Helping to Heal: Behavioral Health Planning

This collage displayed newspaper headlines related to food poisoning stories. It was created by the Minnesota Department of Health in the 1930s, and its message was part of a campaign admonishing citizens to be aware that safe food cannot be taken for granted. CDC/ Minnesota Department of Health, R.N. Barr Library; Librarians Melissa Rethlefsen and Marie Jones

Cover Images: Photo Courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C., NCP 1603 - Emergency hospital during influenza epidemic, Camp Funston, Kansas

Poster image: A Spanish Flu public notice from 1918, http://en.wikipedia.org/wiki/ Image:Spanish_flu_notice.jpg

November 2006

A manual for Community Services Boards and others who may provide behavioral health services during and after a public health emergency.

This manual was produced through the Commonwealth of Virginia’s Department of Mental Health, Mental Retardation and Substance Abuse Services, under contract with Diana Nordboe and Amie Ware.

Module 1: Introduction…………………………………………………………………………………...6

Module 2: Overview of Public Health Emergencies…………………………………………...12

Module 3: Planning for a Public Health Emergency…………………………………………..44

Module 4: Funding for Behavioral Health after a Public Health Emergency………..80

Module 5: Characteristics and Disruptions of a Public Health Emergency…………..94

Module 6: Reactions to Public Health Emergencies………………………………………...112

Module 7: Interventions/Services…………………………………………………………………..142

Module 8: Promoting Behavioral Health During a Public Health Emergency…….198

Module 9: Managing Worker Stress in a Public Health Emergency…………………..236

Module 10: Lessons Learned and Best Practices……………………………………………..252

Note to Reader: Information throughout this manual has been extracted from a number of sources. To help the reader identify information from other sources, it will either be in quotation marks or indented. Sources are included after the quoted or indented sections, and reference lists are provided at the end of each module for additional information.

Public health emergencies may be caused by nature or by man. They may be the primary event, such as a pandemic, or the result of a disaster such as waterborne illnesses after a hurricane. There has been a great deal of attention in the United States and throughout the world on pandemic influenza, and therefore, much of this manual will concentrate on that specific public health threat.

The Implementation Plan for the National Strategy for Pandemic Influenza states that a pandemic “will differ from most natural or manmade disasters in nearly every respect. Unlike events that are discretely bounded in space or time, a pandemic will spread across the globe over the course of months or over a year, possibly in waves, and will affect communities of all sizes and compositions. The impact of a severe pandemic may be more comparable to that of a widespread economic crisis than to a hurricane, earthquake, or act of terrorism. It may present as a particularly severe influenza season, or it may overwhelm the health and medical infrastructure of cities and have secondary and tertiary impacts on the stability of institutions and the economy. These consequences are impossible to predict before a pandemic emerges because the biological characteristics of the virus and the impact of our interventions cannot be known in advance (White House, Homeland Security Council, 2006, page 27).”

Though the impact of a pandemic may differ from a natural disaster or act of terrorism, this manual assumes that a pandemic would be a traumatic event for those impacted, and therefore, like reactions to natural disasters and terrorism, the behavioral health reactions and interventions are expected to be similar. Much of the information in this manual about the impact and characteristics of a pandemic has been extracted from plans developed by state and Federal governments. Information about reactions has been adapted from existing knowledge and information about reactions to natural disasters or acts of terrorism, as well as information about the interventions that have been effective in helping people recognize and cope with those reactions. This manual adapts existing information and knowledge to form a basic understanding of what behavioral health workers may experience after a public health emergency, and encourages them to document their own experiences to help them better prepare and plan for future events.

Without a doubt, there will be differences in the scope and impact of a public health emergency, such as a pandemic, to those of a natural disaster or an act of terrorism, and these differences are acknowledged throughout the manual. However, without recent experience and knowledge of all the consequences of a pandemic, it is not possible to cover all potential impacts, reactions, challenges, and characteristics. This is recognized in the Implementation Plan for the National Strategy for Pandemic Influenza in the introduction to the federal planning assumptions: “Pandemics are unpredictable. While history offers useful benchmarks, there is no way to know the characteristics of a pandemic virus before it emerges (Ibid, page 25).”

While public health emergencies may be naturally occurring or human-caused, the Implementation Plan for the National Strategy for Pandemic Influenza encourages that preparedness for both natural and deliberate threats be merged. It states that “while

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the initial events leading to a deliberate or natural outbreak of infectious disease are dramatically different, the actions necessary to prepare, provide early warning, and respond are nearly identical. We should make this principle explicit in our planning for outbreaks and ensure, to the extent possible, that the mechanisms that we put in place are mutually supportive (Ibid, page 20-21).”

To help behavioral health workers understand the potential scope of a pandemic, and help them start planning now, the planning assumptions from the Implementation Plan for the National Strategy for Pandemic Influenza are provided below in their entirety.

Federal planning efforts assume the following: 1. Susceptibility to the pandemic influenza virus will be universal. 2. Efficient and sustained person-to-person transmission signals an imminent pandemic. 3. The clinical disease attack rate will be 30 percent in the overall population during the pandemic. Illness rates will be highest among school-aged children (about 40 percent) and decline with age. Among working adults, an average of 20 percent will become ill during a community outbreak. 4. Some persons will become infected but not develop clinically significant symptoms. Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. 5. While the number of patients seeking medical care cannot be predicted with certainty, in previous pandemics about half of those who became ill sought care. With the availability of effective antiviral medications for treatment, this pro- portion may be higher in the next pandemic. 6. Rates of serious illness, hospitalization, and deaths will depend on the virulence of the pandemic virus and differ by an order of magnitude between more and less severe scenarios. Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic or immunosuppressive medical conditions. 7. Rates of absenteeism will depend on the severity of the pandemic. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members, and fear of infection may reach 40 percent during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (closing schools, quarantin- ing household contacts of infected individuals, “snow days”) are likely to increase rates of absenteeism. 8. The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately 2 days. 9. Persons who become ill may shed virus and can transmit infection for one-half to one day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children will play a major role in transmission of infection as their illness rates are likely to be higher, they shed more virus over a longer period of time, and they control their secretions less well.

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10. On average, infected persons will transmit infection to approximately two other people. 11. Epidemics will last 6 to 8 weeks in affected communities. Multiple waves (periods during which community outbreaks occur across the country) of illness are likely to occur with each wave lasting 2 to 3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. (Source: Ibid, page 25)

The importance of behavioral health in a pandemic or other public health emergency cannot be understated. Behavioral health workers will be in a unique position to support the public health efforts in providing information to the public within effected communities about steps they can take to protect themselves, which will help them cope more effectively with their reactions. It will also help people who are suffering from a wide range of reactions that may hinder response and recovery efforts. Behavioral health workers will be able to help people cope with potential quarantines and isolation to help them understand the reasons why and how it helps individuals, their families, and the community. They can help those who are providing medical assistance to those who are ill and may face issues of stigmatization as a result. Behav- ioral health workers will be able to help people cope with the fear, anger, anxiety, and stress that may result from inadequate medical supplies, social disruption, quarantines, financial strain, employment Quarantine Sign/CDC issues, travel and transportation limitations, safety and health issues, illness, and death. Behavioral health workers can provide critical services to help individuals, families, and communities cope better, understand ways to protect themselves and keep their families as safe as possible, and lay the groundwork for communities to come back together after facing what could be a deeply difficult time.

