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

the Dialogue 2017 | VOLUME 13 | ISSUE 3-4

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Mass Violence: Planning, Responding, Recovering TABLE OF CONTENTS 1 In This Issue 2 Technical Assistance Snapshot 3 Contributors 5 Recent Technical Assistance Requests 6 Since Columbine: Evolution of Colorado’s Disaster Behavioral Health Response 10 The Aftermath of the Virginia Tech Shootings 14 Lessons Learned From the Boston Marathon Bombing Victim Services Program 17 Tragedy in the Sanctuary 20 Terror Attack at Work 22 Disaster Behavioral Health Challenges Encountered During the Response to the Pulse Nightclub Shooting in Florida 25 Recommended Resources Cover photo: ORLANDO, FL/USA. OCTOBER 1, 2016. Place where Omar Mateen, killed 49 people and wounded 53 others in a terrorist attack/hate crime inside Pulse, a gay nightclub in Orlando, Florida, United States. Photo by Miami2you / Shutterstock.com.

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 behavioral health (mental health and substance misuse) response to disasters. To receive The Dialogue, please go to SAMHSA’s home page (https://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, enter your email address, and mark the checkbox for “SAMHSA’s Disaster Technical Assistance newsletter, The Dialogue,” which is listed in the Newsletters section. 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, please call 1-800-308-3515, email [email protected], or visit the SAMHSA DTAC website at https://www.samhsa.gov/dtac.

The Dialogue is not responsible for the information provided by any webpages, 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. The views, opinions, and content expressed in this publication do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services, SAMHSA, or the U.S. Department of Health and Human Services. A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue In This Issue

IMAGE: Maybe a photograph of immediate aftermath of an incident of mass violence, or people consoling each other.

PHOTO: Stuart Elflett / Shutterstock.com.

On May 22, 2017, yet another incident of mass violence The inclusion of emotional and psychological injury shocked the world. Twenty-two people died, and many in the definition is notable. The behavioral health more were injured, after a suicide bomber detonated an impacts of mass violence events can be far-reaching. explosive device at a concert in Manchester, England. Those immediately and directly affected include Unfortunately, incidents such as this are becoming all victims, their loved ones, and those who were close to too common. the incident when it occurred. The effects may spread, touching lives, worldwide, as people with no personal The U.S. Department of Justice’s Office for Victims connection to the event relive it via social media, of Crime (OVC) uses the following definition of mass television, and newspaper reports. These violent acts can violence: occur anywhere and happen without warning, causing An intentional violent criminal act, for which disorder, anxiety, fear, and grief. The unpredictable a formal investigation has been opened by the nature of mass violence often results in a stressful Federal Bureau of Investigation (FBI) or other environment for survivors and responders. law enforcement agency, that results in physical, This special double issue of The Dialogue focuses on emotional, or psychological injury to a sufficiently the lessons learned from past incidents of mass violence. large number of people to significantly increase the The authors describe how planning efforts contributed burden of victim assistance and compensation for to effective community response and recovery in events the responding jurisdiction as determined by the across the country. Events include the Orlando Pulse OVC Director. nightclub shooting and the Boston Marathon bombing,

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 1 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue as well as events in Colorado and Virginia. The writers exercises, responders are better prepared to handle are a diverse group, including disaster behavioral and recover from an actual mass violence event. The health and trauma experts, emergency management exercises help them develop relationships and plans professionals, and local community health center leaders that build bridges between traditional emergency and staff. They illustrate that there is still no “one size management functions and disaster behavioral health fits all” approach to planning and response—describing providers to facilitate healing and recovery plans that range from relatively small organizational emergency operations procedures to comprehensive, Has your community experienced a disaster or mass statewide disaster behavioral health initiatives. violence incident that has influenced subsequent Ultimately, the authors bring unique perspectives to bear behavioral health responses? Please share your on mass violence events and are leading on-the-ground experiences with us. We encourage you to contact us with efforts to shape how communities anticipate and manage lessons learned or if you would like to learn more about the resulting behavioral health impact. how you can help your community prepare or respond.

Although mass violence events are tragic, many Captain Erik Hierholzer, B.S.N. Program Management communities and organizations have come back stronger Officer, Emergency Mental Health and Traumatic Stress and more resilient. These events have encouraged Services Branch [email protected] disaster behavioral health professionals nationwide to Nikki Bellamy, Ph.D. Public Health Advisor, address issues surrounding response planning. Many Emergency Mental Health and Traumatic Stress areas are now implementing robust all-hazards disaster Services Branch [email protected] behavioral health plans and holding large-scale mass violence planning exercises that engage a number Shannon Loomis, M.A. Director, SAMHSA Disaster of organizations and agencies. By conducting these Technical Assistance Center [email protected]

TECHNICAL ASSISTANCE SNAPSHOT

In 2015, SAMHSA and SAMHSA DTAC In 2016, the number of CCP grants rose to assisted 4 states/territories with 5 CCP grants. 11 CCP grants across 9 states.

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Contributors

center’s Director of Acute Services. In that role she was responsible for services that directly focused on people in crisis such as a Mobile Crisis Team, South Carolina’s Eric Alberts, CEM, CHS V, first Mental Health Court, a Crisis Stabilization Center, FPEM, CHEP, FABCHS, and services in local detention centers. Mrs. Blalock is a dedicated emergency has extensive training in crisis negotiation, crisis manager who is passionate intervention, and critical incident management. about the field in which he works and protecting those he serves. He began his career in emergency management in 2002. Mr. Alberts has responded to emergencies of all types and sizes including a terrorist attack, four hurricanes, tropical systems, communicable disease outbreak, severe weather, wildfires, multi-type vehicle accidents, and mass casualty incidents. He is currently the Corporate Curt Drennen, Ph.D., is a Manager of Emergency Preparedness for the Orlando licensed psychologist with the Health, Inc. hospital system in Central Florida. He Colorado Department of Public is also a member of the Department of Health and Health and Environment. He is Human Services – National Disaster Medical System - currently the Community FL-6 DMAT (Disaster Medical Assistance Team) as a Outreach Branch Supervisor within the Operations Logistician, SMRT-5 (State Medical Response Team) Section of the Office of Emergency Preparedness and as the Deputy Planning Chief, member of the Regional Response. In this role, he is working in partnership with Domestic Terrorism Task Force All-Hazards Incident a diverse stakeholder group to improve the state’s Management Team (AHIMT), and State of Florida capacity to respond to the psychosocial impact of Division of Emergency Management AHIMT as a disaster and public health emergencies. He has 23 years Qualified Liaison Officer. of experience in the fields of mental health and psychology with an emphasis in public psychology and administration, emotional intelligence, servant leadership, systems conflict management, crisis intervention, and behavioral health disaster Deborah S. Blalock, M.Ed., management. Dr. Drennen has led six Colorado Crisis LPCS, CPM has been employed Counseling Programs and one SAMHSA Emergency by the South Carolina Response Grant, and has provided CCP training to at Department of Mental Health least six other states. since 1993. In August 2004, Mrs. Blalock became the Executive Director of the Charleston Dorchester Mental Health Center, one of the largest of the department’s 17 mental health centers. Prior to becoming the Executive Director, she was the

