long term:
Honoring both resilience and needs over time
• Understanding long-term needs of
– Bereaved families
– Those with most direct exposure (e.g., emergency
workers)
• Sensitivity to:
– Importance of anniversaries and individual/familyspecific milestone events and reminders
– Importance of developmental changes for
children leading to new questions and issues
Group A (697, or 82.2%): Family member of a person who died in the 9/11 attacks
Group B (6, or .7%) : Family member of a survivor, impacted resident or recovery worker
who died later of related injuries
Groups C-F (145, or 17.4%): Other impacted individuals
TOTAL RESPONDENTS: 848
Lesson #5 : Collaboration around Resilience
Building (cont.)
Example: Parenting groups for Tuesday’s Children
(foundation for 9/11 bereaved families)
• Their needs assessment had identified need for
assistance with limit setting
• Provided parenting groups: series of three given
twice (once in Nassau County, once in Suffolk
County)
• Follow-up:
– Group for parents of adolescents
– Individual referrals
9-11Healing and Remembrance
Program
NEEDS ASSESSMENT
December 2010
Assisting those affected by 9
9--11 as they
participate in 10th anniversary events
Response totals for all Groups A-F:
Yes
504 (60%)
Don’t know yet
254 (30%)
No
90 (10%)
Approximately 90% of all respondents (a total of 758 out of 848) answered either “Yes” or
“Don’t know yet.”
8
OT H E R FA MILY ME MB E R S : T o ind ic a te fa mil y me m b e rs who wo uld a tte nd with y o u, p le a s e
s ho w the ir R E LA T ION S H IP to Y OU , a nd the ir A GE GR OU P :
R e la tio ns hip to Y o u
A ns we r Op tio ns
s p o us e /
p a rtne r
s ib ling
s o n/
d a ug hte r
p a re nt
g ra nd p a re nt
o the r
R e s p o ns e
Co unt
A
B
C
D
E
F
T o ta l R e la tiv e s
245
20
17
10
6
3
301
48
76
65
48
29
21
287
227
317
194
81
30
10
859
57
27
27
27
18
7
163
0
3
1
2
3
2
11
42
59
94
105
94
70
464
619
502
398
273
180
113
2085
A ns we r Op tio ns
0-5
0
5
6-11
6
11
12-15
12
15
16-21
16
21
21+
R e s p o ns e
Co unt
A
B
C
D
E
F
A g e Gro up T o ta ls
2
13
16
13
14
3
61
23
43
47
26
11
4
154
30
47
28
15
11
5
136
55
60
35
18
12
11
191
495
327
261
188
128
85
1484
605
490
387
260
176
108
2026
A g e Gro up
“Other” included responses such as these: nieces, nephews, cousins,
aunts, uncles, godfather, friends.
Includes all Groups A-F
Approximately 300 respondents (about 80%) self-identified as Christian, and then
further self-identified as Roman Catholic, evangelical, Greek Orthodox, Baptist, and
non-denominational. Approximately 30 (8%) identified as Jewish, and 25 (6%) as
“other,” including agnostic, atheist, Buddhist, Hindu, Shinto, and Tibetan. W/A
•
•
•
Mobility assistance: 160 requests (50 - “You”; 110 - relatives “All Other Responses”).
(wheelchair dependence, limited walking capacity, diminished stamina for standing or
sitting for long periods of time, chairs.
“Language”: 30 respondents, Chinese, Japanese, Russian, and Spanish translation.
“Sight” and “hearing”: about 25 times each.
A total of 277 respondents in Groups A and B who are planning to attend
answered this question. (Note that Group B, represented by scarcely
visible blue bars, figures only in “massage,” “prayer room” and “pet
therapy.”)
Approximately 129 respondents listed 95 children who would need child care,
distributed across these age ranges:
• Ages 0-5:
34
• Ages 6-11:
41
• Ages 12-15
20
Of the 415 respondents in Group A who PLAN TO ATTEND, 354 responded
to this question. Of these 354, about 25% (90) indicated they would
need a transportation subsidy.
9
T R A N S P OR T A T ION N E E D S : IF Y OU A N S W E R E D " Y E S ," p le a s e c o ntinue with
the s e q ue s tio ns :
A , H o w M a ny M ile s ?
A ns we r
R e s p o ns e
0-100
100-250 250-500 500-2000
2000+
Op tio ns
Co unt
24
12
9
B . W ha t Fo rm o f T ra ns p o rta tio n?
A ns we r
Ca r
P la ne
B us
Op tio ns
28
37
C. T ra ns p o rta tio n in N Y C
A ns we r
T a xi
S ub wa y
Op tio ns
14
25
79
R e s p o ns e
Co unt
7
12
84
B us
P a rk ing
g
Ga ra g e
R e s p o ns e
Co unt
44
9
1
D . E s tim a te d T OT A L R o und -T rip
A ns we r
$500$0-250
$250-500
Op tio ns
1000
21
9
T ra in
14
3
57
$10001500
$15003000
$3000+
R e s p o ns e
Co unt
9
11
12
81
• Information and Resources (Newsletter)
• Hotline and website access
Anecdotes: Written
Written--in Comments and
Concerns from Victims’ Family Members
Rank Order:
1. Elderly parents wanting to see memorial before they
pass fear this is their last opportunity
pass-fear
2. Will we have security? Will we be safe?
3. Wanting to have all their family with them
4. How do I tell my children about 9-11? Those who were
young at the time of the event don’t understand context
5. Standing during event and other health concerns
Anecdotes: Written
Written--in Comments and
Concerns from Rescue/Recovery
Population
Rank Order:
1 Wanting to participate in official commemorative
1.
activities-feeling outside
2. Wanting to read names of those who died
3. Concerns about security
10