It is important to note that behavioral health, and the importance of how people react during the crisis of a pandemic, is recognized in Federal and state planning documents. How people react and cope with those reactions is a critical component of helping ensure that our country and communities deal effectively during the different phases of a pandemic to be better able to recover from them. A frightened, angry, anxious, and antagonistic public will make it more difficult for local, state, and Federal officials to take the appropriate steps to contain the disease and treat people during a public health emergency. Yet a public that understands what they can do and why can have a tremendous impact on how well we all get through a pandemic. Behavioral health workers play an important role in responding to a public health emergency.

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The Great Pandemic of 1918 in Virginia Opening Remarks Prepared for Delivery By the Honorable Mike Leavitt Secretary of Health and Human Services, March 23, 2006

That Great Pandemic also touched Virginia.

Navy personnel in Virginia were afflicted with influenza in early September, though the state did not report those cases for about two weeks.

By the last week of September, the pandemic had taken hold in Newport News and Norfolk, and in Petersburg and Portsmouth. It raged all across Virginia throughout the cruel month of October.

Virginians did what they could to contain it. Schools were closed. Public meetings and weekend parties were banned. Even the State Fair was closed early on account of the flu.

Doctors gave succor and support to all the patients they could, although supplies ran short and many were stricken themselves.

In Alexandria, the town's two doctors visited hundreds of patients a day, dispensing their concocted treatment of atropine capsules (belladonna) and whiskey.

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In Richmond, Dr. Bernard Reams resorted to a treatment that had begun to fall from favor in the 1880s—soaking the legs and feet of his patients in scalding water and then swaddling them in blankets until they were red and sweating.

Some Virginians resorted to their own home remedies. For instance, John Brinkley, a share- cropper in the town of Max Meadows (western part of the state, about two hours north of Greensboro), believed that "a little fresh air could be fatal." So he sealed his family in his living room around a fire in a wood stove. For seven days the family remained in the room with the fire. On the eighth day, the house caught fire and the Brinkleys were forced to evacuate.

Fresh air didn't kill Mr. Brinkley's fears. And neither did influenza. But many other Virginians were not so fortunate.

By mid-October, Virginia had seen more than 200,000 cases of influenza. By the end of the year, more than 15,000 Virginians would die.

When it comes to pandemics, there is no rational basis to believe that the early years of the 21st century will be different than the past. If a pandemic strikes, it will come to Virginia.

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INTRODUCTION Module 2: Overview of Public Health Emergencies describes the various types of public health emergencies our country now faces. Public health emergencies may be human-caused, such as a bioterrorism event, or naturally-occurring, such as a pandemic.

Public health emergencies may be the result of a natural disaster or an act of terrorism, or in the case of a bioterror attack or pandemic flu, it may be the primary cause of a declaration. This module describes a variety of public health emergencies, including naturally occurring outbreaks; biological, chemical, and radiological weapons; and public health emergencies resulting from natural disasters, terrorism, chemical hazards, and others. This module does not include all potential public health emergencies. It is meant to be an overview for behavioral health workers to use as a reference, as well as to gain a better understanding of these various risks to be better prepared to respond with appropriate and timely behavioral health messages and interventions.

PUBLIC HEALTH EMERGENCIES INVOLVING COMMUNICABLE OR INFECTIOUS DISEASES The first section of this module deals with public health emergencies or threats that are naturally-occurring, such as pandemic influenza. There are some public health threats that are naturally occurring, that are also potential bioterror threats such as small pox and botulism, and these are discussed in the biological agent section of this module. This section will focus on public health concerns such as pandemic influenza and SARS, as well as outbreaks of other diseases recently reported by the CDC, such as botulism and e coli.

Pandemic Influenza A pandemic is a global disease outbreak. A flu pandemic occurs when a new influenza virus emerges for which people have little or no immunity, and for which there is no vaccine. The disease spreads easily person-to-person, causes serious illness, and can sweep across the country and around the world in very short time.

It is difficult to predict when the next influenza pandemic will occur or how severe it will be. Wherever and whenever a pandemic starts, everyone around the world is at risk. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but cannot stop it.

Health professionals are concerned that the continued spread of a highly pathogenic avian H5N1 virus across eastern Asia and other countries represents a significant threat to human health. The H5N1 virus has raised concerns about a potential human pandemic because it can be: • especially virulent • spread by migratory birds • transmitted from birds to mammals and in some limited circumstances to humans, and like other influenza viruses, continues to evolve.

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Since 2003, a growing number of human H5N1 cases have been reported in Azerbai- jan, Cambodia, China, Djibouti, Egypt, In- donesia, Iraq, Thailand, Turkey, and Viet- nam. More than half of the people infected with the H5N1 virus have died. Most of these cases are all believed to have been caused by exposure to infected poultry. There has been no sustained human-to- human transmission of the disease, but the concern is that H5N1 will evolve into a virus capable of human-to-human transmission.

Historically, the 20th century saw 3 pandemics of influenza: • 1918 influenza pandemic caused at least 675,000 U.S. deaths and up to 50 million Administration of a vaccine during the 1976 New Jersey immunization project for deaths worldwide Influenza A. CDC/Robert E. Bates • 1957 influenza pandemic caused at least 70,000 U.S. deaths and 1-2 million deaths worldwide • 1968 influenza pandemic caused about 34,000 U.S. deaths and 700,000 deaths worldwide (Source: http://www.pandemicflu.gov/general/)

SARS Severe Acute Respiratory Syndrome (SARS) is a viral respiratory illness caused by a coronavirus, called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003. Over the next few months, the illness spread to more than two dozen countries in North America, South America, Europe, and Asia before the SARS global outbreak of 2003 was contained.

Symptoms of SARS In general, SARS begins with a high fever (temperature greater than 100.4°F [>38.0°C]). Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also have mild respiratory symptoms at the outset. About 10 percent to 20 percent of patients have diarrhea. After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia.

How SARS spreads The main way that SARS seems to spread is by close person-to-person contact. The virus that causes SARS is thought to be transmitted most readily by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes. Droplet spread can happen when droplets from the cough or sneeze of an infected person are propelled a short distance (generally up to 3 feet) through the air and deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby. The virus also can spread when a person touches a surface or object

Module 2 14 contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s). In addition, it is possible that the SARS virus might spread more broadly through the air (airborne spread) or by other ways that are not now known.

What does “close contact” mean? In the context of SARS, close contact means having cared for or lived with someone with SARS or having direct contact with respiratory secretions or body fluids of a patient with SARS. Examples of close contact include kissing or hugging, sharing eating or drinking utensils, talking to someone within 3 feet, and touching someone directly. Close contact does not include activities like walking by a person or briefly sitting across a waiting room or office. (Source: http://www.cdc.gov/ncidod/sars/factsheet.htm)

West Nile Virus West Nile Virus (WNV) is a potentially serious illness. Experts believe WNV is established as a seasonal epidemic in North America that flares up in the summer and continues into the fall. This fact sheet contains important information that can help you recognize and prevent West Nile virus.