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Russell Jones, Ph.D., is a April Naturale, Ph.D. is a Professor of Psychology at traumatic stress specialist who Virginia Tech University and directed the mental health a clinical psychologist who response to the 9/11 terrorist specializes in clinical child attacks in New York. Dr. psychology, trauma psychology, and issues related Naturale helped launch SAMHSA’s National Suicide to disaster and terrorism (www.firetrauma.com). He Prevention Lifeline, directed the BP Deepwater is an expert in the behavioral sciences. His research Horizon Oil Spill Distress Helpline, and led the 9/11 concerns the topic of childhood stress and coping with 10th Anniversary program. Dr. Naturale continues to common stressful life events as well as major traumas provide crisis management and clinical intervention (for example, natural and technological disasters as services, curriculum development, and field training in well as interpersonal violence). His major areas of the aftermath of disasters, mass violence, and terrorist study include disaster preparedness, posttraumatic events. At ICF International, Dr. Naturale is a Senior stress disorder, depression, and posttraumatic growth. Technical Specialist where she previously served as He and his students at the Stress and Coping Lab have Program Director for SAMHSA DTAC and the World been engaged in a program of research investigating the Trade Center Health Program’s Outreach and Education mental health impact of the 4/16 shootings at Virginia project. Currently, she is the lead architect of the Boston Tech. More recently, he has been examining the impact Marathon bombings behavioral health response and is of racial trauma as well as the transmission of historical training humanitarian aid workers with the European trauma on people of color. Union. She also provides posttraumatic stress and suicide prevention training to emergency response clinicians and the National Guard in Kiev, Ukraine.

Veronica A. Kelley, LCSW, is the Director and Alcohol and Drug Administrator for the San Bernardino County Department of Behavioral Health. Ms. Kelley is a member of the Governing Board for the California Association of Behavioral Health Directors Association (CBHDA), sits on the Executive Committee, and serves as the co-chair for the Substance Abuse Prevention & Treatment Committee as well as the Cultural Competence and Social Justice Advisory Committee. She represents CBHDA on the State Department of Health Care Services DUI Advisory Board and the California Mental Health Policy Council.

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Recent Technical Assistance Requests

In this section, read about recent questions SAMHSA • Tips Hruska, B., Cullen, P. K., & Delahanty, D. L. Disaster Technical Assistance Center (DTAC) staff have (2014). Pharmacological modulation of acute trauma answered and technical assistance requests to which they memories to prevent PTSD: Considerations from a have responded. Send your questions and comments to developmental perspective. Neurobiology of learning [email protected]. and memory, 112, 122–129. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC4051832/ Request: A state disaster behavioral health coordinator reached out to SAMHSA DTAC through Request: SAMHSA DTAC received an email from an the DTAC email at [email protected]. The emergency manager requesting a literature review on the individual requested a literature review on the use of incidents of child abuse following disasters. pharmaceuticals in the treatment of posttraumatic stress disorder (PTSD). Response: There are mixed conclusions on the presence of increased incidents of child abuse following Response: SAMHSA DTAC provided a brief synopsis a disaster. However, there are some studies with of findings following the conclusion of the literature strong evidence of a positive association. This is an review. The consensus among studies that looked at area consistently under-researched as it is sometimes the efficacy of pharmacological PTSD treatment is that believed that children are resilient and do not face as while drug research has shown promise, there is no many adverse effects following disaster events. Below is single source that provides a high success rate for the a resource for information on various topics concerning mitigation or prevention of the development of PTSD children’s well-being and the effects that disasters can symptoms in trauma survivors with pharmacological have on them. use. SAMHSA DTAC also sent the state behavioral health coordinator links and summaries to selected peer- • Peek, L. (2008). Children and disasters: Understanding vulnerability, developing capacities, and promoting reviewed and federally funded publications. Below are resilience—An introduction. Children Youth and some selections: Environments, 18(1), 1-29. ■ • Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., . . . & Olmsted, K. R. (2013). Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Comparative Effectiveness Review, No. 92. https://effectivehealthcare.ahrq.gov/ ehc/products/347/1436/PTSD-treatment-adult- executive-130403.pdf

• Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta- analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry, 74(6), 541–550. http://www.ncbi.nlm.nih.gov/ pubmed/23842024

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 5 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue Since Columbine: Evolution of Colorado’s Disaster Behavioral Health Response By Curt Drennen, Psy.D., RN, Community Outreach Branch Supervisor, Office of Emergency Preparedness and Response, Colorado State Department of Public Health and Environment

“Yesterday, my life entered the most abhorrent nightmare anyone could possibly imagine.”

Sue Klebold, April 21, 1999

I recently read A Mother’s mental health center, and county and Reckoning: Living in the Aftermath state victim advocates. But a host of The National Institute of of Tragedy by Sue Klebold (2016), volunteers, some with tremendous Mental Health proposes helping the mother of Dylan Klebold, a clinical acumen, descended onto survivors with the following in the perpetrator of the Columbine High the grounds of the school as well as days after a disaster: School violence. She writes about Clement Park (a large urban park pain, trauma, reconciliation, and surrounding the school) to provide Getting food return to health. I recommend support running the gamut from this book, simply because it gives crisis counseling to Critical Incident Getting a safe place us, those in the field of disaster Stress Debriefing to Eye Movement to live behavioral health, a very important Desensitization and Reprocessing perspective on the events that we (EMDR) therapy to “rebirthing”. Getting help from a plan for, train for, and unfortunately, doctor or nurse if hurt too often respond to. A critical lesson learned when Denver hosted the trial for Timothy It is somewhat clichéd to say that McVeigh (Oklahoma City bomber), Contacting loved one every disaster is different—but it but unfortunately did not implement, or friends is true, and that truth is magnified is the importance of relationship- in incidents of mass violence. building and the development of Keeping children with These human-caused events cross-system knowledge. During the parents or relatives are unpredictable, varied, and trial, victim advocates and public devastating, not only to the direct mental health staff built relationships Understanding what victims/survivors, but to whole and a strong understanding of each happened communities. other’s systems and the capacities and strengths of those systems. Understanding what is being done In the Beginning—Columbine During the Columbine response, High School Response those relationships came back into The initial response to the shooting play, allowing leadership to have Knowing where to get help at Columbine was chaotic and instant trust and creating a fair and balanced division of responsibilities. confused. The most effective work SOURCE: Helping children and adolescents happened as a partnership among cope with violence and disasters: What parents can do. (2015). https://www.nimh. the school- and district-based mental nih.gov/health/publications/helping- children-and-adolescents-cope-with- health professionals, the community violence-and-disasters-parents/index.shtml

