First Responder Training: Volume 16, Issue 2

Home , Mannix, Mannix (season 4), Mannix (season 5)

A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center

The Dialogue

2021 | VOLUME 16 | ISSUE 2

First Responder Training IN THIS ISSUE 3 In This Issue 4 Contributors 6 Technical Assistance Snapshot 7 SAMHSA’s Online Training Courses for First Responders 10 P-FLASH©: An Empirically Based Disaster Mental Health Training Program 13 Training with First Responders—Lessons Learned from the U.S. Virgin Islands 15 Improving First Responder Organizational and Personal Resilience and a Guide to Self-care 20 Recent Technical Assistance Requests

The Dialogue is a quarterly technical assistance journal on disaster behavioral health which is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Technical Assistance Center (DTAC). Through the pages of The Dialogue, disaster behavioral health professionals share information and resources while examining the disaster behavioral health preparedness and response issues that are important to the field. The Dialogue also provides a comprehensive look at the disaster training and technical assistance services SAMHSA DTAC provides to prepare states, territories, tribes, and local entities so they can deliver an effective disaster behavioral health response. SAMHSA DTAC provides disaster technical assistance, training, consultation, resources, information exchange, and knowledge brokering to help disaster behavioral health professionals plan for and respond effectively to mental health and substance misuse needs following a disaster. To learn more or receive The Dialogue, please call 1–800–308–3515, email dtac@samhsa. hhs.gov, or visit the SAMHSA DTAC website at https://www.samhsa.gov/dtac.

The Dialogue is not responsible for the information provided by any web pages, materials, or organizations referenced in this publication. Although The Dialogue includes valuable articles and collections of information, SAMHSA does not necessarily endorse any specific products or services provided by public or private organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed by such sites or organizations, nor does SAMHSA warrant the validity of any information or its fitness for any particular purpose. A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center

In This Issue

Disaster response work can be very rewarding for those involved; however, it can also take a toll on your mental and physical health. First responders come face to face with terrible and highly stressful situations on a regular basis and need to develop healthy coping strategies to handle the stress. It is crucial for first responders to take steps to protect themselves from potential mental health effects, such as posttraumatic stress disorder, resulting from disaster response work.

One way to mitigate the effects of stress is support from September 11 to better prepare first responders to supervisors and coworkers. Support from organizational effectively handle the mental health needs of disaster leadership and coworkers is essential to establish a survivors. We then move to an article written by a first work environment that encourages responders to feel responder who provided disaster behavioral health safe to seek help if needed. Additionally, organizations training in the U.S. Virgin Islands after Hurricanes should clearly define roles during response efforts to cut Irma and Maria. We conclude the issue with an down on potential sources of stress. Responders should article from a law enforcement trainer on improving also keep in mind that situations may change once the organizational and personal flexibility after a disaster response begins. Flexibility is key! among first responders. This article also addresses the importance of self-care. Prior to deployment, proper training to educate first responders about the mental health needs of survivors Do you know of a training that would benefit first may encourage responders to feel more confident in responders? We encourage you to contact us to share their ability to help survivors. First responders also need your recommendations. ■ to be trained to assess their own mental health as well as their coworkers’. Stress management techniques are Captain Erik Hierholzer, B.S.N. Program an important tool for first responders. These pre-disaster Management Officer, Emergency Mental Health and actions may lead to decreased on-the-job stress. Traumatic Stress Services Branch [email protected] This issue of The Dialogue focuses on trainings available for first responders to help mitigate the stress Nikki Bellamy, Ph.D. Public Health Advisor, and trauma they encounter every day on the job. We Emergency Mental Health and Traumatic Stress start off the issue with an article about the first responder Services Branch trainings developed by the Substance Abuse and [email protected] Mental Health Services Administration (SAMHSA) Shannon Loomis, M.A. Director, SAMHSA DTAC Disaster Technical Assistance Center (DTAC). These [email protected] trainings are available online, free of charge. The next article discusses a training curriculum developed after

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Contributors

Barry A. Hong, Ph.D., ABPP grants and contracts policy review and approval process, is a Professor of Psychiatry at the Office of Management and Budget clearance Washington University School process, and the indefinite delivery/indefinite quantity of Medicine. He holds joint competition process. Ms. Mannix worked in several appointments in the Department other capacities within SAMHSA developing and of Medicine and in the enhancing program analysis, leading business process Department of Psychology. He is the Vice-Chairman for improvement efforts, and providing expertise in several Clinical Affairs in Psychiatry and the Chief Psychologist key program areas such as disaster preparedness and for Barnes-Jewish Hospital. He is an active researcher response and suicide prevention. In 2005, Ms. Mannix funded by the National Institutes of Health (NIH) served as the Incident Commander for the Hurricane concerning living organ donors, hepatitis C treatments, Katrina, Rita, and Wilma responses—a 24/7 job—for and the study of interstitial cystitis (functional pain). He the SAMHSA Emergency Response Center. Under her has been one of a team of NIH investigators who have leadership, SAMHSA deployed or arranged for the conducted medical and psychological follow-up studies deployment of nearly 3,000 mental health and substance of over 2,500 living kidney donors and several hundred use professionals to assist the states and communities living lung donors from multiple transplant centers. disrupted by Hurricanes Katrina and Rita. Ms. Mannix Presently, he is working with the National Living Donor trained agency personnel in the incident command Assistance Program, a project which has facilitated over structure, functions, and roles as the agency was 5,000 living kidney transplants. Together with Dr. Carol implementing it and delivering services. Ms. Mannix North, he has published on disaster mental health and also visited the affected states to provide oversight to the posttraumatic stress disorder. disaster behavioral health teams, liaise with local and state officials to better understand ongoing needs, and provide technical assistance. Brenda Mannix, LMSW is an Emergency Medical Services Lieutenant at the Rockville Carol S. North, M.D., M.P.E., Volunteer Fire Department DLFAPA serves as Medical where she has served for over Director of the Altshuler Center 7 years. She is also the Vice for Education & Research at President of the organization. Ms. Mannix is a licensed Metrocare Services in Dallas, master of social work working as a consultant. In Texas. Holding the Nancy and addition, she also works as an instructor at Montgomery Ray L. Hunt Chair in Crisis Psychiatry, she is a board- College. Ms. Mannix has 22 years of experience certified Professor with tenure in the Department of working with the SAMHSA and other federal agencies, Psychiatry at The University of Texas Southwestern including her role as Special Assistant to the Deputy Medical Center in Dallas, Texas, where she is Director Administrator of SAMHSA. In that capacity, Ms. of the Division of Trauma and Disaster. Dr. North Mannix led a wide range of efforts to improve policy completed medical school and residency training and operations within the agency, such as changing the in psychiatry at Washington University School of