What Are the Symptoms of WNV? Serious Symptoms in a Few People. About one in 150 people infected with WNV will develop severe illness. The severe symptoms can include high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis. These symptoms may last several weeks, and neurological effects may be permanent.

Milder Symptoms in Some People. Up to 20 percent of the people who become infected have symptoms such as fever, headache, and body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin rash on the chest, stomach and back. Symptoms can last for as short as a few days, though even healthy people have become sick for several weeks.

No Symptoms in Most People. Approximately 80 percent of people (about 4 out of 5) who are infected with WNV will not show any symptoms at all.

How Does West Nile Virus Spread? Infected Mosquitoes. Most often, WNV is spread by the bite of an infected mosquito. Mosquitoes become infected when they feed on infected birds. Infected mosquitoes can then spread WNV to humans and other animals when they bite.

Transfusions, Transplants, and Mother-to-Child. In a very small number of cases, WNV also has been spread through blood transfusions, organ transplants, breast- feeding and even during pregnancy from mother to baby.

Not through touching. WNV is not spread through casual contact such as touching or kissing a person with the virus. (Source: http://www.cdc.gov/ncidod/dvbid/westnile/wnv_factsheet.htm)

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E coli Escherichia coli O157:H7 is an emerging cause of foodborne illness. An estimated 73,000 cases of infection and 61 deaths occur in the United States each year. Infec- tion often leads to bloody diarrhea, and occasionally to kidney failure. Most illness has been associated with eating undercooked, contaminated ground beef. Person- to-person contact in families and child care centers is also an important mode of transmission. Infection can also occur after drinking raw milk and after swimming in or drinking sewage-contaminated water.

What is Escherichia coli O157:H7? E. coli O157:H7 is one of hundreds of strains of the bacterium Escherichia coli. Al- though most strains are harmless and live in the intestines of healthy humans and animals, this strain produces a powerful toxin and can cause severe illness.

E. coli O157:H7 was first recognized as a cause of illness in 1982 during an outbreak of severe bloody diarrhea; the outbreak was traced to contaminated hamburgers. Since then, most infections have come from eating undercooked ground beef.

The combination of letters and numbers in the name of the bacterium refers to the specific markers found on its surface and distin- guishes it from other types of E. coli.

How is E. coli O157:H7 spread? The organism can be found on a small number of cattle farms and can live in the intestines of healthy cattle. Meat can become contaminated during slaughter, and organisms can be thoroughly mixed into beef when it is ground. Bacteria present on the cow's ud- ders or on equipment may get into raw milk.

Eating meat, especially ground This collage displayed newspaper headlines related to food poisoning stories. It was created by the Minnesota beef, that has not been cooked suf- Department of Health in the 1930s, and its message was ficiently to kill E. coli O157:H7 can part of a campaign admonishing citizens to be aware cause infection. Contaminated that safe food cannot be taken for granted CDC/ Minne- meat looks and smells normal. sota Department of Health, R.N. Barr Library; Librari- ans Melissa Rethlefsen and Marie Jones

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Although the number of organisms required to cause disease is not known, it is suspected to be very small.

Among other known sources of infection are consumption of sprouts, lettuce, salami, unpasteurized milk and juice, and swimming in or drinking sewage- contaminated water.

Bacteria in diarrheal stools of infected persons can be passed from one person to another if hygiene or handwashing habits are inadequate. This is particularly likely among toddlers who are not toilet trained. Family members and playmates of these children are at high risk of becoming infected.

Young children typically shed the organism in their feces for a week or two after their illness resolves. Older children rarely carry the organism without symptoms.

What illness does E. coli O157:H7 cause? E. coli O157:H7 infection often causes severe bloody diarrhea and abdominal cramps; sometimes the infection causes non-bloody diarrhea or no symptoms. Usually little or no fever is present, and the illness resolves in 5 to 10 days.

In some persons, particularly children under 5 years of age and the elderly, the infection can also cause a complication called hemolytic uremic syndrome, in which the red blood cells are destroyed and the kidneys fail. About 2%-7% of infections lead to this complication. In the United States, hemolytic uremic syndrome is the principal cause of acute kidney failure in children, and most cases of hemolytic uremic syndrome are caused by E. coli O157:H7. (Source: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm)

Botulism What is botulism? Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the bacterium Clostridium botulinum. There are three main kinds of botulism. Foodborne botulism is caused by eating foods that contain the botulism toxin. Wound botulism is caused by toxin produced from a wound infected with Clostridium botulinum. Infant botulism is caused by consuming the spores of the botulinum bacteria, which then grow in the intestines and release toxin. All forms of botulism can be fatal and are considered medical emergencies. Foodborne botulism can be especially dangerous because many people can be poisoned by eating a contaminated food.

How common is botulism? In the United States an average of 110 cases of botulism are reported each year. Of these, approximately 25% are foodborne, 72% are infant botulism, and the rest are wound botulism. Outbreaks of foodborne botulism involving two or more persons occur most years and usually caused by eating contaminated home-canned foods. The number of cases of foodborne and infant botulism has changed little in recent

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years, but wound botulism has increased because of the use of black-tar heroin, especially in California.

What are the symptoms of botulism? The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness.

Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone. These are all symptoms of the muscle paralysis caused by the bacterial toxin. If untreated, these symptoms may progress to cause paralysis of the arms, legs, trunk and respiratory muscles. In foodborne botulism, symptoms gener-

ally begin 18 to 36 hours after eating a contaminated food, This laboratorian is testing for the but they can occur as early as 6 hours or as late as 10 days. confirmation of botulism toxin. (Source: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ CDC/Dr. V.R. Dowell botulism_g.htm)

BIOLOGICAL, CHEMICAL, AND RADIOLOGICAL WEAPONS This section, extracted from HHS’s document Terrorism and Other Public Health Emergencies: a Reference Guide for the Media, describes potential public health threats from biological, chemical, or radiological weapons that may be used by terrorists.

Biological Agents Overview • The threat from biological agents arises when naturally occurring microbes are weaponized—harnessed and modified to cause disease or even kill many people. • Organisms can be used in their naturally occurring state or they may be able to be modified to increase virulence and/or render the disease they cause resistant to treatment. • To determine if an outbreak may be bioterrorism, scientists will look for the following characteristics: • A large number of cases appearing at the same time, particularly in a discrete population (e.g., people from the same town, people who attended the same event) • A large number of cases of a rare disease or one considered a bioterrorism threat (e.g., plague, tularemia) • More severe disease manifestation than typical for a given disease and/or an unusual route of exposure • A disease that is unusual in a given place or is out of season (e.g., a flu outbreak in the summer in the United States)

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• Multiple simultaneous outbreaks of the same disease or different diseases • A disease that affects animals as well as humans • Unusual disease strains or uncommon antibiotic resistance to an organism • Although some of these characteristics may be true of a naturally occurring outbreak, they will generally signal that the outbreak needs to be closely scrutinized.

UNDERSTANDING BIOLOGICAL AGENTS The first step in understanding biological agents and how they affect the human body is a review of associated terminology.