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Improving Capacity With support from a 2003 Substance Successful Partnerships Training Abuse and Mental Health Services Following Hurricanes Katrina, Since that day in 1999, Colorado has Administration (SAMHSA) Rita, and Wilma, Colorado purposefully grown its capacity to Disaster Mental Health Planning welcomed over 14,000 evacuees, respond to the psychosocial impact grant, Colorado built its first robust and participated in the first multi- of mass violence. The three years behavioral health emergency state national Crisis Counseling following Columbine included some operations plan. With a small Assistance and Training Program. In major events: September 11, 2001, local grant, we began educating October of the following year, a man and the largest series of wildfires in our providers, helping them to entered Platte Canyon High School, Colorado’s history. During this time, understand that just because they holding a room full of girls hostage a three-year school and community are outstanding clinicians, does not for the day. The incident resulted recovery program called Columbine mean they are prepared to respond in the death of one of the students, Connections was implemented by the to individuals in crisis. Colorado Emily Keyes, and the perpetrator. local mental health center, Jefferson built two core trainings to guide In December, Colorado started Center for Mental Health. Lessons knowledge development. The first an effort to build a partnership learned from these experiences led training provided information on across systems to improve disaster to the building of a strong disaster how to respond as a part of the behavioral health response. The two- behavioral health response system. larger system. It also addressed year effort that followed resulted in These lessons include: being a part of the larger emergency the formation of the Colorado Crisis management system and provided Education and Response Network 1. Behavioral health response to disaster guidance on early intervention. (CoCERN), a partnership of the or community crisis is not therapy. The second training focused on public behavioral health system, the 2. When critical events happen, people recognizing trauma and building a American Red Cross, the Salvation want to help; they just don’t know trauma-informed system of care. We Army, victim advocates, and a how to get it. then took these trainings to every variety of professional organizations 3. Disaster behavioral health is larger community mental health center in with support from state public health than any one system. Colorado and offered them several and emergency management. This times over the next two years. We partnership set the structure for 4. Preparation is absolutely critical to an continue to update these trainings disaster behavioral health response effective response. based on our direct experiences as in the areas of cooperation, resource We chose to start our efforts well as current research. management, communication, and with planning and training. With standards of practice. The Colorado

LESSONS LEARNED

TRAINING PLANNING/DEFINING ROLES PARTNERSHIPS

April 20, 1999 July 20, 2012 November 27, 2015 Columbine High School shooting Aurora Cinemark Theater shooting Colorado Springs Planned Parenthood shooting Colorado began to work on the capacity Colorado began to work on defining to respond by improving the disaster specific missions that behavioral Improved partnerships at the state level behavioral health trainings provided to health teams can implement based and the clear role of disaster behavioral community mental health centers. on the event and environment. health led to a successful response.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 7 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Standard of Practice for individuals wanting to participate in disaster behavioral health requires the following trainings: the Federal Emergency Management Agency (FEMA) Independent Study (IS)-100 course, Introduction to Incident Command System (ICS); FEMA’s IS-700 course, National Incident Management System; Psychological First Aid; and the Colorado Field Response Training or the Red Cross Disaster Mental by five sister community mental Health Fundamentals. health centers. A key aspect of this With the CoCERN partnership response was the close support in the middle of its development, provided by their Emergency Colorado experienced a major Support Function (ESF) 8 lead, tornado in May 2008 that Tri-County Public Health. Tri- treatment; assisted victim advocates challenged the system. Lessons County provided communication in providing direct support to around communicating, identifying and logistical support as the mental survivors, first responders, and others missions, and articulating health centers deployed teams of affected by the shooting during the boundaries were quickly integrated trained disaster behavioral health criminal justice proceedings and the into organized processes. Then responders. As a result, teams trial of the perpetrator; and launched between 2010 and 2015, Colorado responded to 77 requests for a community resilience center called experienced an unprecedented series community support serving over Aurora Strong. of natural and human-caused public 1,830 individuals. The agency’s It became clear that disaster health and mass violence events. phone bank saw a 111 percent behavioral health needs to better Each event brought new challenges increase in call volume in the three define itself, its purpose, and its and stretched our understanding months after the shooting with over mission. Colorado began to clearly of what it means to respond to 11,000 calls, and they served an articulate the purpose of disaster community crises. additional 1,100 people through walk-in clinics. behavioral health: to support adaptive functioning by decreasing Defining Disaster Behavioral However, an event such as stress and fear in both survivors and Health—Aurora Cinemark the theater shooting is not a responders. This clear articulation Theater Shooting Response singular event. Aurora’s response of the role of disaster behavioral By July 2012, our systems had built a continued for the next several health has continued to evolve with great deal of institutional knowledge years. In partnership with the city a document that defines specific around a behavioral health response. and the state, the mental health missions that behavioral health When the Aurora Cinemark Theater center implemented a SAMHSA teams can implement based on shootings happened, Aurora Emergency Response Grant (SERG) event and environment. We have Community Mental Health hit the focused on community outreach, found this articulation of possibility ground running and was backed up trauma education, and trauma leads to continued development

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 8 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue of partnerships with local ESF 2 days strictly for law enforcement After the Aurora Cinemark 8 leadership and emergency and their families. Over the 5 days, Theater shooting, the state management. the response team provided food, mental health centers saw networking, therapy animals, gifts, a 111 percent increase in and informal counseling, and the Working To Improve call volume with 11,000 Colorado Acupuncture Medical Partnerships among Response calls, and they served an Reserve Corps provided the National Organizations—Colorado additional 1,100 people Acupuncture Detoxification Springs Planned Parenthood through walk-in clinics. Response Association auricular acupuncture Recently, Colorado Springs protocol for stress. the state level, support and guidance experienced our latest mass violence could easily be provided to local Because of this successful event. While smaller in scale than leadership, encouraging creative response, the CoCERN partnership Aurora or Columbine, the shooting partnership to address the impact of is furthering the emphasis on at Planned Parenthood on November this event. While the response was relationship-building among its 29, 2015 illustrated the variety of relatively short-term, the partnership partners, especially offices of victim ways disaster behavioral health involving law enforcement victim advocates, the public behavioral personnel respond to an event. advocates, the community mental health system, and local public The development of partnerships health center, AspenPointe, and El health agencies. at multiple government levels and Paso County Public Health (as the with various types of organizations, ESF 8 lead) resulted in an immediate including Victim Advocates, A Passion for Supporting response that was impressive. Two encourages a more efficient and Disaster Behavioral Health sequential efforts were launched to successful response. Disaster behavioral health requires support victims and the community an ongoing commitment to planning The mission of Victim Advocates is as well as law enforcement (developing emergency operations to support victims’ navigation of the personnel and their families. In the and continuity of operations plans); criminal justice system. This event form of a mini-disaster assistance training (ICS, Psychological First resulted in community victims, but center, 3 days of direct care were Aid, roles, self-care, and limitations); also responder victims. However, provided to support victims and exercises; and relationship because of strong relationships at the larger community followed by development. Disaster behavioral health also requires advocates and leadership who battle against The average active- both the inertia of systems and the negative perceptions of behavioral shooter incident health. One of the reasons I am lasts 12 minutes. passionate about building strong disaster behavioral health systems is Thirty-seven that responders, survivors, and the 12 percent last less larger community gain an experience than 5 minutes. with behavioral health professionals Minutes and systems that can have a positive

SOURCE: Nicoletti, J. (2012, December). Detection and impact. ■ disruption of insider/outsider perpetrated violence. Lecture, Colorado Emergency Preparedness Partnership.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 9 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue The Aftermath of the Virginia Tech Shootings By Russell Jones, Ph.D., Professor of Psychology, Virginia Tech University

Due to the nature of the event and families of the injured and deceased. Assistance Center, housed at the Inn the location, Virginia Tech did not Their assignments were to contact at Virginia Tech, not only provided have a “roadmap” to follow to family members of the deceased and lodging for the families, but also guide response and recovery efforts injured and to provide a wide range served as an initial information hub. in the aftermath of the shooting on of help primarily serving as a contact Media centers were also established campus in 2007. As such, initial between them and the university. with the primary goal of protecting efforts involved the provision of These liaisons were tasked with a families from their encroachment at immediate comfort and stability as host of helping behaviors that ranged this difficult time. well as meeting the acute needs of from contacting funeral homes family, friends, and coworkers. In and transporting the deceased to University-wide Counseling the moments and days following addressing more immediate needs Virginia Tech’s Cook Counseling the shootings, Virginia Tech framed such as finding lodging for the night. Center initiated several efforts to its own recovery and identified meet the emotional and physical steps to move forward. In my In the short term, arrangements were made for attendance at the 2007 needs of students, including opinion, many of these initial additional hours of service steps led to an extraordinary level graduation ceremony the following month for affected students who immediately after the event. Within of safety and stability for those 30 minutes, two therapists from affected by the shootings. were scheduled to graduate. Arrangements were also made to Cook Counseling Center arrived at At the outset, I should say how provide more long-term help, which West Ambler Johnston dormitory, much I was moved by the flood included researching procedures the site where the first two students of expressions of love, concern, for accessing victim compensation. were killed, to help friends and other support, and expertise shown Simultaneously, the Family students who lived in the dorm with by individuals, agencies, and organizations and by local, state, and federal partners.

