Mental Health

The following is an article from the American Psychological Association Help Center: “Managing Traumatic Stress: Tips for Recovering From Disasters and Other Traumatic Events” (http://www.apahelpcenter.org/articles/article.php?id=22)

“Disasters are often unexpected, sudden, and overwhelming. In some cases, there are no outwardly visible signs of physical injury, but there is nonetheless a serious emotional toll. It is common for people who have experienced traumatic situations to have very strong emotional reactions. Understanding normal responses to these abnormal events can aid you in coping effectively with your feelings, thoughts, and behaviors, and help you along the path to recovery.

1.  What happens to people after a disaster or other traumatic event?

Shock and denial are typical responses to traumatic events and disasters, especially shortly after the event. Both shock and denial are normal protective reactions. You may temporarily feel numb or disconnected from life.

As the initial shock subsides, reactions vary from one person to another. The following, however, are normal responses to a traumatic event:

  • Feelings become intense and sometimes are unpredictable. You may become more irritable than usual, and your mood may change back and forth dramatically. You might be especially anxious or nervous, or even become depressed.
  • Thoughts and behavior patterns are affected by the trauma. You might have repeated and vivid memories of the event. These flashbacks may occur for no apparent reason and may lead to physical reactions such as rapid heart beat or sweating. You may find it difficult to concentrate or make decisions, or become more easily confused. Sleeping and eating patterns also may be disrupted.
  • Recurring emotional reactions are common. Anniversaries of the event, such as at one month or one year, can trigger upsetting memories of the traumatic experience. These `triggers´ may be accompanied by fears that the stressful event will be repeated.
  • Interpersonal relationships often become strained. Greater conflict, such as more frequent arguments with family members and coworkers, is common. On the other hand, you might become withdrawn and isolated and avoid your usual activities.
  • Physical symptoms may accompany the extreme stress. For example, headaches, nausea and chest pain may result and may require medical attention. Pre-existing medical conditions may worsen due to the stress.

2.  How do people respond differently over time?

It is important for you to realize that there is not one `standard´ pattern of reaction to the extreme stress of traumatic experiences. Some people respond immediately, while others have delayed reactions - sometimes months or even years later. Some have adverse effects for a long period of time, while others recover rather quickly.

Reactions can change over time. Some who have suffered from trauma are energized initially by the event to help them with the challenge of coping, only to later become discouraged or depressed.

Fence at Oklahoma City National Memorial/G. Jill Evans

A number of factors tend to affect the length of time required for recovery, including

  • The degree of intensity and loss. Events that last longer and pose a greater threat, and where loss of life or substantial loss of property is involved, often take longer to resolve.
  • A person's general ability to cope with emotionally challenging situations. Individuals who have handled other difficult, stressful circumstances successfully may find it easier to cope with the trauma.
  • Other stressful events preceding the traumatic experience. Individuals faced with other emotionally challenging situations, such as serious health problems or family-related difficulties, may have more intense reactions to a new stressful event and need more time to recover.

3.  How should I help myself and my family?

There are a number of steps you can take to help restore emotional well being and a sense of control following a disaster or other traumatic experience, including the following:

  • Give yourself time to heal. Anticipate that this will be a difficult time in your life. Allow yourself to mourn the losses you have experienced. Try to be patient with changes in your emotional state.
  • Ask for support from people who care about you and who will listen and empathize with your situation. But keep in mind that your typical support system may be weakened if those who are close to you also have experienced or witnessed the trauma.
  • Communicate your experience in whatever ways feel comfortable to you - such as by talking with family or close friends, or keeping a diary.
  • Find out about local support groups that often are available such as for those who have suffered from natural disasters, or for women who are victims of rape. These can be especially helpful for people with limited personal support systems.
  • Try to find groups led by appropriately trained and experienced professionals. Group discussion can help people realize that other individuals in the same circumstances often have similar reactions and emotions.
  • Engage in healthy behaviors to enhance your ability to cope with excessive stress. Eat well-balanced meals and get plenty of rest. If you experience ongoing difficulties with sleep, you may be able to find some relief through relaxation techniques. Avoid alcohol and drugs.
  • Establish or reestablish routines such as eating meals at regular times and following an exercise program. Take some time off from the demands of daily life by pursuing hobbies or other enjoyable activities.
  • Avoid major life decisions such as switching careers or jobs if possible because these activities tend to be highly stressful.