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Medicine in St. Louis, Missouri, followed by a National Diversion, to include Crisis Intervention Team training, Institute of Mental Health postdoctoral fellowship and and homeless outreach. She also co-led a DHS-wide a master’s degree, both in psychiatric epidemiology, at Trauma-informed Care Initiative. She functioned as the the same institution. Dr. North has been an international Mental Health Liaison to the Arlington County Police leader in shaping the science of disaster mental health, Department’s Crisis Negotiation Unit. Ms. Weisman is continuously conducting federally funded research for an adjunct instructor at the Northern Virginia Criminal more than a quarter of a century, and has studied 3,500 Justice Academy where she trains law enforcement and survivors of 15 major disasters of all types. dispatchers on trauma, self-care, flexibility in times of trauma, mindfulness, and meditation. She has presented at local, state, regional, and national conferences Leslie Weisman, LCSW has related to emergency mental health and the provision over 30 years of experience in of mental health expertise to law enforcement. Ms.

the mental health and criminal Weisman is certified in Psychological First Aid Training

justice sectors. She retired from and Critical Incident Stress Debriefing. Ms. Weisman Arlington County, Virginia, as a was a participant on the Diane Rehm Show (nationally Bureau Chief in the Behavioral syndicated NPR production) in December 2012, Healthcare Division of the Department of Human representing the community mental health perspective Services (DHS). Ms. Weisman provided oversight to after the Sandy Hook tragedy. She is a licensed clinical the Crisis Intervention Center, intake and discharge social worker in Virginia as well as a registered yoga planning services, Forensic Case Management/Jail teacher with a certification in yoga for first responders.

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TECHNICAL ASSISTANCE SNAPSHOT Views of SAMHSA’s Online Training Courses for First Responders August 2016–September 2020

30K 29K 28,670 VIEWS 28K 27K 26K 25K 24K 23K 55,345 22K TOTAL VIEWS 21K 20K 19K 18K 17K 16,327 VIEWS 16K 15K 14K 13K 12K 11K 10K 9,232 VIEWS 9K 8K 7K 6K 5K 4K 3K 2K 1,116 VIEWS 1K Creating Safe Sheild of Service to Self First Response Scenes Resilience POSTED AUGUST 2018 POSTED AUGUST 2020 POSTED AUGUST 2016 POSTED AUGUST 2017

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SAMHSA’s Online Training Courses for First Responders By SAMHSA DTAC Staff

First responders are Shield of Resilience disproportionately affected by is now a mandatory disaster behavioral health issues. In training for the 36,000 fact, 30 percent of first responders officers in the New York experience substance use and/or City Police Department, mental health issues, including, but not limited to, depression the largest police and posttraumatic stress disorder department in the country. (PTSD), as compared with 20 Source: Rayman, 2019 percent in the general population (Abbot et al., 2015). First responder jobs—within law enforcement, training—especially if it focuses on and to learn where and how to reach emergency medicine, and seeking mental health and substance out to for help. firefighting—are physically and use or emotional support. Too often emotionally demanding and stress- the “hero” culture or the “suck it The intention is for training inducing. Studies have shown that up” mentality prevails, resulting coordinators within departments levels of PTSD in first responders in stigma—or the fear of being and agencies to share these trainings are comparable to levels among labeled—and preventing someone with groups of first responders war veterans, specifically those in needing help from seeking it. or require that they complete the the Iraq and Vietnam Wars (Berger, courses individually. SAMHSA 2012). SAMHSA DTAC has developed DTAC is also working with several four free, online trainings for first police departments across the Over the past several years, responders. These trainings were country, including the New York SAMHSA DTAC has been designed to help anyone from a City Police Department, who have reviewing and publishing content rookie police officer to a seasoned adapted a course into their own surrounding mental health and emergency medical technician learning management systems substance use concerns for first (EMT) to a career firefighter for training use for hundreds, or responders. While the scope of this improve their awareness and thousands, of first responders. problem seems to be expanding, understanding of the mental health there remains a dearth of resources and substance use effects emergency Each course was developed based available to address it. While high- response may have on themselves on research and an environmental quality trainings exist, they are and their peers. These courses scan of existing trainings on these typically hours—or days—long and are meant to help first responders topics. Beyond videos, the courses require approvals for attendance and understand not only their increased contain interactive features and often a fee to complete. The fast- risk for mental health and substance assessment tools such as quizzes, paced, on-the-go nature of a first use issues, but also how to act—by scenarios, and a final exam. Real responder’s job makes it difficult learning the signs and risk factors to first responder faces and voices from to prioritize a classroom-style note in themselves and their peers, various professions and departments

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This free, 1-hour, online course provides law enforcement officers with a foundational skill set to better understand and address the stressors that are unique to law enforcement.