Acute Aftermath From 2000 to 2013, 39 of the 160 Immediate actions were taken to assist and support the families of mass shooting incidents in the students and faculty who were United States have taken place in injured or fatally wounded, as well as the Virginia Tech community at educational environments. large. Many university departments spearheaded these efforts. For example, the Division of Student SOURCE: DOJ, FBI. https://www.fbi.gov/file-repository/active- Affairs established a group of family shooter-study-2000-2013-1.pdf liaisons. These Virginia Tech staff members served as contacts for

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 10 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue adjusting to the tragedy. Special roommates of those killed, Resources Department tasked their care was also provided to survivors classmates and victim’s professors Employee Assistance Providers with who were in Norris Hall at the time in other classes they attended, and assisting in the recovery process. of the shootings. Critical Incident students who shared membership Stress Management activities in Virginia Tech’s clubs, sororities, University staff anticipated that were also carried out by local and fraternities, and other organizations. people who attended the upcoming regional emergency medical services graduation would experience an providers for those exposed in During the recovery process, increase in anxiety and sorrow. Norris Hall. Wounded individuals psycho-education was provided The Cook Counseling Center staff were taken to local hospitals for across campus. Experts from members attended the ceremony to immediate attention. Virginia Tech’s national, state, local, and university provide counseling and recovery Schiffert Health Center assisted in departments distributed information resources to those in need. Hokie this process. and made themselves available to United, Residence Life, Human every level of the university. To Resources, and the Cranwell Counselors targeted other highly meet a variety of needs of faculty International Center representatives exposed individuals, including and staff, Virginia Tech’s Human were also on hand to help.

Interagency Cooperation and Support

The Department of Criminal Injuries Compensation Fund arrived and provided their expertise to help the distressed families. Throughout the day and days following the shootings, state and local police were available to provide announcements of death and injury. A 24-hour call center was also initiated to aid in the response effort. The Virginia Department of SAMHSA offers the folowing coping tips for college students Emergency Management provided dealing with a disaster or other trauma: manpower to work with university personnel to aid in this effort. ■ Talk about it.

■ Take care of yourself. Dr. Mark McNamee, the University

■ Give yourself a break—turn off the television/radio. Provost, secured grant funding from the U.S. Department of ■ Avoid using alcohol, drugs, and tobacco. Education during the acute phase ■ Get back to your daily routines. of the recovery period. The primary ■ Gen involved in the community. goal of this grant was to develop ■ Help others. a model for identifying, assessing,

SOURCE: Tips for college students: After a disaster or other trauma. (2013). https://store. and responding to students, faculty, samhsa.gov/product/Tips-for-College-Students-After-a-Disaster-or-Other-Trauma/ and staff whose behaviors might SMA13-4777. suggest risk for perpetrating PHOTO: Monkey Business Images / Shutterstock.com. violence. Given the department’s

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 11 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue extensive history of developing and implementing programs to assist students facing a variety of challenges, it was hoped that many of the initial recovery efforts would be sustained while new efforts would be implemented in a timely fashion. Key partners identified to assist with the actual administration and implementation of the grant included the University Provost, the Division of Student Affairs, the Human Resources Department, the Virginia Tech Police Department, In the aftermath of a shooting, the American Counseling Virginia Tech professors and Association provides the following tips to help survivors cope: researchers in psychology and ■ Attend to self-care. sociology departments, and several ■ Pay attention to your emotional health. off-campus partners (such as the Community Services Board). It was ■ Try to recognize when you or those around you may need extra decided that the Cook Counseling support. Center would serve as the primary ■ Avoid overexposure to media. vehicle for students to gain access to ■ Maintain contact with friends and family. mental health services on campus, ■ Focus on your strength base. while services for the faculty and ■ Talk to others as needed. staff would be provided by Human SOURCE: Dailey, S. F. Coping in the aftermath of a shooting. https://www.counseling.org/ Resources. knowledge-center/coping-in-the-aftermath-of-a-shooting

PHOTO: Photographee.eu / Shutterstock.com. Culturally Informed Care and Response Efforts The Cranwell International Center including the Asian American Culturally competent care is a key made impressive efforts to ensure Student Union and Multicultural component of any recovery effort. the safety of and provide support Program and Services. The Virginia Tech community is to the Asian student population composed of people of a variety on campus and in the surrounding LESSONS LEARNED of races and ethnicities, including community. One-third of the April 16 Caucasians, Koreans, African victims were international students. Several recommendations were American, and Hispanics. It was Cranwell Center staff and volunteers spelled out in the report of the determined that special attention called every international student. Virginia Tech Review Panel to the should be given to the Asian Additionally, phone cards were given Governor of Virginia, including that population, given that the shooter to assist students’ communication universities and colleges develop was Korean. with their loved ones. These efforts plans, establish a joint information were facilitated through partnerships center and create a family assistance with several university organizations, center following a criminal mass casualty, provide scheduled briefings

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Visitors to the Virginia Tech campus can visit the April 16 Memorial in honor of the victims of the shooting. PHOTO: John McCormick. to victims’ families, ensure the The openness to strategies based on The high quality and quantity of availability of short-and long- our “best science” further enhanced culturally sensitive actions initiated term counseling, and coordinate and facilitated the recovery effort. by the Cranwell International provision of training in crisis The knowledge obtained from Center at Virginia Tech was yet management (2007). The Virginia members of the Virginia Tech another ingredient in the success Tech community’s outstanding community as well as a host of of the response efforts. Due to the recovery efforts were due in part to local, state, and federal agencies efforts of many professionals at the a high degree of social support prior and organizations proved to be Cranwell Center and throughout the to, during, and after the shootings invaluable. university, culturally competent care among members of the Hokie was provided to many individuals, Nation. One of the greatest strengths The trauma literature provided particularly members of the Asian of the Virginia Tech recovery helpful insight. The adoption and community. effort was the fact that a solid integration of knowledge on several infrastructure for both the university topics proved to be quite beneficial. I am hopeful, as are thousands and the surrounding community had These topics included the integration of others, that this senseless act been established in previous years. of public mental health surveillance/ of violence will inspire countless The timely and insightful support monitoring strategies with mental members of the Hokie Nation to from many community partners health assessment efforts, evidence- uphold the university’s motto, Ut contributed to the recovery and based treatments for traumatic Prosim (That I May Serve). ■ stress, dissemination of evidence- transition efforts. Virginia Tech Review Panel. (2007, August). Mass based interventions, and conducting shootings at Virginia Tech, April 16, 2007: Report of assessments and intervention-based the Review Panel. Retrieved from https://governor. virginia.gov/media/3772/fullreport.pdf efforts with people of color.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 13 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue Lessons Learned From the Boston Marathon Bombing Victim Services Program By April Naturale, Ph.D., Senior Technical Specialist, ICF International