4.  When should I seek professional help?

Cover of Psychological First Aid: Field Operations Guide, now available through the Terrorism and Disaster Center

Some people are able to cope effectively with the emotional and physical demands brought about by traumatic events by using their own support systems. It is not unusual, however, to find that serious problems persist and continue to interfere with daily living. For example, some may feel overwhelming nervousness or lingering sadness that adversely affects job performance and interpersonal relationships.

Individuals with prolonged reactions that disrupt their daily functioning should consult with a trained and experienced mental health professional. Psychologists and other appropriate mental health providers help educate people about normal responses to extreme stress. These professionals work with individuals affected by trauma to help them find constructive ways of dealing with the emotional impact.

With children, continual and aggressive emotional outbursts, serious problems at school, preoccupation with the traumatic event, continued and extreme withdrawal, and other signs of intense anxiety or emotional difficulties all point to the need for professional assistance. A qualified mental health professional can help such children and their parents understand and deal with thoughts, feelings and behaviors that result from trauma.”

Long Term Recovery – Crisis Counseling Programs

A Presidential disaster declaration activates the programs available in the National Disaster Response Plan administered through FEMA.  One of the programs under this plan is the Crisis Counseling program.  Just as all of the federal programs in the National Disaster Response Plan enter through state agencies, the conduit for this program is the state mental health authority.

State mental health authorities may vary in name from state to state, but can always be accessed by contacting the state’s social services division. The federal government has a wealth of mental health assistance programs that might be available to a community even if a disaster does not receive a Presidential declaration.  The state mental health authority is an excellent resource for any community desiring to know what is available to assist them in a post disaster setting.

“In dealing with mental health in a post disaster situation, the challenge is not the lack of resources but rather the abundance of resources.  It is important to find the point agency that can bring the best resources to bear given the circumstances.  This is best done by contacting the state mental health authority, which can always be located through the state’s social services division of the Executive Branch.”  (Harmon interview)

The Crisis Counseling program divides Post Traumatic Stress (PTS) into reaction and disorder.  Reaction can be handled through education and brief counseling.  If the crisis counselor feels the PTS is greater than just reaction and has become a disorder, the client is referred to professional mental health providers.

Following the initial Presidential declaration, a grant award for a Crisis Counseling program becomes available for 60 days of immediate service and assessment.  Based on the initial assessment, a regular award can be granted for nine additional months, with the potential of extensions.  Project Heartland in Oklahoma City, Project Liberty in New York City and KARE in Greensburg, KS, are all examples of these programs.

Project Heartland – Oklahoma City

Project Heartland was established with funding from FEMA through the Center for Mental Health Services to assist Oklahoma City after the 1995 bombing of the Alfred P. Murrah Federal Building.  It provided crisis counseling, support groups, outreach and education for individuals affected by the bombing.

In an article evaluating the success of Heartland Project two years after its founding, Dr. John Call and Dr. Betty Pfefferbaum made several valuable suggestions for future mental health response based on lessons learned.

  • Planning – Specially trained staff from the state agency responsible for developing and maintaining the post-disaster planning should work closely with other agencies in the pre-disaster planning and should be knowledgeable about the various organizations likely to be involved in the response.

    In May 1995, a statewide forum was held in Oklahoma City “to obtain community input in the development of service goals for the mental health recovery plan.  This use of a quasi-public disaster relief planning workshop appears unique in the disaster literature.” (Call & Pfefferbaum, 954)

    Because exposure to trauma and survivor rage eroded the physical and mental well-being of the staff, a psychologist with training in disaster mental health was employed to debrief and support the staff.  It was recommended that staff support personnel should not be involved with case consultancy for the victims.  (ibid.)
  • Project Heartland contracted with both state and private organizations to extend services to predefined populations.  It was felt that this blend of state and private groups was both unique and highly desirable because it offered accessible services by experienced professionals and integrated post-disaster services with existing programs.  (ibid.)