Infectious Diseases • Infectious diseases are caused by the invasion of the body by harmful microorganisms. • Microorganisms multiply and make the person sick by attacking organs or cells in the body. • These harmful microorganisms include viruses and bacteria, as well as certain other microscopic organisms, and are sometimes called pathogens. • There is usually a lag time, called an incubation period, between when a person is infected and when the symptoms appear. • People can become infected with these diseases in any number of ways, including consuming contaminated water or food, being bitten by insects or animals, or inhaling or touching the microorganisms or their spores. • Spores are produced by certain bacteria and plants. Like seeds, spores do not grow until the environment is conducive for them to do so. They are highly resistant to heat and other environmental factors.

Contagious Diseases • A contagious disease is an infectious disease that can be “caught” by a person who comes into contact with someone who is infected. Not all infectious diseases are contagious. • Exposure to a contagious disease usually happens through contact with the infected person’s bodily fluids or secretions, such as a sneeze. • Depending on the disease, the level of contact required to pass on the illness could be as casual as water droplets in the air from a cough (e.g., smallpox). • The level of contagiousness has nothing to do with how serious the resulting disease may be. For example, pneumonic plague and the common cold are both highly contagious, but pneumonic plague is obviously a much more serious disease. • There are some infectious diseases that are not contagious at all, no matter how close the contact with an infected person (e.g., botulism, tularemia).

Toxins • Toxins are the poisonous, usually protein-based, substances produced by

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microorganisms (bacteria, mold, virus) in certain infectious diseases. • Microorganisms use these toxins as the specific weapons for attacking organs or cells in the body. • Antitoxins are medications that attempt to neutralize a toxin without necessarily killing the bacteria, mold, or virus that is producing the toxin. • Many different types of antitoxins exist because a specific antitoxin will usually only fight a particular kind of toxin. • Although toxins are usually classified as being biologically produced, common language often refers to the poisons created by nonliving chemical agents as chemical toxins.

Bacteria and Viruses Both bacteria and viruses can cause infectious diseases.

Bacteria • Bacteria are one-celled microorganisms that are capable of multiplying. • Not all bacteria are harmful (e.g., bacteria turn milk into cheese). • Antibiotics are medications that can be used to kill harmful bacteria. • Some bacteria can develop resistance to antibiotics, making the medications less effective. • Hospitals will typically have supplies of antibiotics known to be effective against most Cate- gory A and B bacterial agents (described later in this module). This negative stained transmission electron micrograph (TEM) Viruses shows recreated 1918 influenza virions that were collected from • Viruses are simpler than bacteria, often made supernatants of 1918-infected up merely of a bit of deoxyribonucleic acid Madin-Darby Canine Kidney (DNA) or ribonucleic acid (RNA) that is sur- (MDCK) cells cultures 18 hours rounded by a protective coat of protein. after infection. CDC/ Dr. Terrence Tumpey • Viruses are parasitic in nature and unable to multiply without host cells—cells within a person’s body that the viruses invade and use to multiply. • Antibiotics are not effective against viruses. • Some antiviral medications do exist, but many that might help against Cate- gory A agents are still in clinical trials.

Delivery of Biological Agents • The ability to successfully deliver a biological attack depends on: • The type of agent or organism • The method of dissemination • The weather (e.g., wind speed, humidity, time of day, precipitation, temperature): • Wind speed affects how widely an agent can be spread • Humidity can cause decomposition of an agent

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Routes of Entry Biological agents can enter the body through: • Absorption • Inhalation • Ingestion • Injection

Delivery Methods Biological weapons can be prepared for delivery as a weapon in wet or dry form: • In dry form, agents are more stable and refinement is easier • In liquid form, agents are less stable, require refrigeration, and are difficult to refine to small particle sizes

Biological weapons can be delivered by: • Wet or dry aerosol sprayers • Explosive devices • Transmission through insects, animals, or humans • Introduction into food, water, or even medications • In or on objects, in some cases (e.g., anthrax in envelopes)

Effectiveness of Release The effectiveness of a biological release depends on: • The particle size and its potency (for example, in an aerosol release, the size must be between 1 and 5 microns to be inhaled and cause illness) (Note: 1 mi- cron is one millionth of a meter. A strand of hair ranges between 20 and 200 microns in width.) • How well the agent survives in the environment • Weather conditions

Categories of Bioterrorism Agents Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents are considered the highest risk and Category C agents are those that are considered emerging threats for disease.

Category A These high-priority agents include organisms or toxins that pose the highest risk to the public and national security because they: • Easily spread or transmitted from person to person • Result in high death rates and have the potential for major public health impact • Cause public panic and social disruption • Require special action for public health preparedness.

Threats in category A include: • Anthrax (Bacillus anthracis) • Botulism (Clostridium botulinum toxin) • Plague (Yersinia pestis)

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• Smallpox (variola major) • Tularemia (Francisella tularensis) • Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])

Category B These agents are the second highest priority because they may: • Be moderately easy to spread • Result in moderate illness rates and low death rates • Require specific enhancements of CDC's laboratory capacity and enhanced disease monitoring.

Threats in Category B include: • Brucellosis (Brucella species) • Epsilon toxin of Clostridium perfringens • Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella) • Glanders (Burkholderia mallei) • Melioidosis (Burkholderia pseudomallei) • Psittacosis (Chlamydia psittaci) • Q fever (Coxiella burnetii) • Ricin toxin from Ricinus communis (castor beans) • Staphylococcal enterotoxin B • Typhus fever (Rickettsia prowazekii) • Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) • Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Category C These third highest priority agents include emerging pathogens that could be engineered for mass spread in the future because they can be: • Readily available • Easily produced and spread • Potentially catastrophic with high morbidity and mor- This photograph showed two CDC health officials securing a containment suit before the tality rates and suited scientist began a Hantavirus field study, which was conducted after the onset of a viral major health outbreak. In the United States, it is the deer mouse, Peromyscus maniculatus, that is the impact. primary reservoir of the hantavirus, which causes hantavirus pulmonary syndrome. CDC

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BASICS ABOUT BIOLOGICAL AGENTS IN CATEGORY A Anthrax Basic Facts • Scientific name: Bacillus anthracis; rod-shaped bacteria (not a virus). • Anthrax is the disease that develops after exposure to spores produced by this bacteria. • The spores can remain dormant for long periods but are still capable of causing infection when someone comes in contact with them by touching or breathing them in. • Anthrax spores can cause three types of illness, depending on how a person is exposed: • Inhalational (respiratory)—most lethal • Cutaneous (skin) • Gastrointestinal (digestive) • The anthrax illness is not contagious. • Anthrax can be treated with antibiotics if diagnosed early. • An anthrax vaccine exists but is not in widespread use.

Anthrax Spores as a Weapon Historically, many nations have weaponized anthrax by turning it into a concentrated powder or aerosol form. Generally, anthrax spores tend to clump together and the body can defend itself against them in that form. In a refined state, however, the spores are very dangerous when inhaled.

Botulinum Toxin Basic Facts • Scientific name: Botulinum toxin. The toxin, or poison, is produced by the bacterium Clostridium botulinum (not a virus). • Botulinum toxin is the most poisonous substance known to science. • Botulism is a muscle-paralyzing disease that develops after a person is poisoned with botulinum toxin. • The toxin is colorless, odorless, and tasteless. • Clostridium botulinum exists naturally in the environment, and the botulinum toxin it produces can cause two types of illness: • Foodborne botulism • Infant botulism • Wound botulism • Inhalation botulism, caused by breathing botulinum toxin, does not occur naturally but could happen as a result of deliberate dissemination of the toxin in the air by a technologically sophisticated terrorist or as a laboratory accident. • Botulism is not contagious.