The Boston Marathon bombing draws runners, supporters, and The Massachusetts Office for Victim terrorist event of April 15, 2013, spectators from all parts of the Assistance (MOVA) implemented resulted in the death of three people globe. Graphic reports and videos of a disaster response program with and injury of several hundred the bombing and survivors appeared Antiterrorism and Emergency more. Over the next several days, in various media continuously for Assistance Program funds from the after a massive law enforcement an extended period. This intentional, U.S. Department of Justice’s Office effort ending in Watertown, human-caused mass violence for Victims of Crime. MOVA funded Massachusetts, one of the suspects incident accompanied by graphic, victim services and behavioral was killed, and the other was gruesome, and extensive media health agencies within the affected captured. Each year, the Boston exposure exacerbated the behavioral areas as well as the Boston Police Marathon is highly publicized and health risks of those exposed. Department, Boston Public Schools, and the Watertown School system. The program is continuing through The National Child Traumatic Stress Network suggests the following tips for talking to children about mass violence: September 2017 to work directly with survivors, responders, and their family members, many of whom are still experiencing long-lasting negative psychological effects.

The overall goals of MOVA’s marathon bombing response Start the conversation. Encourage your child to ask questions, program were to provide timely and answer those relief with immediate and ongoing questions directly. victim assistance via victim navigators whose role was that of case managers and victim advocates, helping survivors Listen carefully to identify their needs and access find out what the already know. the services available to them. Limit media exposure. The overall objectives were to help guide individuals and the SOURCE: Talking to children about community onto a recovery path, mass violence. http://www.nctsn. org/sites/default/files/assets/pdfs/ increase opportunities to support talking_to_children_about_mass_ violence.pdf and build resilience, and increase

PHOTOS: Iakov Filimonov, the capacity of the community Gently correct imtmphoto, Lopolo, and BrunoRosa / to continue to address these inaccurate information. Shutterstock.com. concerns in the future. Services

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 14 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue have varied according to the at highest risk of developing with the immediate days of the disaster phases and have included serious behavioral health problems, attack throughout the following four crisis response; consequence including survivors with injuries, years with a significant increase management; crime victim amputations, burns, traumatic brain in requests just prior to and at the compensation; criminal justice injuries, or loss of hearing or vision; time of the anniversaries. MOVA support (such as support for victim families of homicide victims; close staff provided a compassionate participation in criminal justice friends and coworkers of victims; presence and support during and proceedings); crisis counseling; school-aged children exposed to after public anniversary activities emergency transportation and the bombing and the Watertown such as the ceremony held at the Old travel; compensation for medical lockdown and shootout; and those South Church and the memorial on and mental health costs, lost wages, at the next levels of exposure, such the campus of the Massachusetts and funeral expenses; temporary as first responders exposed to the Institute of Technology for Sean housing; emergency food and fear, chaos, and injuries involved Collier, the university police officer clothing; repatriation of remains; in the event, as well as their family who was killed by those responsible victim advocacy, outreach, and members; survivors with prior for the bombing. Staff also sent out education; victim notification; trauma or mental illnesses, medical SAMHSA’s Disaster Tip Sheets and vocational rehabilitation. A problems, or limited mobility or about what to expect leading up to behavioral health response plan other functional and access needs. the anniversary and suggestions for was developed to provide disaster- coping activities. Many survivors specific treatment interventions, Successes responded to a direct email and a large-scale media and A continuum of care working group campaign with comments about how communications effort provided was initiated, bringing together helpful it was to have information outreach, information, and education over 30 agencies that interacted about coping, recommendations to to the broadly affected community. with survivors. The working group plan ahead, and the suggestion to be included state and city responders, with others. They also noted how federal law enforcement, community comforting it was to see the victim advocates at the anniversary events. “There is a need for providers funded through the greater awareness of the Victims of Crime Act, American MOVA developed a media plan to negative physical, social, Red Cross personnel, and members provide messages of support, hope, emotional, spiritual, and of the private sector. The group recovery, and resiliency. Messaging financial impacts of crime, discussed and analyzed the types of was delivered via major television particularly terrorism.” services needed, both short and long networks, and actual survivors used term. They identified service gaps scripts in which they talked about Services provided have been and made recommendations about their own experiences of the event, informed by a needs assessment, how to address them. This working their reactions, and what they felt along with survivor and family group provided an opportunity for had helped them most. forums, victim compensation, and members to learn about each other other provider reports and direct as well as a platform to discuss LESSONS LEARNED contact with survivors. Targeted issues and activities. We learned that victim services outreach was possible due to the There was an expressed need for response should be immediate coordinated effort of federal, state, behavioral health support from and systemic; thus, political, law and local agencies. MOVA planned survivors and their families starting enforcement, and emergency to reach those victims/survivors

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Individuals demonstrate their solidarity with the victims of the Boston Marathon bombing by displaying a Boston Strong flag during the 2014 race. PHOTO: Provided by April Naturale. management leadership needs to be We found it difficult to create and care in the field and the nearby informed about what victim service implement self-care activities for hospitals that saved lives, to the agencies can offer in the wake of a staff when they were not already self-sufficiency with which the tragedy. Victim services agencies part of how the office operates. city picked itself up and continued must be represented on state, city, Many staff working in the response its regular activities and more. and local community emergency had a shared experience of trauma. Still, many of the experiences of management planning committees Creating more formal and informal the victims’ families, survivors, before and after incidents. We also opportunities for staff to discuss and and various responders echoed learned that due to the nature of address their own experiences would those of prior terrorist events disasters, it is crucial to hire project likely have reduced some of their and mass shootings. We all need staff as soon as the determination to concerns and distress. to share our lessons learned and provide response services is made. recommendations so that we can Establishing new contracts was time There is a need for greater awareness identify best practices and learn consuming, and thus reaching out of the negative physical, social, from each other. We are Boston to behavioral health providers with emotional, spiritual, and financial Strong, but every community that existing contracts to provide crisis impacts of crime, particularly experiences these types of events intervention and behavioral health terrorism. Providing broad public can work together to support the support was more efficient. One education on the signs and impacts of needs of survivors. ■ challenge encountered was ensuring traumatic events can help to reduce the administration of disaster and stigma and increase help-seeking. trauma-specific, evidence-based The Boston Marathon bombing interventions targeted to the needs of response was exemplary, from the the affected population. extraordinary immediate medical

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 16 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue Tragedy in the Sanctuary By Deborah S. Blalock, M.Ed., LPCS, CPM, Executive Director, Charleston Dorchester Mental Health Center/ South Carolina Department of Mental Health