    Using a contract allows for specifications of service that are of importance such as designating the amount of time to be spent in direct clinical service, requiring minimal educational and licensing requirements for subcontracted clinicians and mandatory additional training in auxiliary areas such as outreach, evaluation and referral, crisis and grief counseling, and record keeping.  (ibid., 954-955)
  • Services – Twenty-one support groups were established in the first two years.  All were considered successful.  They fluctuated in attendance and duration.  Flexibility is recommended in deciding what kinds of groups to offer based upon the changing needs and interest of potential participants.  The outreach staff visited every home and business within a mile radius of the blast.  Home visits were also made to survivors, families of those who were killed, and rescue workers. Staff members attended meetings, reunions, held retreats, assisted in the return of displaced persons, and mailed literature.  It is recommended that outreach training be included in the pre-disaster training.  (ibid., 955)

Project Liberty - New York City

Project Liberty was created by the New York State Office of Mental Health, with support from the Federal Emergency Management Agency (FEMA) and the Center for Mental Health Services (CMHS). The program, which was designed to respond to the intense need for crisis services stemming from the World Trade Center disaster, was a collaboration of the Office of Mental Health, local governments, and providers of crisis counseling services. Project Liberty is now committed to mental health promotion and wellness.  Information about Project Liberty can be found at http://www.projectliberty.state.ny.us/

A great deal of work has been done in the area of mental health challenges in the wake of disasters, both man-made and natural, by the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services.

According to the SAMHSA Web site, “When disasters strike, state and territory mental health/substance abuse agencies and local service providers are suddenly thrust onto the frontline for response and recovery efforts.  Often they find themselves confronting new or unknown problems for which no amount of preplanning is possible.”  (http://mentalhealth.samhsa.gov)  To help, SAMHSA has created a Disaster Technical Assistance Center to provide quick information in such areas as 

  • Disaster Planning and Preparedness
  • Business Continuity and Recovery Plans
  • Crisis Counseling Program
  • Cultural Competence
  • Natural Disasters
  • Psychological First Aid
  • Stress Management
  • Terrorism/Man-made Disasters

http://mentalhealth.samhsa.gov/dtac/

Resources for Help 

American Red Cross
American Red Cross National Headquarters
2025 E. Street, NW
Washington, D.C.  20006
Phone     202.303.4498
http://www.redcross.org/

The American Red Cross provides information, resources, and services in the wake of natural disasters, terrorist attacks, war and other violence, as well as information on disaster preparedness.

APA Help Center from American Psychological Association
The APA Help Center has a section on disaster and terrorism to provide information and services in the wake of massive trauma.  For Hurricane Katrina, APA activated its Disaster Response Network (DRN), a partnership with the Red Cross that sends APA member psychologists who have received ARC disaster mental health training to volunteer at disaster sites. APA has also developed materials and resources to help victims and first responders deal with the aftermath of Hurricanes Katrina and Rita. 

The APA Help Center continually updates this website with information gained from large scale disasters and other traumatic events.

http://www.apahelpcenter.org/

Center for the Study of Traumatic Stress (CSTS)
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD  20814
Phone     301.295.3013
www.usuhs.mil/csts

CSTS is part of the Department of Psychiatry of the Uniformed Services University Medical School.  In June 2006, the CSTS held a national conference in Bethesda, MD, that included workplace professionals in the public and private sector and academicians and policy-makers in disaster mental health and disaster planning and response who presented findings from disaster research, and firsthand accounts of corporations and federal agencies involved in 9/11, the anthrax attacks and Hurricanes Katrina and Rita.  The end product was “A Leadership Document to Inform Planning, Response and Policy for Workplace Preparedness and Behavioral risk Management of Disaster and Terrorism,” Conference Report, June 29-30, 2006, Bethesda, MD

