Psychosocial Support Public health CBRN course Bonnie Henry, MD, FRCPC.

Psychosocial SupportPsychosocial Support

Public health CBRN course

Bonnie Henry, MD, FRCPC

Goals of sessionGoals of session

To understand normal reactions to stress To learn do’s and don’ts of emergency psychological first

aid To understand the impact of infectious disease outbreaks

on HCWs and ways to mitigate the impact To understand the role of public health in reception centres

The Impact PyramidThe Impact Pyramid

Disaster ResponseDisaster Response

Guiding Principles• No one who experiences a disaster is

untouched by it • Panic is rare• Most people pull together and function during

and after a disaster• Mental health concerns exist in most aspects

of preparedness, response and recovery• Disaster stress and grief reactions are “normal

responses to an abnormal situation”

Disaster ResponseDisaster Response

Guiding Principles• Survivors respond to active, genuine interest and

concern. • Disaster mental health assistance is often more

practical than psychological in nature (offering a phone, distributing coffee, listening, encouraging, reassuring, comforting).

• Disaster relief assistance may be confusing to disaster survivors. They may experience frustration, anger, and feelings of helplessness related to disaster assistance programs and may reject disaster assistance of all types.

PsychosocialPsychosocial

1

Psychosocial Phases of DisasterPsychosocial Phases of Disaster

1. Warning of Threat: Ranges from no advance notice (suicide bomber) to weeks (hurricane)

2. Impact: Actual onset of disaster Varies. BT has fuzzy beginning/end; bombing is precise

3. Rescue or Heroic: People watch out for, protect, even risk own safety to save strangers

4. Remedy or Honeymoon: People initially pitch in and collaborate for the collective good

Psychosocial Phases of DisasterPsychosocial Phases of Disaster

5. Inventory: External resources begin to come online—people watch what goes where

6. Disillusionment: Resource allocation often seen as too little too late, poorly distributed

7. Reconstruction and Recovery: People move beyond self interests and start to rebuild

Severity of Psychological ReactionsSeverity of Psychological Reactions

Emotional SupportEmotional Support

In a major disaster, some victims arriving at reception centres, hospitals, or morgues will be experiencing such strong emotional reactions as

Fear Anxiety Helplessness Confusion Others may be grieving the loss of a loved one, of

their home, of their community Or experiencing distress because a loved one is

seriously injured or missing

Psychological First Aid: DoPsychological First Aid: Do Do help people meet basic needs for food & shelter,

and obtain emergency medical attention. Provide repeated, simple and accurate information on how to obtain these

Do listen to people who wish to share their stories and emotions and remember there is no wrong or right way to feel

Do be friendly and compassionate even if people are being difficult

Do provide accurate information about the disaster or trauma and the relief efforts. This will help people to understand the situation

Do help people contact friends or loved ones

Psychological First Aid: DoPsychological First Aid: Do

Do keep families together. Keep children with parents or other close relatives whenever possible

Do give practical suggestions that steer people towards helping themselves

Do engage people in meeting their own needs Do find out the types and locations of government

and non-government services and direct people to services that are available

If you know that more help and services are on the way do remind people of this when they express fear or worry

Psychological First Aid: Don’tPsychological First Aid: Don’t

Don’t force people to share their stories with you, especially very personal details

Don’t give simple reassurances like “everything will be ok” or “at least you survived”

Don’t tell people what you think they should be feeling, thinking or doing now or how they should have acted earlier

Psychological First Aid: Don’tPsychological First Aid: Don’t

Don’t tell people why you think they have suffered by giving reasons about their personal behaviors or beliefs

Don’t make promises that may not be kept Don’t criticise existing services or relief

activities in front of people in need of these services

Support for Emergency RespondersSupport for Emergency Responders

Characteristics of the SARS outbreak that Characteristics of the SARS outbreak that increased psychological riskincreased psychological risk