On June 17, 2015, the unthinkable Relationship Between Active Shooter and Victims occurred . . . a self-avowed white supremacist entered Emanuel African Methodist Episcopal 6% Familial (AME) Church in Charleston, South Professional 38% Carolina, and after attending Bible 8% Other study with church members, opened fire, murdering nine. Because of a longstanding relationship with the Charleston Police Department (CPD), a Charleston Dorchester Mental Health Center (CDMHC) 22% Academic mental health professional embedded with the CPD was immediately deployed to the family staging area No relationship 26% to offer support to the five survivors SOURCE: New York City Police Department. Active shooter: Recommendations and analysis for risk mitigation, and nine victims’ families. Thus 2012 edition. http://www.nypdshield.org/public/SiteFiles/documents/Activeshooter.pdf began CDMHC’s journey with Emanuel AME—a journey that CDMHC assisted the Federal taught all of us many lessons about LESSON LEARNED Bureau of Investigation (FBI) responding to and recovering from A human-caused disaster is Victims’ Assistance Team in an event like this one. different from a natural disaster. establishing a Family Assistance LESSON LEARNED Center and established a Church Survivors may view a human-caused Assistance Center for church disaster in a different light then a Relationships established before members unrelated to victims. natural disaster, and the recovery disaster strikes are invaluable. The church’s entrance became a process may follow a different It is critical to build partnerships prior memorial site where hundreds came trajectory. We as disaster Responders need to keep this in to an incident that you can rely on to grieve and show love for the mind while aiding survivors. during the response and recovery victims and survivors. Many were phases. You should work to identify overcome by grief and in need of Emanuel’s leadership recognized key partners you can turn to in the support. CDMHC deployed its RV, CDMHC as a partner 2 days after event of a disaster. Ideally this would a mobile mental health clinic, to the be done before a disaster and would the shooting. CDMHC assisted site to offer support, as well as water cover a wide range of scenarios. the church in a funeral planning and snacks. CDMHC also staffed a meeting with the victims’ families. phone bank on a local news show to The congregation of approximately address the community’s concerns. 550 had to plan, with limited resources, nine funerals, including

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 17 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue one for its pastor and three others office, law enforcement, emergency expertise. Together, the agencies for ministerial staff. This meeting medical services and fire personnel, created informational flyers for was highly emotionally charged, clinical staff, and even members of the church. The Substance Abuse and staff had to use their de- the media. and Mental Health Services escalation skills many times. As Administration also created requested, CDMHC attended LESSON LEARNED customized informational brochures numerous prayer vigils. Church Clinicians’ needs must be which were distributed. The leadership asked CDMHC to attend addressed regularly. partners created and distributed a worship services the Sunday after needs assessment survey to church Self-care is important no matter what the shooting. The church, usually members. While returning church the disaster. For responders to be hosting 100 people on Sundays, members became very familiar with able to properly assist survivors, they was filled past its 1,200-person must address their own personal the counselors, many members had capacity on the first Sunday after needs. Response staff must be not returned, out of sadness and the shooting. Worshippers were continually monitored for signs of fear, and they had to be reached. overcome with shock, sadness, stress and compassion fatigue. Counselors attended ministry and horror as they entered. Center meetings, including the Women’s staff attended Sunday services for 7 CDMHC knew it had to further its Ministry, Seniors’ Ministry, and months, and they offered support at reach to touch more affected by the Children’s Church. The clinical team every wake and every funeral and tragedy. The center partnered with facilitated a weekly grief support at the church’s weeklong children’s the Medical University of South group that is still meeting, and vacation Bible school. The Carolina’s National Crime Victims helped plan and attended 2 weeks CDMHC provided support for many Research and Treatment Center of memorial events with family responders, including the coroner’s (NCVC) to bolster capacity and members and survivors.

Things To Think About When Planning for Active Shooter Incidents: Location Number of incidents, 2000-2013 From 2000 to 2013, six mass shooting incidents have taken place in the United States in places of worship, 73 Businesses resulting in 21 deaths. 45.6% SOURCE: DOJ, FBI. https://www.fbi. gov/file-repository /active-shooter- study-2000-2013-1.pdf

Schools 39 24.4% LESSON LEARNED

4 2.4% In a church shooting, clinicians 6 Health care facilities 3.8% must be skilled in addressing 7 Houses of worship 4.4% spirituality. 16 15 10.0% 9.4% Residences Government properties When assisting disaster survivors, Open spaces responders need to be aware of any

SOURCE: U.S. Department of Justice (DOJ), Federal Bureau of Investigation (FBI). (2013). A study of factors that may play a role in the active shooter incidents in the United States between 2000 and 2013. https://www.fbi.gov/file-repository/ recovery process as well as how to active-shooter-study-2000-2013-1.pdf

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The NCVC received a grant from the Office for Victims of Crime to fund community efforts serving those affected. The grant has funded an Empowerment Center on church property housing the five (two NCVC, two CDMHC, and one Berkeley Mental Health Center) counselors and case managers. The grant funds were instrumental in supporting the survivors and families during the perpetrator’s federal death penalty hearings and trial. A victims’ support team was created. It included victims’ assistance staff from CPD, the Charleston County Sheriff’s Office, the FBI, and the U.S. Attorney’s Office; clinicians from NCVC and CDMHC; and, for the The Emanuel African Methodist Episcopal Church congregation first time in a federal trial, a spiritual continues to move forward in the recovery process. support team of clergy, in this case PHOTO: Provided by Deborah S. Blalock. comprising members from the South Carolina Law Enforcement improve acceptance of resources I was worried that my race would Assistance Program, Emanuel AME, and materials among survivors in the hinder me from comforting those I St. Michael’s Episcopal Church, and affected community. They must be was there to serve. I am Caucasian. many other local churches. The team sensitive to the beliefs of the The family members, the members was in the trial daily from its start survivors. of the church, and the leadership of on November 28, 2016, through its the church accepted me, welcomed conclusion on January 5, 2017. From the beginning, we knew race me. I am honored to say that I think was wound very tightly in this they trusted me. Their strength, their LESSON LEARNED tragedy. We had to make sure that resilience, their forgiveness, is real. Mental health support must be we were not afraid to face the issue for the long haul. of race head on. We could not send LESSON LEARNED Long-term recovery survivor needs two Caucasian clinicians to any Cultural competency is crucial. function. If one was Caucasian, one must be identified, and a plan put in had to be African American. We had You will be more likely to succeed in place to address them. to pay attention to the needs of those outreach activities if you engage key This experience has been profound we were there to serve. members of the community to improve access to and credibility for all involved . . . one that shall among survivors. never be forgotten. ■ LESSON LEARNED If race is a factor, it must be faced immediately.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 19 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue Terror Attack at Work By Veronica Kelley, LCSW, Director, Behavioral Health, San Bernardino County Department of Public Health

On December 2, 2015, in Southern of the shooting were not the only of our clinic and administration California, the Environmental Health group that required our assistance; the sites were on lockdown due to the Services (EHS) Division of San disaster responders were also deeply shooting and active pursuit of the Bernardino County’s Department of affected by the incident. assailants, to 10 county departments Public Health (DPH) was holding and nine community organizations. their annual General Education Pre-incident Planning Led to a Deployment locations included Meeting. At a little after 11 a.m., Successful Response the sites that EHS survivors were two masked terrorists, later to be Our response was successful in part brought to from the triage area, identified as a radicalized EHS due to existing emergency plans the site where family could pick staffer and his wife, ran into the and prior staff training. Thanks to up a loved one, and the coroner facility hosting the meeting, the a well-developed infrastructure substation. Inland Regional Center, and killed and community crisis response 14 people and wounded 22 others. We also developed a liaison model programs (funded through the of support for all the EHS staff and Shortly after the shooting took Mental Health Services Act in affiliated staff such as Public Health place, the local law enforcement California), DBH could immediately and Land Use Services staff, who agency requested, along with the deploy Community Crisis Response worked hand in hand with EHS and administration of DPH, assistance Teams throughout the county upon who lost many coworkers that day. from the Department of Behavioral request from the San Bernardino Based on the fire department model Health (DBH). As DBH staff were Police Department and county utilized when a fallen firefighter’s deployed, we discovered the survivors sheriff. This request allowed DBH family is supported by colleagues, to deploy teams, even while many working in teams of two, 60 people were deployed as liaisons. These staff members were the points of contact for the families of the victims as well as the survivors and affiliated county staff. Liaisons assisted with timesheets, workers’ compensation paperwork, death benefits paperwork, funeral arrangements, and general support. These teams remain active to this day.