Mental health and substance use issues are the most significant risk to the safety of law enforcement come alive in these trainings to offer After completing this course, you officers. their peers an authentic experience. will be able to do the following: Shield of Resilience is a training Further, SAMHSA DTAC worked • Describe the opioid crisis, course that helps law enforcement with active duty and retired first including its extent and how it officers learn to recognize signs and responders to develop and review symptoms of stress, depression, the course content to ensure affects the critical work that first responders do. posttraumatic stress disorder accuracy and relevancy. (PTSD), and suicidal thoughts and Following are brief descriptions of • Describe mental health and actions. each course and its objectives. substance use issues and mental and substance use disorders that This course will suggest ways to develop and build the ability to First Response: Working on are more common among first recovery quickly after a trauma, and the Front Lines of the Opioid responders than the general public. offer tips on where and how to seek Crisis • Recognize the warning signs of help, if it is needed. According to the Centers for Disease mental and substance use disorders Control and Prevention (CDC), drug in yourself and your peers. Shield of Resilience helps law overdoses claimed more than 630,000 enforcement officers understand the lives from 1999 to 2016—and roughly • Help reduce stigma, or negative following: 66 percent of those deaths involved an and incorrect ideas about mental and opioid, either prescription or illicit (CDC, substance use disorders—including • The unique stressors that law

2018, September 10). the nature of opioid use and misuse, enforcement officers are exposed to opioid use disorder, and addiction, in the course of their duties

This free, 1-hour, online training and the needs of first responders. course was developed in response • How to recognize the signs and to the impact of the opioid crisis • Identify and use stress management symptoms of acute and chronic on first responders across the and healthy coping strategies. stress, depression, and PTSD country. It addresses the mental • Share evidence-based practices and • The signs and symptoms of and physical stressors faced by suicidal ideation and how to talk resources for self-care and positive firefighters, emergency medical responses to work stress. with a fellow officer who may be services personnel, and police when experiencing suicidal thoughts responding to opioid overdose calls. Shield of Resilience: A Course This course is accredited by the • How to facilitate peer-to-peer for Law Enforcement Officers Commission on Accreditation for mental health and substance use

Pre-Hospital Continuing Education Law enforcement officers are more likely issues support (CAPCE). to die by suicide than in the line of duty (Heyman et al., 2018). 2021 | VOLUME 16 | ISSUE 2 | PAGE 8 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center

Studies of the psychological impact of disasters on responders show that provision of pre-disaster training and information enables individuals to be emotionally and cognitively ready for what they may face, leading to better well-being outcomes. Source: Brooks et al., 2016

• The resources and support tools mental health and substance use Creating Safe Scenes helps first that help build flexibility during issues in yourself and your peers. responders: recovery • Discuss mental health and • Understand how individuals come • Where to find help and support for substance use-related issues with to experience a mental health or themselves or fellow officers colleagues to help reduce stigma. substance use crisis

Service to Self: Behavioral • Identify and use stress management • Understand how best to make a Health for Fire and EMS and healthy coping strategies. safe connection with an individual Personnel experiencing a crisis • Be aware of and share evidence- Individuals serving dual emergency based practices and resources for • Learn about de-escalation medical services (EMS)/firefighting roles increasing capacity to cope with strategies for working with people had six times the likelihood of suicide occupational stressors. in crisis attempts as compared to those serving in firefighting roles only (Stanley et al., Creating Safe Scenes: • Learn strategies for developing 2016). A Training Course for community networks and referral First Responders Helping resources Service to Self: Behavioral Health Individuals in Crisis for Fire and EMS Personnel • Understand how to improve the is accredited CAPCE. Course People with mental illness may be safety of both the responder and the participants complete a final exam to more vulnerable to injury because individual in crisis obtain continuing education credit. officers misinterpret their behavior and demeanor (Kerr et. al, 2014). That these training courses have This 60-minute course includes been viewed and shared by first relatable firsthand video accounts Creating Safe Scenes helps first responders thousands of times since from volunteer and career responders use safe, positive their posting on the SAMHSA firefighters and EMTs, as well as approaches to assist individuals website is a positive indication that helpful resources and interactive in mental illness or substance use we are addressing the very real components to support learning. crisis. The course, which is CAPCE mental health and substance use

accredited, is designed to help first issues first responders face. The This course is designed to help responders understand more about common goal of these courses is firefighters and EMS personnel to: mental health, mental illness, and to help make it easier to talk about substance use disorders so they can • Be aware of risk factors for these realities, and to acknowledge better assess risks and apply the that asking for help is an important and prevalence of mental health safest strategies for taking care of and substance use issues in their way to care for ourselves and one themselves and the individuals in another. ■ professional communities. crisis. Course participants complete

• Recognize the warning signs of a final exam to obtain continuing education credit.