Conditions

Rapid spread

Rapidly changing state

of knowledge

Initially unclear

infectivity and mortality

Hospital-based infection

Adverse Consequences

Uncertainty

Inconsistency & changeInformation, rules

Protective equipment

High perceived risk for

HCWs

Acute effects of SARS on Acute effects of SARS on Healthcare WorkersHealthcare Workers

By July 2003 more than 20,000 HCWs worldwide had participated in quantitative studies of the psychological impact of caring for SARS patients– Moderate to high levels of distress in the short-

term– Significant distress in 18-57 %

Acute effects of SARS on Acute effects of SARS on Healthcare WorkersHealthcare Workers

Acute distress is associated with– Fear of contagion– Concern for family health– Treating colleagues with SARS – Job stress– Interpersonal isolation– Perceived stigma – Quarantine

The Impact of SARS StudyThe Impact of SARS Study

Designed to assess the long term psychological and occupational impact of working during the SARS outbreak

Broad range of indicators of the impact of SARS

Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32.

MethodsMethods HCWs surveyed at 8 Toronto

hospitals that treated SARS patients in 2003

Comparison group of recruited from 4 hospitals in Hamilton– similar public health precautions

and surveillance but had no SARS cases.

August 2004 to September 2005, 13 to 25 months after the last SARS patients were treated in Toronto.


ParticipantsParticipants

Primarily nurses– 71% in Toronto, 83 % in Hamilton

ICU, ER, medical and surgical inpatient units (including dedicated SARS isolation units)


Toronto Hamilton P-value

n = 587 n = 182

BurnoutMBI-EE27

30.4 % 19.2 % 0.003

Psychological distressK1016

44.9 % 30.2 %< 0.001

Posttraumatic stressIES26

13.8 % 8.4 % 0.06

Proportion of healthcare workers who report problems


Toronto Hamilton P-value

n = 587 n = 182

↓patient contact 16.5 % 8.3 % 0.007

↓work hours 8.6 % 2.2 % 0.003

smoke, drink,

other prob.21.0 % 8.1 % 0.001

4 shifts missed in 4 mo.

21.6 % 12.6 % 0.007

Proportion of healthcare workers who report problems & changes since SARS


Psychiatric diagnosisPsychiatric diagnosis

There was no difference between cities in– Lifetime history of psychiatric disorder before

SARS– Onset of new psychiatric disorder since SARS

Rates of psychiatric disorder were ≤ rates in Canadian community samples


Maladaptive copingMaladaptive coping

Escape & avoidanceI hoped for a miracleI wished that the situation would go away or be over with…

Confrontive copingI tried to get the person responsible to change his or her mindI expressed anger to the person(s) who caused the problem…

Self-blame & taking responsibilityI promised myself things would be different next timeI criticized or lectured myself…


Training, Protection and SupportTraining, Protection and Support

I had adequate training to deal confidently with the situations that I faced.

Infection control procedures were adequately explained.

The hospital where I worked took my well-being into account when decisions were made that affected me.

Emotional support (e.g. counseling) was available to those who needed help.

I felt appreciated by the hospital/clinic/my employer etc.


Things that Things that were notwere not related to adverse related to adverse outcomeoutcome

Intensity of contact with SARS patientsTreating SARS patient-colleaguesWorking in a SARS isolation unit


Conclusions and DiscussionConclusions and Discussion

ResilienceResilience

SARS does not appear to have caused psychiatric disorder in health care workersDepression

Post-traumatic stress

Other anxiety disorders

Substance abuse

Somatoform disorders


DistressDistress

In Toronto HCWs, 1-2 years after SARS

55% were experiencing at least one of:• Traumatic stress symptoms• Nonspecific psychological distress• Burnout


Functional ImpactFunctional Impact

In Toronto HCWs, 1-2 years after

SARS:21% had increased smoking, drinking or

problematic behaviour since SARS

22% had missed 4 shifts due to stress,

fatigue or illness over 4 months


Staff RetentionStaff Retention

In Toronto HCWs, 1-2 years after SARS, 22% had decreased direct patient work since SARS– Decreased direct patient contact– Decreased work hours