Adapting Response Plans To Fit the Immediate Need DBH has extensive experience The community of San Bernardino showed support to the victims in addressing the needs of the of the shooting and their families with candles, uplifting messages, community and survivors after flowers, and the American flag. incidents such as fires and other PHOTO: Ted Soqui Photography, 2015.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 20 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue natural disasters. This terrorist attack crisis intervention. Assess the situation, was vastly different from a fire; RESPONSE STATISTICS and determine the appropriate however, we had experience working DBH deployed 200 clinical inventions for the current need. under very stressful circumstances boots on the ground in the first Understand trauma. Traumas and could adapt our response to fit 48 hours after the event and vary, and in this case the trauma the incident. provided over 10,000 counseling/ was complex. Trauma can be acute supportive contacts, both by or chronic and lead to other, more DBH’s primary focus is on treating negative effects such as vicarious serious and persistent mental telephone and in person. These contacts were provided 24/7 trauma and compassion fatigue for illness for the Medicaid population. behavioral health first responders. However, in the aftermath of this following the event, for a total Don’t forget the children. incident, we utilized our crisis of 1,344 hours of continuous behavioral health crisis care Remember that children are not response skill set to address all small adults. Their needs should be issues that came up, including the through February 2016 (care is still being provided). addressed differently from those of immediate trauma response and adults. retraumatization that occurred Not all crisis response is because of other terrorist attacks related to such incidents. Helping clinical. We found that simply being and related events. Having a system the helpers has been critical as the present, acknowledging the horror, in place since 2005 to address trauma remains; our coworkers are and providing physical comfort was community trauma, such as suicide still affected, but we as a county are at times as effective as a more and violent crimes, greatly enhanced surprisingly resilient and SB Strong! clinically focused intervention. our department’s ability to be fluid Be prepared for a long recovery and effective in providing crisis LESSONS LEARNED process. We have found that intervention to our brothers and trauma responses have escalated sisters in county government. Be prepared. Having an infrastructure that works with law after the year mark. As trauma and enforcement and other first stress are cumulative, you need to Helping the Helpers responders is critical. This enabled be vigilant about trauma response This horrifying terrorist attack was DBH to respond immediately, while and affiliated issues such as perpetrated by one of our own, we awaited mutual aid from other depression, anxiety, and which added to the level of stress local counties, the state, and our posttraumatic stress disorder in the and anxiety among survivors and federal partners. years and months following the event. responders. All our behavioral Be flexible. Not all emergency health first responders were at situations are the same. Be prepared Use resources available. risk for retraumatization and even to allow the team to adjust to the SAMHSA has a wealth of written vicarious trauma. We made special special needs of each incident. brochures and tip sheets on trauma that we used, reproduced, shared concessions to ensure that responders Do not underestimate the attended to self-care, brought in staff with our community partners, and impact of trauma on you. Our left with survivors and victims’ from neighboring counties to do staff were immediately affected but families. Having a tip sheet to leave Critical Incident Stress Debriefing carried out their duties as needed. that an affected person could use for for our staff, and tried to be proactive Monitor staff stress levels. Allowing guidance was very helpful. We also in sharing trauma tips from the time for self-care is essential! used social media in all its forms to Substance Abuse and Mental Health Be open to many interventions. share the same information. ■ Services Administration (SAMHSA) There is no one perfect method of

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INTERVIEW

Disaster Behavioral Health Challenges Encountered During the Response to the Pulse Nightclub Shooting in Florida By Eric Alberts, CEM, CHS V, FPEM, CHEP, FABCHS, Corporate Manager, Emergency Preparedness, Orlando Health

In the early morning hours of June Before Pulse, we tried to include to the Pulse nightclub shooting, 12, 2016, 49 people were killed behavioral health components in including an incident in which a City and 53 wounded by a shooter at our exercises, and we have general of Orlando police officer was shot Pulse nightclub in Orlando, Florida. policies that address behavioral and killed and another police officer The New York Times identifies this health. Pulse highlighted the need died as a result. Again, Orlando incident as “the worst mass shooting for behavioral health planning Health was concerned, and the EAP in U.S. history.”1 efforts and inclusion of behavioral was on hand to provide assistance health in exercises. We just did our for our team members, too. It’s the Many of the people injured in 2017 annual full-scale community new normal. Things have definitely the attack–44–were treated at the exercise, and because of Pulse, we changed since Pulse. Orlando Regional Medical Center had Employee Assistance Program How did you provide behavioral (ORMC), which is less than a (EAP) staff at two Orlando Health mile from Pulse. Of those 44, 35 health support to your staff and hospitals: ORMC and Arnold survivors of the event? survived. Palmer Hospital. They were there We had different levels and layers. to talk with people who needed it, The Dialogue recently spoke We have chaplains throughout our and there was a room set up where with Eric Alberts, who manages hospitals that team members can talk people could go for counseling. I emergency preparedness for to at any time. We also have our own was concerned about posttraumatic Orlando Health, a large health care EAP team. Immediately after Pulse, stress disorder and flashbacks. In organization that includes ORMC. we had our EAP team come and the exercise, of course the injuries He spoke about responding to the they provided group and individual are fake, but police, fire, rescue, Pulse shooting, its ongoing effects, sessions for a few days. There were and Federal Bureau of Investigation and lessons learned that may help over 1,200 EAP sessions. others supporting behavioral health (FBI) staff are there, and it looks and before, during, and after incidents of feels like a real incident. We wanted What were the biggest challenges (related to behavioral health mass violence. to make sure that we had behavioral health care there for our staff. preparedness and response) you and Did you have a behavioral health your staff faced? response plan in place prior to the ORMC staff members have dealt One was trying to compassionately event? How have things changed with recent incidents in addition care for the families. They often since Pulse?

1 Alvarez, L., Pérez-Peña, R., & Hauser, C. (2016, June 13). Orlando gunman was ‘cool and calm’ after massacre, police say. The New York Times. Retrieved from https:// www.nytimes.com/2016/06/14/us/orlando-shooting.html?_r=0

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 22 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue didn’t know where their loved one was, and then, when they figured out where they were, they weren’t sure what to do. They could be deceased, in critical condition, or okay. At ORMC we had to figure out how to provide services. Some families didn’t know before the incident that their loved ones were in the LGBTQ (lesbian, gay, bisexual, transgender, and queer/questioning) community. Others knew and were accepting.