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P-FLASH©: An Empirically Based Disaster Mental Health Training Program By Barry A. Hong, Ph.D., ABPP and Carol S. North, M.D., M.P.E., DLFAPA

Mental health and healthcare The September 11th Fund response and research efforts. With professionals, first responders, was created by the New York input from local expert consultants, and others who work with disaster Community Trust and the United we produced the “Practical Front survivors must be prepared to Way of New York City to address Line Assistance and Support for respond effectively to mental health the psychosocial needs of 9/11 Healing” (P-FLASH©) training needs. Well-designed training victims and their families through program (North et al., 2008). programs can support this mission. both direct services and training New York City’s mental health programs. The Fund contracted The P-FLASH curriculum was community was largely unprepared with us to develop and deliver a delivered in a day-long presentation to meet the psychological needs 9/11 disaster response curriculum to groups of 12–25 mental health of survivors after the September similar to the mental health training professionals. P-FLASH was 11, 2001, terrorist attacks on the we had created for St. Louis area distributed by local professionals World Trade Center. Few mental community leaders after the great to encourage communities to health professionals in the area had Midwestern floods of 1993. We were continue using it after we developed experience caring for distressed joined by Dr. Betty Pfefferbaum, the original program. A 2-day survivors of large-scale disasters or who provided child and family “train-the-trainer” model for local training to prepare them for their disaster mental health expertise presenters was organized around new roles in disaster mental health. from her Oklahoma City bombing an easy-to-follow slide deck and a

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manual with detailed background for each slide, imparting consistency of presentation and fidelity to the curriculum.

Sections of the P-FLASH curriculum cover 1) empirical disaster mental health research, providing the foundation for disaster response; 2) assessment of mental health needs, which is fundamental to choosing effective interventions; and 3) formal treatment and other interventions. An important feature of P-FLASH is that it builds from empirical disaster mental health research in establishing decision paths for assessment and intervention efforts (summarized in other publications, such as North et al., 2018, and North et al., 2013). recover quickly from psychological mental illnesses linked to disaster, The P-FLASH curriculum provides difficulties. Research findings is a reasonable initial focus of detailed instruction on treatment of show that only 30–45 percent of assessment. People must be exposed PTSD and other post-disaster mental people exposed to disasters develop to trauma to be diagnosed with illness, and Psychological First Aid PTSD or other psychopathology. PTSD, which is usually the most (PFA) for psychological distress, Most people, however, experience prevalent post-disaster disorder, directed by assessment findings. psychological distress. Thus, occurring in 20–35 percent of Four enduring principles of disaster individuals providing mental health people; major depressive disorder is mental health response summarize assistance after disasters are more typically second in frequency. These relevant scientific findings likely to encounter survivors with disorders may lead to substantial to organize disaster response emotional distress than mental suffering and functional impairment, recommendations. illness. Clinicians may see survivors thus requiring attention. Because with emotional and behavioral PTSD is usually comorbid with The first principle is that post- responses to disasters that they other disorders, assessment and disaster mental illness must be have not previously encountered. treatment must be more broadly separated from the distress people They also may need to adopt new focused than for PTSD alone. Self- commonly experience after a approaches to provide care in report symptom questionnaires may disaster. This difference is critical for nontraditional settings; conduct be useful for screening and referring choosing interventions appropriate focused, rapid assessment; and have to treatment, but diagnosis requires to needs: mental illness requires effective encounters with individuals assessment of full psychiatric professional treatment, but distress they see only one time. criteria and is needed for choosing can be addressed through crisis appropriate treatment. Psychiatric counseling and PFA. Many do not The second principle is that PTSD, symptoms usually begin quickly, realize that disaster survivors often the signature diagnosis among but they must last at least 1 month 2021 | VOLUME 16 | ISSUE 2 | PAGE 11 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center

for a diagnosis of PTSD and at least drug use disorders. Individuals vulnerable groups. Women have 2 weeks for a diagnosis of a major with preexisting substance use twice the risk for PTSD and post- depressive episode. Recovery may disorders may need extra support disaster depressive and anxiety not occur for months or years if at after disasters, and the post-disaster disorders, but men have higher all, highlighting the need for mental setting may be an opportunity for risk for substance use disorders. health services over the long term. identification and care of these Preexisting mental illness doubles disorders. the risk for development of PTSD. The third principle is that alcohol These factors are even stronger and drug use after disasters may The fourth principle is that predictors of PTSD than severity increase somewhat over limited understanding the risk for post- of trauma exposure. Major timeframes, but disasters do not disaster mental illness can help avoidance and numbing symptoms regularly lead to new alcohol or focus efforts toward the most are strong predictors of PTSD, whereas intrusion and hyperarousal symptoms without prominent avoidance and numbing largely reflect more common varieties of post-disaster distress.

The P-FLASH curriculum features separate modules tailored for first responders, clergy, child and day care center providers, medical practitioners, and medical centers. With assistance from the New York Mental Health Association, more than 5,000 people completed P-FLASH training during funding years 2002 through 2004. The full P-FLASH training was later expanded to other centers across the United States, and modified versions were developed for briefer presentations and disseminated through web-based training. Check out the SAMHSA DTAC Supplemental Research Bulletin edition, Disaster Behavioral Health Interventions Inventory, For more information about to learn more about the full range of disaster behavioral health P-FLASH, please contact Dr. interventions. This publication lists interventions that can be used Carol North at carol.north@ in the early, intermediate, and long-term disaster response phases utsouthwestern.edu. ■ to help survivors cope with the most common reactions. For each intervention, a table lists delivery modality and settings and populations for whom the interventions can be used.