Disaster Technical Assistance Center
United States Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
1 Choke Cherry Road
Rockville, MD  20857
240.276.1310

International Society for Traumatic Stress Studies (ISTSS)
60 Revere Drive, Suite 500
Northbrook, IL 60062
Tel. 847.480.9028
Fax  847.480.9282
http://www.istss.org/

Founded in 1985 for professionals to share information about the effects of trauma, ISTSS is a multidisciplinary, professional membership organization that promotes advancement and exchange of knowledge about severe stress and trauma.  It is dedicated to the discovery and dissemination of knowledge about policy, program and service initiatives that seed to reduce traumatic stressors and their immediate and long-term consequences.  It provides a forum for the sharing of research, clinical strategies, public policy concerns and theoretical formulations on trauma in the United States and around the world.  Members of ISTSS include psychiatrists, psychologists, social workers, nurses, counselors, researchers, administrators, advocates, journalists, clergy and others with an interest in the study and treatment of traumatic stress.  ISTSS has produced several guides to dealing with disaster and terrorism related trauma, as well as providing, on their website, multiple links to other organizations that also provide educational materials related to this type of trauma.

The Northern Ireland Centre for Trauma and Transformation
2 Retreat Close
Omagh
N. Ireland  BT79 0HW
Phone     +44 28 82 251500
http://www.nictt.org/

The Centre for Trauma and Transformation was established in the aftermath of the Omagh bombing to provide psychological treatment to victims and education, training and aid to the community.

Project Heartland
Project Heartland has concluded, but a collection of all grant applications and reports can be found in the Oklahoma City National Memorial Archives, Project Heartland Collection

Additional information may be obtained from
Betty Pfefferbaum, M.D., J.D.
OUHSC
920 Stanton L. Young Blvd., Suite 3470
Oklahoma City, OK  73104
Phone     405.271.5121
betty-pfefferbaum@ouhsc.edu

Project Liberty
Roger Klingman
New York State Office of Mental Health
44 Holland Avenue
Albany, NY 12229
Phone     518.474.6540
http://www.projectliberty.state.ny.us/

Sunbridge Program
Mental Health Association of Oklahoma County
5104 N. Francis, Ste. B
Oklahoma City, OK 73118
mentalhealth@coxinet.net 
Phone     405.843.9903

The Sunbridge program cooperates with the Red Cross in providing mental health services for persons severely affected by the Murrah Building bombing who cannot find help elsewhere.  The associates of the Sunbridge Program are all licensed mental health professionals from the community who provide these services in their own offices.

University of Oklahoma Health Sciences Center
Terrorism and Disaster Center (TDC)
OU Health Sciences Center
Brian Houston
Phone    405.271.5251, ext. 47633
www.tdc.ouhsc.ued
TDC focuses on achieving an effective, nationwide mental health response to the impact of terrorism and disasters on children, families, and communities.  TDC is a Category II Center of the National Child Traumatic Stress Network (NCTSN), a national network funded by the Substance Abuse Mental Health Services Administration to improve the standard of care for traumatized children and to increase their access to care.  A PDF version of the Psychological First Aid: Field Operations Guide can be downloaded at http://nctsn.org/nccts/nav.do?pid=typ_terr_resources_pfa.
TDC has also developed “Building Community Resilience for Children and Families” for use in preparedness to create a strong foundation to mitigate the impact of disaster and a CD, “Students & Trauma” to help in mitigating the impact of all types of trauma on students.

The Victims Unit
Office of the First Minister and Deputy First Minister
Castle Buildings, Stormont
Belfast BT4 3SR
Northern Ireland
Phone     0808 127 3333
Fax         028 9052 8354
info@victimsni.gov.uk

The Victims Unit raises awareness of issues affecting victims of the conflicts in Northern Ireland, and promotes an improvement in the standard of services provided to victims.  It has a very helpful “information on trauma” section.
http://www.ofmdfmni.gov.uk/index/equality/victims-unit/information-on-trauma.htm

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