Those in the hospital were quite PHOTO: cleanfotos / Shutterstock.com. shocked as well. Many families came here from out of the area and grandfather that he didn’t make different when you experience a real did not bring anything with them. it. I went into work the next day, I incident, but still you just go with They wanted to know where they confirmed that he was one of the your training. We held our yearly could stay, where they could find deceased, and I went to the open full-scale community exercise in something to eat, how they could get casket funeral. March 2016, with the scenario of home, even where they could charge an active shooter in Orange County their phones. We provided $500 When you’re part of the response Middle School. The Pulse nightclub worth of cellphone chargers alone. effort, it really does affect you. shooting happened in June. A lot of It’s things like that that people don’t People think these bad situations our staff said the exercise helped think of. Our team members were will occur at a big mass gathering save lives. You have to get past trying to care for the patients, in the far from hospitals. Pulse was no the initial fear and go back to your most acute situations, which was more than half a mile from ORMC. training, methods, processes, and taking all of their focus, and then You have to broaden your scope and plans you remember in your head. the families got involved. It was an realize what’s surrounding you. emotional time for them. Were there any partners that played Did you have any special training or a key role in your ability to prepare resources to help effectively respond Also, some of our staff knew for, respond to, and recover from to the event? people who were shot. The night this event? If not, whom would you recommend organizations develop of the event at Pulse, I finally got I have a bachelor’s degree, nine partnerships with? home from my shift and saw prayer certifications, and I’ve taken over requests from our church for a 200 courses, which prepared me A ton of folks and agencies member whose grandson was in the to be able to respond to this type responded. The local jurisdiction, club during the shooting. He was of incident. I have responded to the City of Orlando, was a huge there with his girlfriend to learn to emergencies of all different types assistance. The FBI also played salsa dance. He came to our hospital and sizes over the years. We also a role in our full-scale exercise, and unfortunately ended up being have regular exercises in our which is how we understood one of the deceased. I didn’t have facilities. With that background and how we would respond together. confirmation that he was one of experience, you fall into place; you We’ve continued to broaden that the deceased, so I couldn’t tell his just do what you need to do. It’s partnership. For our latest full-

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 23 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue scale community exercise just last How has this event changed your violence, if people aren’t given the week, six FBI agents came just for behavioral health emergency proper treatment. Take it seriously ORMC in the exercise. We continue response plan? because it could come back and our partnership to plan, train, and After the incident, our EAP team cause something serious if you exercise together. developed a written crisis plan. It’s don’t. Just because you have never about a page and a half and pretty been through a serious incident How did you coordinate and work with simple, but it brings to light that they other responders and stakeholders? before with major behavioral health have a role in crisis management or effects, and you think you can’t That is a continual, ongoing process, emergency response. know the issues until you go through through planning, training, and that kind of an incident, you can still exercises. We continue to coordinate leverage lessons learned from others and collaborate with them. We Days after the shooting, the and try to apply those practices learned from Pulse that you can’t Employee Assistance Program to your efforts. The information I know just one person in a particular (EAP) conducted over 1,200 provided within this article, Katrina, agency—you need to know two or sessions at the two Orlando and 9/11 provide valuable lessons three. You need to know a couple hospitals treating victims. learned—learn and implement of layers of individuals who work What are EAPs? lessons from those experiences. in those agencies. It’s a continual Don’t ignore them. process, not a one-time thing. Helpful Tip to Include in Someone gets a business card, puts it Disaster Response Plans: “An Are there any other lessons learned or away, and thinks he or she is done. If Employee Assistance Program other information you’d like to share? someone doesn’t know you well and (EAP) is a voluntary, work-based I am not a medical clinician; I am trust you, he or she won’t answer a program that offers free and administrative, but that doesn’t phone call or email. confidential assessments, short- mean I can’t help save lives as well. term counseling, referrals, and I don’t provide direct patient care How did you and your staff cope with follow-up services to employees the event? or EAP counseling sessions, but I who have personal and/or work- helped ensure the correct stuff was Our staff is compassionate, and related problems.” in place to do that during and after we care about each other. We pay SOURCE: U.S. Office of Personnel Pulse. HICS (the Hospital Incident attention to each other. We have Management. https://www.opm.gov/faqs/ QA.aspx?fid=4313c618-a96e-4c8e-b078- Command System) saved lives when camaraderie, and we help to care 1f76912a10d9&pid=2c2b1e5b-6ff1-4940- b478-34039a1e1174 we had Pulse. To me that is for each other. Otherwise you extremely humbling, because I am feel isolated. For Pulse, we had not a clinician. It fuels the fire for approximately 500 people who me to want to keep doing this work responded, so we were not alone. From your experience, what would and keep helping others in hopes of They still talk about that experience. you suggest other professionals helping the efforts of saving lives. It all comes down to being open, include in their behavioral health emergency response plans? The trauma surgeon can’t do this talking to each other, and trying to alone. It still takes an administrative care for each other. I would just suggest they have person, EAP counselor, security behavioral health plans in the first officer, and emergency manager to place and don’t ignore behavioral help with all those efforts. ■ health. If you ignore it, you will have major problems: employees leaving, lawsuits, or even workplace

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 24 A Quarterly Technical Assistance Journal on Disaster Behavioral Health Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

RECOMMENDED RESOURCES

Disaster-Specific Resources: Psychosocial and Mental Health Mass Violence or Riots Interventions in Areas of Mass Violence: This part of the Disaster-Specific Resources installment A Community-based Approach of the SAMHSA Disaster Behavioral Health Information In this guide, author Kaz de Jong and Médecins Sans Series features resources about mass violence. The Frontières provide information and suggestions for collection includes websites, tip sheets, toolkits, supporting people around the world who have survived manuals, and videos about incidents of mass violence human-caused disasters, including incidents of mass and their mental health and substance use (behavioral violence and terrorism. Sections of the guide explain health) effects, school crisis response, coping with how the traumatization process works; describe reactions to an incident of mass violence, and supporting interventions; and cover special topics, including children in coping. training, monitoring, and evaluation.

Access the installment section at http://bit.ly/2oWAAE3. Access the guide at http://bit.ly/2qu9Hsb.

Acts of Violence, Terrorism, or War: Triggers for Veterans In this article, the National Center for Posttraumatic Stress Disorder explains the ways in which veterans may react slightly differently from the rest of the population to incidents of mass violence, terrorism, and war. Authors present research findings about how these incidents may affect veterans differently, and they provide suggestions for veterans for coping with their reactions, finding additional help, and supporting children and members of their communities. Mass Violence and Terrorism Access the article at http://bit.ly/2qtS1g8. ■ SAMHSA’s National Child Traumatic Stress Network (NCTSN) provides links to tip sheets and information about how incidents of mass violence may affect children and families, how parents and other caregivers can support children in coping, and helping children and adolescents who were injured in mass violence incidents. Also included are materials for school staff and pediatric providers.

Access this part of NCTSN’s website at http://bit. ly/2pNdFA0. https://www.samhsa.gov

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 25 Behavioral Health is Essential To Health

Prevention Works • Treatment is Effective • People Recover

SUBSCRIBE The Dialogue is a publication for professionals in the disaster behavioral health field to share information, resources, trends, solutions to problems, and accomplishments. To receive The Dialogue, please go to SAMHSA’s home page (https://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, enter your email address, and select the box for “SAMHSA’s Disaster Technical Assistance newsletter, The Dialogue.” 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.To subscribe, please enter your email address in the “SAMHSA DTAC Bulletin” section of the home page of our website at https://www.samhsa.gov/dtac. 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 CONTACT US materials. SAMHSA Disaster Technical Assistance Center Toll-Free: 1-800-308-3515 [email protected] https://www.samhsa.gov/dtac