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Training with First Responders—Lessons Learned from the U.S. Virgin Islands By Brenda Mannix, LMSW

The U.S. Virgin Islands requested assistance from SAMHSA DTAC in developing an in-person training for their first responders to help first responders better assist individuals in a disaster behavioral health crisis. Over several months I worked with SAMHSA DTAC and the U.S. Virgin Islands to scope out an in-person training designed for law enforcement, fire, and emergency medical services. Some community members may attend but the target audience was traditional first responders. Several factors complicated the design of Hurricane Maria, Saturday, September 23, 2017. Satellite image by National Oceanic and Atmospheric this training, including: Hurricane Administration (NOAA). Maria destroyed much of the infrastructure so many services two sessions were held per day. Our How they interacted independently necessary to support individuals desired training outcome was very and together to support individuals with mental health and substance use simple—have responders walk out in a mental health or substance issues were no longer available; staff of the room feeling they had learned use crisis varied by island and the shortages among first responders something they could immediately community resources available on created increased workload on top use. According to post-training that island. For example, for all the of their personal recovery needs; evaluations, we were successful with training sessions on St. Croix, only and managing training time so as not most participants saying they wished the police attended along with a to create more stress for the public they had more training time or more few clergy. The police played the safety system. frequent opportunities to have this primary role in assisting individuals training. In addition, we learned in crisis. It is also important to Ultimately, the training format three key lessons: understand that even first responders would be a 4-hour in-person training may be unclear about each other’s modeled after SAMHSA DTAC’s 1. First responders have separate role. In one session a spirited online training Creating Safe cultures and different roles to play exchange occurred between law Scenes. The training included stress in public service. It is essential to enforcement and EMS over a management for first responders and understand those roles. For example, perceived lack of support for each role-playing exercises. To meet the in the U.S. Virgin Islands, police, other’s roles. Law enforcement

U.S. Virgin Islands’ goal of training fire, and emergency medical services believed that EMTs were not helpful as many responders as possible, (EMS) are three separate systems.

2021 | VOLUME 16 | ISSUE 2 | PAGE 13 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center when called to a scene to assist requirements. Nearly all of the mental illness is not a crime. It’s police after taser deployment. EMTs first responders I spoke with were okay to assess the situation and do tried to explain they could not personally affected by the hurricane nothing in terms of transporting to remove the prongs on scene. Law and many were still not back in the hospital or arresting. Referring to enforcement was also frustrated their homes. All of the participants other agencies or organizations (for when EMTs called for assistance reported severe staff shortages at example, food banks, housing, etc.) with a patient because they were not their organizations, increasing the would be helpful if such services sure what the EMTs wanted them workload on those that remained. exist. (2) Skip the PowerPoint and to do. As a nationally registered Recognizing and attending to their the statistics and focus on role- EMT myself, I was able confirm the mental and emotional health needs, playing de-escalation strategies EMT’s assertion that they are not allowed them to be more open using examples the participants allowed to remove the prongs from and empathetic to individuals with have. Allow them to act out past a taser deployment in the field. This mental health and substance use situations with an instructor’s can only be done at the emergency challenges. support and feedback. Background room by a physician. I was also information on the prevalence of able to help the police understand 3. First responders want better mental illness and substance use that EMS receives no training on information and training on disorder can be woven in. The best restraints or holds so sometimes the helping individuals with mental session I ran was on St. John where police are needed to help protect health and substance use needs. there was no projector or screen, so EMTs while they are assisting They feel the pressure of aiding no PowerPoint. We had a lot more someone in crisis. when citizens call 911 about an time for role-playing. (3) Role- individual in crisis when there playing is incredibly effective at 2. Attend to first responder stress are few if any mental health and both modeling skills (instructor) levels first. This training occurred substance use services to access in and allowing participants to practice nearly 2 years after Hurricane the community. There are really safely. Two instructors would be Maria and the police were just three key subcomponents to this ideal. relieved of mandatory overtime lesson: (1) Gentle reminders that As a first responder and a social Dolores Harvey/stock.adobe.com worker it was a privilege to bring these skills together for the U.S. Virgin Islands’ first responders. I was incredibly heartened at the level of participation in the training and the desire to better understand the needs of individuals in a crisis. Communities interested in learning more about first responder trainings should visit the SAMHSA DTAC website for resources including online training courses available to first responders free of charge at https://www.samhsa.gov/DTAC/ education-training. ■

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Improving First Responder Organizational and Personal Resilience and a Guide to Self-care By Leslie Weisman, LCSW

Given the well-documented and responder culture is the “ability efforts are more likely to have sobering statistics related to first to survive a crisis and thrive in a personnel who experience less responder suicide and the prevalence world of uncertainty…it is not just stress overall and higher quality of PTSD, it is imperative that first about getting through the crisis performance. responder organizations become but the foresight and situational trauma-informed and knowledgeable awareness to prevent future To improve organizational resilience related to resilience. Statistics show crises from emerging” (Resilient an agency must integrate knowledge that no less than a third of first Organizations Ltd). In addition, about trauma, resilience, and responders will suffer from some first responder agencies must self-care into their policies and form of acute posttraumatic stress remain focused on maintaining procedures. They recognize the during their career (“Changing a trauma-informed organization. need to develop programs that Police Culture: 5 things cops need This type of organization is based promote whole body health as well to know about PTSD” – PoliceOne. on a solid understanding of the as resilience. These organizations com – June 2016). For organizations physical, psychological, and recognize the potential negative and individuals to fully grasp the social effects of trauma. Per the consequences of the work and importance of resilience, they need Law Enforcement Mental Health they assume responsibility for to fully understand the deep and Wellness Act of 2017, it is highly proactively addressing the effect lasting effect of trauma and the scars recommended that agencies “support of vicarious trauma through their it can leave within the body and the the identification, development, and policies and procedures (Office of psyche. delivery of successful resiliency Justice Program’s Vicarious Trauma training programs…” The focus Toolkit). This includes trauma- How to Improve Organizational must be on developing resilience to informed supervision where the

Resilience the constant onslaught of stress and effect of the calls and the events that

There are many definitions of learning the skills of self-regulation. occur in the field are reviewed by a organizational resilience but Organizations that undertake these commander with the first responder, one that is most fitting for first not just for tactical soundness but to ensure the mental wellness

Police and firefighters The Ruderman White Paper on Mental take their life Health and Suicide of First Responders 20% more states that firefighters and often than the law enforcement officers are more likely to die by suicide general public. than from a line-of-duty death.