Botulinum Toxin as a Weapon • Clostridium botulinum bacteria produce a toxin. Terrorists have tried to weaponize botulinum toxin by refining the toxin and putting it into an aerosol form. Refined or crude preparations of toxin could be used to poison food or

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beverages, and refined toxin, with a sophisticated delivery system, could be used to disseminate the toxin by air. • Botulism toxin can be disseminated via the air, water, or food. • Such contamination would be hard to detect because botulinum toxin is colorless, odorless, and tasteless. • Poisoning the water supply would be difficult for terrorists because: • Large quantities of toxin would be needed to affect the water system • Chlorine in most water treatment facilities would destroy the toxin 54 Plague Basic Facts • Scientific name: Yersinia pestis; a bacterium (not a virus). • Plague is the disease that develops after infection with this bacterium. • Humans contract plague by inhaling it or from the bite of an infected flea. • Plague infection takes three primary forms: • Bubonic • Pneumonic • Septicemic • Only pneumonic plague is contagious through respiratory droplets with direct close contact (within 6 feet). • Plague is highly lethal if untreated. • Plague can be treated with antibiotics if caught early. • Some plague infections occur naturally each year (usually bubonic).

Plague as a Weapon • Because pneumonic plague is highly lethal and contagious and would quickly overwhelm communities and their health care systems, countries with biological weapons programs have explored using plague in aerosol form to infect large groups of people. • A pneumonic plague outbreak would be difficult to contain. • Treatment must be immediate (within 24 hours of first symptoms) to be successful. • Once refined, plague bacteria can be released into the air undetected. • Once released into the air, plague bacteria remain infectious for up to an hour. • Aerosolized plague bacteria can infect large groups of people quickly. • Plague bacteria degrade quickly in sunlight or heat.

Smallpox Basic Facts • Scientific name: Variola Major; a virus from the Orthopoxvirus family. • A closely related virus, Variola Minor, causes a less severe form of illness with less than 1 percent fatality rate. • Smallpox was a naturally occurring disease that killed an estimated 300 million people in the 20th century. • Officially eradicated in nature in 1980, smallpox has more recently been of concern as a potential bioterrorism threat.

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• The smallpox virus is moderately contagious; direct, face-to-face contact is usually required to spread the disease. Smallpox can also be spread through direct contact with infected body fluids or contaminated objects (e.g., bedding). • Characterized by skin lesions and high fever, smallpox historically has killed approximately 30 percent of those infected. • Routine vaccinations in the United States ended in 1972. At present, a large portion of the population is considered vulnerable to infection should a bioterrorism incident occur.

Smallpox as a Weapon • Smallpox would be an attractive weapon for terrorists, because it is contagious from person to person and could potentially infect large groups of people, taxing the health care systems of a community. The smallpox virus could be disseminated into the air as a fine spray or powder and could infect large numbers of people. • In aerosol form, the smallpox virus may be infectious for 24 hours before degrading. Heat and sunlight (UV exposure) may destroy the virus within hours. • Terrorists could possibly use smallpox virus samples to intentionally infect a few people, possibly themselves, with the intention of infecting others. However, it is A vial of Dryvax® dried calf doubtful that any one individual would succeed in infect- lymph type smallpox vaccine, ing more than a few others. By the time that these indi- which is reconstituted with a viduals were contagious, they would be very obviously diluent prior to vaccination. CDC seriously ill.

Tularemia Basic Facts • Scientific name: Francisella tularensis; a bacterium (not a virus). • Tularemia is the disease caused by this bacterium; it is also known as Rabbit Fe- ver or Deer Fly Fever. • Tularemia spreads to humans from infected animal tissue. • The disease can be spread through contaminated food and water. • Tularemia is not contagious. • A small amount of the bacteria can cause the disease. • There are three types of tularemia: • Ulceroglandular • Inhalational • Typhoidal

Tularemia as a Weapon • Weaponized tularemia bacteria would most likely be disseminated through the air. But terrorists could also use the bacteria to contaminate food or water. • If released into the air, F. tularensis can remain potent for up to 2 hours. • The bacteria can survive at low temperatures in water, soil, hay, or frozen animal carcasses.

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• The bacteria quickly degrade in heat once released in the air.

Chemical Agents Basic Facts This section discusses four major types of chemical agents, grouped according to how they affect the human body: • Blister (e.g., mustards) • Blood (e.g., cyanides) • Choking (e.g., chlorine) • Nerve (e.g., sarin, VX agents)

Other categories of chemicals include: • Biotoxins • Caustics (acids) • Incapacitating agents • Long-acting anticoagulants • Metals • Organic solvents • Riot control agents/tear gas • Toxic alcohols • Vomiting agents

Chemical agents can come in the form of poisonous gases, liquids, or solids. These agents are usually fast acting and toxic to people, animals, or plants. (Note: A major exception is mustard agents for which symptoms appear several hours after exposure.)

Poisoning by chemicals is not contagious. However, if residual chemical agents or vapors are on the skin, clothing, hair, or in biologic fluids (such as vomit), others can be exposed and affected. Once the agent is removed (e.g., by removing clothing and showering), the illness caused by a chemical agent cannot be spread.

CHEMICAL AGENTS AS WEAPONS • Sufficient quantities must be used for chemical weapons to be effective. • Weather factors have an impact on the effectiveness of an open-air release. These factors include: • Temperature • Wind speed and direction • Humidity and air stability • Chemical agents are typically more deadly in confined or crowded areas, such as buildings, subways, or battlefields, where evacuation options are limited. • Chemical agents can be deployed in five ways: • Spraying the chemical with wet or dry aerosol sprayers (e.g., crop dusters, handheld spraying devices) • Using a heat source to vaporize the chemical for release

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• Using an explosive device to disperse the chemical • Pouring the chemical on a specific site (e.g., building floor, sidewalk, subway platform) • Contamination of food, water, or pharmaceuticals (such as the 1982 intentional contamination of acetaminophen products with cyanide)

BLISTER AGENTS This family of chemical agents is also called vesicant agents: • Mustards (e.g., sulfur mustard) • Lewisites/chloroarsine agents • Phosgene oxime • Mustards and lewisites cause blistering on the skin after exposure. Mustard gas is the best-known example. A lesser-known but possible threat is lewisite.

Mustard Gas Basic Facts • Mustard agent, in some forms, can be a colorless, oily, odorless liquid. • Mustard agent can be vaporized to form a gas, if heated. • In some quantities, this agent may have a slight garlic odor and a yellowish-to- brownish tint.

Mustard Gas as a Weapon • The agent may be persistent in the soil for weeks but generally only remains on materials after release for days to hours. This is highly dependent on the air temperature and purity of the compound. • It can still be harmful if it settles in the ground. • It was introduced as a weapon in World War I.

Lewisite Basic Facts • Lewisite is also known as L. • This agent is a chemical warfare agent that causes immediate blistering of the skin and damage to the respiratory system. • Lewisite is an oily liquid that can be colorless or can appear amber to black. • This agent smells like geraniums and could be confused with the smell of ammonia. • Lewisite contains arsenic. • Lewisite is not found naturally in the environment; when released there, • however, it can last for days.