RecommendationsRecommendationsPre-eventPre-event

Training– Unfamiliar tasks – Unfamiliar roles

Development of effective, responsive communications

Identification of natural opinion leaders– Training, partnering with organizational

leaders

RecommendationsRecommendationsPre- eventPre- event

Attend to pre-existing distress Building the relational infrastructure in which

support will be delivered during the event Staff participation in transparent planning

process Especially regarding policy for contentious

and difficult to resolve issues– support of family/dependants– prioritizing scarce resources– distributing medications, vaccine

RecommendationsRecommendationsDuring EventDuring Event

Implementation of strategies determined in pre-event period– Communications– Psychological support

• Multiple options, personal choice

– Family & care of dependents, pets etc.– Workplace safety and security

Long-term Psychological SupportLong-term Psychological Support In some areas public

health has trained psychological support counselors

Most often we will need to connect people who need longer term support to other community resources

Knowing who in your community can provide these services is key

Community and Personal Support Community and Personal Support ServicesServices

Emergency Clothing Emergency Lodging Emergency Food Registration and

Inquiry Personal Services Reception Centre

Service

Community and Personal Support Community and Personal Support Services (1)Services (1) Community and personal support services are most

effective when they: are provided in a coordinated, timely and culturally-

appropriate manner are available for all people affected by the disaster,

including:– individuals– families– communities– groups/organisations, and– emergency service, recovery workers and volunteers;

include the affected community in their development and management

Community and Personal Support Community and Personal Support Services (2)Services (2)

facilitate sharing of information between agencies provide people with accurate and current

information about the situation and the services available

are integrated with all other recovery services enhance and support existing community

resources recognize that cultural and spiritual symbols and

rituals are an important dimension to the recovery process

involve personnel with appropriate capacities, personal skills and who know the full range of services available

Community and Personal Support Community and Personal Support Services (3)Services (3)

In major disasters or emergencies, evacuees may arrive at Reception Centres:– with minor wounds or injuries– without their medication, mobility aids – having been recently discharged from hospital – with various ailments or illnesses– experiencing medical symptoms as a result of the disaster

(e.g., rising flood waters, approaching forest fires)– with health concerns generated by the disaster (e.g., fear

that their own health or their children’s health are at risk because of exposure to toxic smoke, radiation, biochemical agents)

– from nursing homes, special care facilities, hospitals because of damage or interruption of utilities in their facility

Objectives of Personal ServicesObjectives of Personal Services

Arrange for the initial reception of disaster victims/evacuees arriving at reception centres

Provide people with information on the emergency help available

Provide temporary care (i.e. children) Provide information on financial or other aid

available Offer immediate support to people with emotional

or medical issues Assist in arranging long-term support for those in

need

Public Health Roles in Reception Public Health Roles in Reception Centres (1)Centres (1)

Providing regular inspection of all Reception Centres to ensure compliance with public health regulations

Monitoring food, water, sanitation and crowding, vector control

Carrying out water purification measures if required

Providing consultation to the Reception Centre Supervisor of all public health related activities.


Establishing surveillance for communicable disease, respiratory infections and other illnesses

Establishing procedures to detect and refer persons with medical or health problems

Assisting evacuees requiring health services (for example infants, the elderly, pregnant women)


Provide KI or other prophylactic medications or vaccinations if needed

Assisting evacuees with special needs get what they need (e.g. canes, wheelchairs)

Assisting evacuees to get prescription drugs if needed

Assisting in arranging transportation for those evacuees requiring hospitalization.

SummarySummary

We all need to know the principles of “psychological first aid’

Disasters have an impact on entire communities

Psychological impact on our staff can be great and long term but there are things we can do pre-event to mitigate

We need to define the role public health will play in providing personal support services and in reception centres in each health unit

Psychosocial Support Public health CBRN course Bonnie Henry, MD, FRCPC.

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Transcript of Psychosocial Support Public health CBRN course Bonnie Henry, MD, FRCPC.