Source: Heyman et al., 2018 Source: Heyman et al., 2018

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of the responder. Departments need to provide their staff a range Stress Management Tips for First Responders of mental health and substance misuse services and these should and Disaster Responders be introduced and normalized from • Know your role during a disaster. hiring through—and past—retiring. By normalizing these conversations • Develop a self-care plan prior to and incorporating them into each deployment, and use it during deployment. department’s culture, there is less • Practice stress management during all stigma associated with seeking help phases of the disaster response effort. and acknowledging when there are challenges in the ranks. • Involve loved ones in your preparation and planning activities. For organizations to be resilient • Make sure you have an individual and family there needs to be a focus on the preparedness plan to cover loved ones if general wellness of staff. Agencies should encourage and incentivize the disaster is in your community. wellness activities like yoga, For more information on how to manage the stress of deployment to a meditation, and other forms of disaster, please see SAMHSA DTAC’s Tips for Disaster Responders: exercise. Trainings should be Preventing and Managing Stress at https://store.samhsa.gov/product/ provided that specifically reference sma14-4873. the chronic emotional stress inherent in first responder work and the importance of self-care. Organizations will do well to to be resilient is not static and can There are many aspects to resilience emphasize social cohesion among both grow and dissipate depending to include cultural, racial, and ethnic staff and create opportunities for on circumstances in a person’s life. characteristics. Resilience can be workplace connectedness. High rates A person’s ability to be resilient can seen in workers with strong family of suicide may be partially due to a be eradicated following an acute bonds, in those who have strong sense of isolation and the stigma of trauma or it can be strengthened practices of a spiritual or religious mental health issues that still prevail through a process of self-reflection, nature, and those who use humor in in many departments. surrounding oneself with supportive their life and in their work as well friends, family, and colleagues. as creativity. Resilience can also be How to Improve Personal A truly resilient first responder seen in those workers who practice Resilience can successfully move from one healthy coping skills and have an Resilience has been defined as challenging event to the next without ability to stay present and mindful. the ability to bounce back or rise undue emotional struggle. Through These workers value strong, safe above adversity. To be resilient in a proactive approach to resilience, relationships where one can give and this work, is to use one’s internal the first responder will more easily receive support. resources to negotiate hardship and grow from adversity and find the look closely at the results of adverse posttraumatic growth necessary to Self-care for First Responders events on the mind and body. It is continue the work. Per Blue H.E.L.P., a non-profit critical to recognize that the ability organization that collects data on

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police suicide and supports families effects of stress and trauma in a wide will increase one’s resilience and in the aftermath, first responders variety of ways both mental and lead to a more successful career and have high rates of suicide, PTSD physical. An attitude of gratitude, a longer life expectancy. to include cumulative PTSD, and despite the horrors that have been other serious medical issues. Life experienced, will help to keep the For more information about expectancy is notably shorter than mind in a more positive place. Not the signs of stress and stress civilians. If first responders are to surprisingly, more physical exercise management, visit the SAMHSA live a longer, fuller life, the need for will result in fewer physical ailments DTAC First Responders and self-care is paramount. This begins and bring increased serotonin and Disaster Responders Resource with a healthy work and life balance therefore a more optimistic outlook. Portal. ■ where each individual leaves space In addition, it is critical to maintain and time to care for their mind, a healthy diet, reduce caffeine, The following page is an body, and spirit. sugar, and nicotine, monitor alcohol informational pullout poster consumption, and get enough sleep. that you can print and post. It First responders have a significant provides information on ways task in their need to regulate stress. To conclude, it is essential for first first responders can reduce As is now well known, the body responders to connect the dots and survivor stress. “keeps the score” and shows the see that practicing daily self-care

The body “keeps the score” and shows the effects of stress and trauma in a wide variety of ways both mental and physical.

2021 | VOLUME 16 | ISSUE 2 | PAGE 17 A Quarterly Technical Assistance Journal on Disaster Behavioral Health First on the Producedscene by the SAMHSA Disaster Technicaland Assistance Centerneed to reduce disaster survivors’ distress? Provide Psychological First Aid (PFA):

Respond to requests and Empower people to take initiate contacts in a non- steps to meet their needs. intrusive, compassionate, and helpful way. Keep families together or help people contact friends Help people meet basic and family. needs and help them COMMON STRESS feel safe. SYMPTOMS Provide information about common stress reactions Calm emotionally and coping. overwhelmed or disoriented individuals. Link people with available services. Identify immediate needs and concerns.

ADDITIONAL RESOURCES:

Disaster Distress Helpline: 1–800–985–5990 PFA Online Course from the National Child Traumatic Stress Network and National Center for Posttraumatic National Suicide Prevention Lifeline: Stress Disorder: https://www.nctsn.org/resources/ 1–800–273–TALK (1–800–273–8255) psychological-first-aid-pfa-online. The Substance Abuse and Mental Health Services SAMHSA Disaster Technical Assistance Center website Administration (SAMHSA) National Helpline: at https://www.samhsa.gov/dtac or call us at 1–800– 1–800–662–HELP (1–800–662–4357) 308–3515.