Lewisite as a Weapon • Lewisite was developed for use in World War I by the United States but was produced too late to be used. • Lewisite has no other uses except as a chemical warfare agent. • In a vapor state, lewisite can be released into the air. • The liquid form of lewisite could possibly be used to poison water or food.

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• People are exposed to lewisite by breathing in or ingesting it, or if it comes into contact with their skin or eyes.

Blood Agents • Blood agents include: • Arsine • Cyanide • These agents deprive the blood and organs of oxygen.

Arsine Basic Facts • Arsine is a colorless toxic gas. • Arsine has a mild garlic odor that can be detected only at levels greater than those nec- This historic illustration depicted a sil- essary to cause poisoning. houette of a laboratory researcher at a • Accidental formation of arsine in the work- 1930s lab bench. CDC/ Minnesota De- place is the most common route of expo- partment of Health, R.N. Barr Library; sure. Librarians Melissa Rethlefsen and Marie Jones Arsine as a Weapon • Arsine was explored for chemical warfare in World War II by the British but was never used. • Arsine is relatively easy to create for a deliberate release into the air because it is most commonly used in the semiconductor and metals refining industries and is readily available.

Cyanide Basic Facts • Cyanide can come in many different forms, however, the following four types are more likely to be seen: • Hydrogen cyanide • Cyanogen chloride • Potassium cyanide • Sodium cyanide • Legitimate uses of cyanide compounds include manufacturing applications, such as metal refining and photography. • In gas form, the agent is colorless and may have a slight almond odor.

Cyanide as a Weapon • The agent can be released into the air, soil, drinking water, or food supply. • Cyanide is fast acting. • Breathing in and ingesting cyanide are the most harmful routes of exposure. • Cyanide is most dangerous in enclosed spaces. • Cyanide evaporates quickly in open areas. • Cyanide is relatively easy to obtain and release.

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Choking Agents • Choking agents include: • Ammonia • Chlorine • Hydrogen chloride • Phosgene • Phosphine • Phosphorus (certain forms) • These agents attack the respiratory system, making it difficult to breathe.

Chlorine Basic Facts • Chlorine is used in industry and is found in bleach and other common household products. • Chlorine can take a gas or yellow-green liquid form. • Chlorine emits a strong odor, which is like the odor of bleach, and can become explosive and flammable when mixed with other chemicals.

Chlorine as a Weapon • Chlorine is most likely to be released as a gas. • It can be released into the air and spreads rapidly. • Chlorine settles close to the ground. • In liquid form, it can be released into the water or food supply. • Chlorine was used in World War II as a chemical weapon. • Terrorists may attempt to access large quantities stored at water treatment facilities, swimming pool complexes, and industrial sites.

Phosgene Basic Facts • Phosgene is also known as CG. • Phosgene is an industrial chemical used to make plastics and pesticides. • Phosgene is a poisonous gas at room temperature. • When cooled, phosgene is converted into liquid form. • In a liquid release or spill, phosgene changes to gas and stays close to the ground. • Phosgene may appear colorless, or as a white or pale yellow cloud. • In low concentrations, phosgene smells like newly mown hay. • In high doses, phosgene has a strong unpleasant odor. • Phosgene can cause flammable substances to burn but is not flammable itself. • Phosgene is not found naturally in the environment. • Phosgene may be relatively easy to obtain since it is used in industry.

Phosgene as a Weapon • Phosgene was used extensively during World War I, by both German and Allied armies, causing many deaths. • Phosgene could be released into the air. • Phosgene liquid could be released into water to expose those who drink it or touch it.

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• Phosgene could be used in liquid form to poison food.

Nerve Agents Nerve agents do damage by affecting the nervous system of victims. These agents are of the greatest concern because of the low amounts needed to produce significant symptoms and even death. These agents include: • Sarin • Soman • Tabun • VX

Sarin Basic Facts • Sarin is a manufactured compound that is colorless, odorless, and tasteless. • Sarin can take a gas or liquid form and is highly volatile and lethal. • Sarin is absorbed through the skin or respiratory tract and causes severe respiratory damage. • Even very small amounts can kill people. • Vaporized sarin stays near the ground. • Sarin remains deadly in warm, dry temperatures but can degrade in humidity.

Sarin as a Weapon • Sarin can be released into the air and expose people through ingestion or contact with the skin or eyes. • Sarin can be released into water and expose people who touch or drink the contaminated water. • Sarin can be used to contaminate food. • Sarin is most dangerous in enclosed spaces. • Victims need only be exposed to a small amount to become ill. • Sarin was used by Aum Shinrikyo, a Japanese cult, in a 1995 Tokyo subway attack, which demonstrated to the world that it could be used as a terrorist weapon.

Soman Basic Facts • Soman is also known as GD. • Soman is a clear, colorless, tasteless liquid that can smell fruity or like oil of camphor. • Soman can be heated into a vapor form. • Soman is not found naturally in the environment.

Soman as a Weapon • Soman is a human-made chemical warfare agent. • Germany developed soman as an insecticide in 1944. • Soman is suspected of being used during the Iran-Iraq war in the 1980s. • Soman can be released into the air in vapor form. • Soman could be used in liquid form to poison water or food.

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Tabun Basic Facts • Tabun is also known as GA. • Tabun is a clear, colorless, tasteless liquid with a faint fruity odor. • Tabun can become a vapor, if heated. • Tabun is not found naturally in the environment. • Tabun is toxic and affects the body rapidly.

Tabun as a Weapon • Tabun is human-made for chemical warfare. • Tabun was originally developed by Germany in 1936 as a pesticide. • Tabun was possibly used in the 1980s during the Iran-Iraq war. • Tabun could be released through the air. • Tabun could be used to poison water. • Tabun could be used to contaminate food.

VX Basic Facts • VX can be heated to create a vapor form, but only in small amounts. • The agent is stable in the environment. • In average weather, VX can last on objects for days. • In extremely cold weather, VX can sustain its potency for months. This was a hazmat technician analyz- ing the contents of a potentially envi- • VX can be a long-term hazard on surfaces. ronmentally toxic site wearing a pro- • VX is considered more toxic than other nerve agents. tective suit. CDC

VX as a Weapon • VX is a human-made chemical warfare agent. • The agent was originally developed in the United Kingdom in the early 1950s. • VX may have been used in the Iran-Iraq war in the 1980s. • VX is primarily used in liquid form to contaminate water or food. (Source: http://www.hhs.gov/emergency/mediaguide/PDF/04.pdf)

Radiation Emergencies Basic Facts • Radiation is energy moving in the form of particles or waves. Some examples of electromagnetic radiation are heat, light, radio waves, and microwaves. The specific type of radiation discussed here is ionizing radiation. • Ionizing radiation is a very high-energy form of electromagnetic radiation and cannot be detected without specialized equipment. • Radioactivity is the process of spontaneous transformation of the nucleus of an atom, generally with the emission of alpha or beta particles often accompanied by gamma rays. This process is referred to as decay or disintegration of an atom.