Source: National Child Traumatic Stress Network (n.d.). About PFA. Retrieved from https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for- psychological-recovery/about-pfa

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 2020 | VOLUME 16 | ISSUE 2 | PAGE 18 1 ––––––––– 877 SAMHSA 7 (1 877 726 4727) • 1 800 487 4889 (TTY) • https://www.samhsa.gov A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center

RECOMMENDED RESOURCES

Disaster Behavioral Health Planners Resource Portal Disaster Behavioral Health Online Training The SAMHSA DTAC has developed a Disaster This free, 1-hour online training from the University Behavioral Health Planners Resource Portal to help of Washington Northwest Center for Public Health you find resources to assist and strengthen your disaster Practice was developed for public health workers behavioral health plans. The portal includes relevant looking to learn more about the psychological phases of issues of SAMHSA’s Supplemental Research Bulletin, a community-wide disaster. It covers disaster behavioral podcasts, webcasts, the Crisis Counseling Assistance health outcomes that usually occur, abnormal reactions and Training Program Toolkit, and more. that may require further help, and more.

Find the resources at https://bit.ly/2Nmz7WO. Find the training at https://bit.ly/2pDydMV.

Approaching Alzheimer’s: First Responder Training Crisis Management for School-Based Incidents— This training was developed by the Alzheimer’s Partnering Rural Law Enforcement, First Association for first responders with input from first Responders, and Local School Systems responders. Understanding Alzheimer’s is important to This 8-hour first responder training from the Rural ensuring your response is appropriate when providing Domestic Preparedness Consortium was developed for support to a person with dementia. This training delivers rural law enforcement personnel, school administrators, an interactive format on learning how to respond to teachers, and staff. It provides information on how to these types of calls and related topics you can explore in respond to an emergency in a K–12 environment and detail. establishing a school-based emergency response plan.

Find the course at https://bit.ly/2pLEm9y. Find the course at https://bit.ly/2JhIc4l.

Dealing with Stress in Disasters: Building Psychological Resilience This online training from the Institute of Massachusetts is intended for emergency responders and public health workers to better understand stress. This 2-hour training summarizes the three major types of stress and the effects it has on health. The course teaches participants how to identify compassion fatigue, risk factors, and provides coping strategies to help ease stress.

Find the course at https://bit.ly/2pfbXZj.

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Recent Technical Assistance Requests In this section, read about responses SAMHSA DTAC staff have provided to recent technical assistance (TA) requests. Send your questions and comments to [email protected].

Request: SAMHSA DTAC received a TA request Request: SAMHSA DTAC received a TA request from a first responder looking to train local first from a disaster behavioral health professional requesting responders in his state to prepare them for an upcoming resources on working with and managing disaster large-scale event. response volunteers.

Response: SAMHSA DTAC provided the following Response: SAMHSA DTAC provided the following resources: resources:

Online Disaster Behavioral Health Trainings—This Successful Strategies for Recruiting, Training, and installment of the SAMHSA Disaster Behavioral Utilizing Volunteers—This guide from SAMHSA Health Information Series is a comprehensive provides information for helping to manage collection of online trainings for disaster behavioral volunteers, including training and evaluating them. health professionals and first responders. Find the Find the guide at https://www.samhsa.gov/sites/ installment at https://www.samhsa.gov/dbhis- default/files/volunteer_handbook.pdf. collections/online-trainings?term=Online%20 Training%202018-DBHIS. Managing Spontaneous Volunteers in Times of Disaster—This training from the Corporation for The Rural Domestic Preparedness Consortium— National and Community Service provides information Their website offers several online trainings for first and activities for professionals who may be in the role responders. Several of them cover topics such as of managing disaster response volunteers. The training terrorism and event security planning. The website can is available at https://www.nationalservice.gov/sites/ be found at https://www.ruraltraining.org/training/ default/files/resource/hon-cncs-msvtd_participant_ online. materials.pdf.

U.S. Department of Homeland Security’s Training Resources—This web page has some information Help Improve SAMHSA’s Disaster for training first responders on a wide range of topics Services and Products including bioterrorism, emergency preparedness, and As a subscriber to this suicide prevention. Find the web page at https://www. newsletter, you are dhs.gov/science-and-technology/frg-training. invited to participate in a short, web-based The National Consortium for the Study of survey to provide the Terrorism and Responses to Terrorism—Their SAMHSA Disaster website offers resources, information, and training Technical Assistance Center (DTAC) with for better understanding terrorism and a community’s feedback about your experiences with our ability to bounce back after a disaster. Find the website products and services. The survey should take no at https://www.start.umd.edu/training. more than 15 minutes. Complete the survey by clicking on this link, or copy and paste the URL https://iqsolutions.qualtrics.com/jfe/form/SV_ bjYCSJDUQAGi1h3 into your web browser.

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Capability 15: Volunteer Management—This Trauma and Your Family—This tip sheet from The Centers for Disaster Control and Prevention planning National Child Traumatic Stress Network provides document on volunteer management clearly outlines information for families on the causes and symptoms public health volunteer capabilities. The document is of traumatic stress. It also provides some coping available at https://www.cdc.gov/cpr/readiness/00_ strategies. The tip sheet is available at https://www. docs/capability15.pdf. nctsn.org/resources/trauma-and-your-family.