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• An alpha particle is the nucleus of a helium atom, made up of two neutrons and two protons. Alpha particles generally carry more energy than gamma or beta particles and deposit that energy very quickly while passing through human body tissue. Alpha particles can be stopped by a thin layer of light material, such as a sheet of paper, and cannot penetrate the outer, dead layer of skin. Therefore, they do not damage living tissue when outside the body. When alpha-emitting atoms are inhaled or swallowed, however, they are especially damaging because they transfer relatively large amounts of ionizing energy to living cells. • Beta particles are electrons ejected from the nucleus of a decaying atom. Al- though they can be stopped by a thin sheet of aluminum, beta particles can penetrate the dead skin layer, potentially causing burns. They can pose a serious direct or external radiation threat and can be lethal depending on the amount received. They also pose a serious internal radiation threat if beta- emitting atoms are ingested or inhaled. • Gamma rays are a high-energy electromagnetic radiation. Gamma rays are very penetrating and generally require material such as lead or thick concrete to reduce the exposure. Gamma rays are a serious direct or external radiation threat. They also pose a threat when they are inhaled or ingested. Gamma rays are very similar to X-rays. • Neutrons are small atomic particles found within an atom’s nucleus. Neu- trons are a highly penetrating radiation when released by nuclear fission (the splitting of an atom) and are a serious direct or external radiation threat after a nuclear detonation (e.g., nuclear weapon or an improvised nuclear device). • Any or all of the types of radiation described above may be present after a radiological event. Public health officials would determine the specific protective actions that the public should take as soon as the nature of the event is determined by radiological experts. • Radioactive material is material that contains unstable (radioactive) atoms that give off radiation as they decay. • Radioactive decay is the spontaneous disintegration of the nucleus of an atom. • Radioactive half-life is the time required for a quantity of a radioactive material to decay by half. • Radioactive contamination is the deposition of radioactive material (e.g., dirt, dust, debris, liquid) on the surfaces of structures, areas, objects, or people. It can be airborne, external, or internal. • Radiation exposure is not the same as contamination. Exposure occurs when radiation penetrates the body and deposits its energy. For example, when a person has a chest X-ray, he or she is exposed to radiation, but he or she is not contaminated.

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NUCLEAR/RADIOLOGICAL AGENTS AS WEAPONS The first step in understanding radiation emergencies is to draw the distinction between a nuclear event (like the bomb dropped on Hiroshima, Japan) and a radiological event, such as a nuclear power plant incident or a radiological dispersal device (e.g., dirty bomb). In short, a nuclear event involves nuclear fission (splitting of atoms) and a highly destructive explosion that instantly devastates people and buildings because of extreme heat and impact of the blast. A nuclear event typically leaves large amounts of radioactivity behind. On the other hand, a radiological event does not involve nuclear fission but may be accompanied by an explosion and release of radioactivity. A radiological event typically involves the release of less radioactivity than a nuclear event. With both nuclear and radiological events, wind direction and weather patterns can spread radioactivity beyond the immediate incident site. Four specific radiation incidents will be discussed: nuclear power plant attack, radiological dispersal device (e.g., dirty bomb), and improvised nuclear device (e.g., suitcase bomb), nuclear weapon.

Nuclear Power Plant Attack • This is a radiological threat that does not involve a nuclear blast. • Terrorists could attack a nuclear power plant by using explosives, hacking into the computer system, or crashing a plane into the reactor or other structures on site. • Security measures are in place so that such attempts are likely to be detected early. Also, nuclear power plants have well-established emergency response procedures in place. • Nuclear power plants are built to sustain extensive damage without releasing radioactive material. • Theoretically, radioactive materials could escape in some cases and contaminate the surrounding area and the environment. • Costly and time-consuming cleanup efforts could be required to remove released radioactive materials from the environment. • Though the death toll and radiation exposure could be limited, the psychological impact could Three Mile Island nuclear power plant near Middletown, be severe. In the case of the lim- Pennsylvania, which was the site of a March 28, 1979 power ited meltdown accident at Penn- plant accident. CDC sylvania’s Three Mile Island in 1979, a governor’s commission report showed that one of the main health effects of the accident was on the mental health status of people in the region.

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Radiological Dispersal Device (RDD) • This is a radiological threat that does not involve a nuclear blast. • Terrorists could obtain radioactive materials to use in such a device. Radioactive materials can come from a nuclear power plant, medical or research facility, or food processing plant. • Radioactive materials could be dispersed by using explosives (e.g., dirty bomb) or other means, such as aerosols or sprays. • A dirty bomb involves conventional explosives laced with radioactive material, so that the blast would contaminate an area with radioactive particles. • In the case of a dirty bomb, the resulting blast could kill people in the immediate area and spread contamination around an area the size of several city blocks. • Though the death toll and radiation exposure would be limited, the psychological impact could be severe. In this vein, some have dubbed the dirty bomb a “weapon of mass disruption.” • Radiological material can also be covertly placed in areas where it could easily expose people to radiation. This hidden source is often referred to as a “silent” source or may be called a radiation-emitting device. This method of radiation release does not involve an explosion or dispersal of radioactive materials by any other means.

Improvised Nuclear Device (IND) • This is a small nuclear weapon (see section below) capable of producing a nuclear blast. • The physical size of these weapons can be small enough to fit in a suitcase (i.e., suitcase bomb). • The design and destructive nature of an improvised nuclear device is comparable to the bomb dropped on Hiroshima, Japan, at the end of World War II.

Nuclear Weapon • A nuclear weapon produces a nuclear detonation involving the joining (fusion) or splitting (fission) of atoms to produce an intense pulse or wave of heat, light, air pressure, and radiation. • Highly processed plutonium or uranium undergoes fission in a chain reaction blast. • The blast is designed to cause catastrophic damage to people, buildings, and the environment. • Highly guarded materials and technical expertise are required to produce these weapons. • The extent of damage depends on the yield (power) of the bomb. The destructive nature of these weapons can be in the order of 100 times the bomb dropped on Hiroshima. • When a nuclear weapon explodes, a large fireball is created. Everything inside of this fireball vaporizes, including soil and water, and is carried upwards. This creates the mushroom cloud that is associated with a nuclear blast, detonation, or explosion.

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• Radioactive material from the nuclear device mixes with the vaporized material in the mushroom cloud. As this vaporized radioactive material cools, it becomes condensed and forms particles, such as dust. The condensed radioactive material then falls back to the earth; this is what is known as fallout. • Because fallout is in the form of particles, it can be carried long distances on wind currents and end up miles from the site of the explosion. • Fallout is radioactive and can cause contamination of anything on which it lands, including food and water supplies.

IMPACT OF RADIATION EMERGENCIES A nuclear or radiological event could have a wide range of impacts, including immediate or long-term health effects, psychological impacts, environmental contamination, and economic consequences. The magnitudes of these impacts are highly dependent on specific circumstances of the incident.