Request: SAMHSA DTAC received a TA request for Risk and Resilience Factors After Disaster and traumatization resources for communities that have been Mass Violence—This web page from the U.S. re-affected by disasters. Department of Veterans Affairs includes information on the risk and protective factors for individuals Response: SAMHSA DTAC provided the following experiencing traumatic events such as disasters. resources: Find the web page at https://www.ptsd.va.gov/ . Tips for Survivors of a Disaster or Other Traumatic professional/treat/type/disaster_risk_resilience.asp Event: Coping with Retraumatization—This tip Post-disaster Retraumatization: Risk and Protective sheet from SAMHSA DTAC provides information for Factors—This SAMHSA DTAC webcast informs survivors who have been retraumatized by a disaster. disaster behavioral health professionals about It lists the signs and symptoms of retraumatization the concepts and signs of retraumatization and and provides suggestions for building flexibility associated risk and protective factors, and highlights after a disaster. The tip sheet can be found at https:// promising treatment strategies and tips for avoiding store.samhsa.gov/product/Tips-for-Survivors-of-a- retraumatization. The webcast is available at https:// Disaster-or-Other-Traumatic-Event-/sma17-5047. www.youtube.com/watch?v=1O7w6pu4BdI&list=P LBXgZMI_zqfRcTt9ndxkbieQ-pQslk-R6. ■

Are you looking for disaster behavioral health resources? Check out the new and updated SAMHSA DTAC Disaster Behavioral Health Information Series (DBHIS) installments.

https://www.samhsa.gov/dtac/dbhis-collections

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REFERENCES

Abbot, C., Barber, E., Burke, B., from https://rudermanfoundation.org/ Rayman, G. (2019, August). NYPD Harvey, J., Newland, C., Rose, white_papers/police-officers-and- orders cops to take mandatory M., & Young, A. (2015). What’s firefighters-are-more-likely-to-die-by- suicide prevention training. killing our medics? Ambulance suicide-than-in-line-of-duty Daily News. Retrieved from Service Manager Program. Conifer, https://www.nydailynews.com/ CO: Reviving Responders. Kerr, A. N., Morabito, M., & Watson, new-york/nyc-crime/ny-suicide- Retrieved from http://www. A. C. (2010). Police encounters, prevention-training-20190816- revivingresponders.com/originalpaper/ mental illness and injury: An mlyvmvh53vgndeg7pxsu2d523u- pt5lehsknczsaofld89leijbmehz3c exploratory investigation. Journal story.html of Police Crisis Negotiations: An About NYPD. (n.d.). Retrieved from International Journal, 10, 116–132. Stanley, H., Hom, M. A., & Joiner, https://www1.nyc.gov/site/nypd/ doi:10.1080/15332581003757198 T. E. (2016). A systematic review about/about-nypd/about-nypd- of suicidal thoughts and behaviors landing.page North, C. S., Downs, D. L., & Hong, among police officers, firefighters, B. A. (2018). PTSD: A systematic EMTs, and paramedics. Clinical Berger, W., Coutinho, E. S. F., Figueira, approach to diagnosis and treatment. Psychology Review, 44, 25–44. doi: I., Marques-Portella, C., Luz, M. Current Psychiatry, 17, 35–43. 10.1016/j.cpr.2015.12.002 P., Neylan, T. C., Marmar, C. R., & Mendlowicz, M. V. (2012). Rescuers North, C. S., Hong, B. A., & The Dialogue is not responsible for the at risk: A systematic review and Pfefferbaum, B. (2008). P-FLASH: information provided by any web pages, meta-regression analysis of the Development of an empirically-based materials, or organizations referenced worldwide current prevalence and post-9/11 disaster mental health in this publication. Although The correlates of PTSD in rescue workers. training program. Missouri Medicine, Dialogue includes valuable articles and Social Psychiatry and Psychiatric 105, 62–66. collections of information, SAMHSA Epidemiology, 47, 1001. doi:10.1007/ North, C. S., & Pfefferbaum, B. (2013). does not necessarily endorse any s00127-011-0408-2 Mental health response to community specific products or services provided Brooks, S. K., Dunn, R., Amlt, R., disasters: A systematic review. JAMA, by public or private organizations Greenberg, N., & Rubin, G. J. (2016). 310, 507–518. unless expressly stated. In addition, Social and occupational SAMHSA does not necessarily factors associated with endorse the views expressed psychological distress and by such sites or organizations, disorder among disaster nor does SAMHSA warrant responders: a systematic the validity of any information review. BMC Psychology, or its fitness for any particular 4(18). doi:10.1186/s40359- purpose. 016-0120-9 The views, opinions, and CDC. (2018, September 10). content expressed in this Opioids portal. https://www. publication do not necessarily cdc.gov/opioids reflect the views, opinions, or policies of the Center Heyman, M., Dill, J., & for Mental Health Services Douglas, R. (2018, April). (CMHS), the Substance Abuse The Ruderman white paper and Mental Health Services on mental health and Administration (SAMHSA), or suicide of first responders. the U.S. Department of Health Ruderman Family and Human Services (HHS). Foundation. Retrieved

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SUBSCRIBE The Dialogue is a publication for professionals in the disaster behavioral health field to share information, resources, trends, solutions to problems, and accomplishments. Contact SAMHSA DTAC to be added to The Dialogue subscription list. SHARE INFORMATION Readers are invited to contribute to The Dialogue. To author an article for an upcoming issue, please contact SAMHSA DTAC at [email protected]. ACCESS ADDITIONAL SAMHSA DTAC RESOURCES The SAMHSA DTAC Bulletin is a monthly e-communication used to share updates in the field, post upcoming activities, and highlight new resources. Contact SAMHSA DTAC to be added to the SAMHSA DTAC Bulletin subscription list. The SAMHSA Disaster Behavioral Health Information Series contains resource collections and toolkits pertinent to disaster behavioral health. Installments focus on specific populations, specific types of disasters, and other topics related to all-hazards disaster behavioral health preparedness and response. Visit the SAMHSA DTAC website at https://www.samhsa.gov/dtac/dbhis-collections to access these materials.

CONTACT US SAMHSA Disaster Technical Assistance Center Toll-free: 1–800–308–3515 [email protected] https://www.samhsa.gov/dtac