RADIATION INJURIES • Radiation injuries could result from the aftermath of a nuclear blast and are less likely following a radiological incident. • Health effects may not be apparent for months or even years after exposure to radiation. • The type and extent of injury may depend on: • The amount (dose) of radiation to which a person is exposed • The type of radiation (alpha, beta, gamma) to which a person is exposed • Whether a person is exposed to radiation externally (e.g., skin) versus inter- nally (e.g., inhaled) • If someone is contaminated with radioactive materials externally (e.g., on his or her clothing), exposure may be reduced by decontamination (e.g., removing outer layer of clothing and showering). • Internal contamination occurs if someone ingests or inhales radioactive materials and the materials are incorporated by the body. Medications may help reduce the amount of radioactive materials in the body. • A person may be exposed to radiation without being contaminated with radioactive materials. For example, after a nuclear detonation, penetrating radiation may expose a person to radiation (similar to receiving an X-ray) without necessarily contaminating the person with radioactive materials. • More information on the distinction between exposure and contamination (internal and external) can be found at http://www.bt.cdc.gov/radiation/ contamination.asp. • If the radiation dose is large enough, victims can develop what is called acute radiation syndrome or radiation sickness. Symptoms, not all of which develop at the same time, include nausea, vomiting, diarrhea, fever, loss of appetite, skin damage (e.g., redness, itching, swelling, blisters), seizures, and coma. These symptoms are non-specific and may be indistinguishable from those of other injuries or illness. More information on acute radiation syndrome can be found at http://www.bt.cdc.gov/radiation/ars.asp.

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• If the radiation dose is small, no immediate health effects will be observed. In the long-term, there may be an increased risk of developing cancer. • In general, the higher the radiation dose the greater the severity of immediate health effects and the greater the possibility of long-term health effects. • Children exposed to radiation may be more at risk than adults. Radiation exposure to the unborn child is of special concern because the human embryo or fe- tus is extremely sensitive to radiation. (Source: http://www.hhs.gov/emergency/mediaguide/PDF/05.pdf)

PUBLIC HEALTH CONCERNS AFTER OTHER DISASTERS AND INCIDENTS Public health emergencies may result from other types of disasters, including natural disasters and acts of terrorism using conventional weapons. These disasters may be declared disasters under the Stafford Act and may include individual assistance, through which a Crisis Counseling Assistance and Training Program (CCP) may be implemented. Public health emergencies are more likely to be a secondary component of these disasters, and any behavioral health response to a public health emergency would already be available through the CCP implemented for the primary disaster. Because these public health emergencies are not primary, this module will cover basic information about some of the public health emergencies that may result. This is not a comprehensive review, and any information about public health issues that arise after a disaster should be gathered from local public health officials.

Terrorist Attacks Using Conventional Weapons Though some terrorist attacks may be biological, chemical, or radiological, other types of terrorist attacks involve bombing and other types of destruction. Examples include the 9-11 attack in Northern Virginia and New York, and the Oklahoma City bombing in 1995.

Some potential public health concerns may include exposure to asbestos, smoke, dust, or inhalation of chemicals released or burned. Others may include illnesses related to the disruption of the physical infrastructure such as waterborne and foodborne diseases. The type of public health concerns will be directly related to the type of attack. For instance, after the 9-11 terrorist attack in New York, including the initial explosion and the resulting collapse of the buildings, there were concerns about asbestos, syn- thetic vitreous fibers (SVF), mineral components of concrete (quartz, calcite, and port- landite), and mineral components of building wallboard (gypsum). “The primary health effects of immediate concern are respiratory effects and irritant effects from inhalation of or direct contact with building-related materials. Many of the materials expected to be in airborne dust can cause eye, nose, and throat irritation. In addition, those materials that can be inhaled or respired from airborne dust can cause respiratory irritation and exacerbation of pre-existing problems such as asthma, emphysema, and cardiopulmonary disease. Materials in the surface dust can cause skin irritation on contact. There have been reports of burning throat and eyes from residents returning

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Another specific concern related to the 9-11 terrorist attacks was the exposure to “contaminants released in the first fed by jet fuel and the combustible materials in the buildings (Final Technical Report of the Public Health Investigation to Assess Poten- tial Exposures to Airborne and Settled Surface Dust in Residential Areas of Lower Manhattan, September 2002; http://www.atsdr.cdc.gov/asbestos/asbestos/ types_of_exposure/executive_summary.html).”

In another terrorist attack that uses more conventional weapons, including bombs, shootings, and explosions, public health officials will provide information about the potential hazards involving public health concerns. Behavioral health workers should coordinate with public health officials to understand the exposures and hazards that will be specific to the attack and the surrounding areas.

Natural Disasters After a natural disaster, whether it is a hurricane, earthquake, fire, tornado, or flood, a variety of public health concerns must be considered. Below are some of the concerns that are more applicable to the community on the whole. There are additional health concerns for individuals and families, such as potential carbon monoxide poisoning, concerns cleaning up the damage, and the potential for injury, as they return to their damaged homes which are not covered here. Food A flood, fire, national disaster (did you mean natural disaster?), or the loss of power from high winds, snow, or ice can jeopardize the safety of your food. Minimize the potential loss of food and reduce the risk of foodborne illness by taking steps to determine if food is safe and how to keep food safe. (Source: http://www.fsis.usda.gov/Fact_Sheets/ keeping_food_Safe_during_an_emergency/index.asp)

Water Water may not be safe to drink, clean with, or bathe in after an emergency such as a hurricane or flood. During and after a disaster, water can become contaminated with microorganisms, such as bacteria, sewage, agricultural or industrial waste, chemicals, and other substances that can cause illness or death. (Source: http://www.bt.cdc.gov/disasters/foodwater.asp)

Infectious Disease Although infectious diseases are a frightening prospect, widespread outbreaks of infectious disease after hurricanes are not common in the United States. Rare and deadly exotic diseases, such as cholera or typhoid, do not suddenly break out after hurricanes and floods in areas where such diseases do not naturally occur. (Source: http://www.bt.cdc.gov/disasters/hurricanes/ keyfactsinfectiousdisease.asp)

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Communicable disease outbreaks of diarrhea and respiratory illness can occur when water and sewage systems are not working and personal hygiene is hard to maintain as a result of a disaster. Below are additional points to consider. • Decaying bodies create very little risk for major disease outbreaks. • Short bouts of diarrhea and upset stomach and colds or other breathing diseases sometimes occur in developed countries, such as the United States, after a natural disaster, particularly among large groups of people in a shelter. Basic hygiene measures like frequent hand washing or use of an alcohol hand gel, especially after using the restroom or changing diapers and before eating, can help prevent these diseases. • Diseases like cholera or typhoid are rare in developed countries, and do not typically occur after a natural disaster. Unless a disease is brought into a disaster area from elsewhere, any outbreaks that occur are almost always from diseases that were already in the disaster-affected area before the disaster struck. • Because cholera and typhoid are not commonly found in the U.S., it is very unlikely that they would occur after a hurricane. • Communicable disease outbreaks can occur when sanitation and hygiene are compromised as a result of a disaster. • As has been the case in past hurricanes, the U.S. Department of Health and Hu- man Services quickly sets up tracking systems that monitor illnesses in hurricane-affected areas. In the unlikely event that a disease outbreak occurs, these systems provide an early warning that enables prompt public health response. (Source: Ibid)

Mosquitoes Rain and flooding in a hurricane area may lead to an increase in mosquitoes, which can carry diseases like West Nile virus. In most cases, the mosquitoes will be pests but will not carry communicable diseases. • To protect against mosquitoes, use screens on dwellings, and wear long pants, socks, and long-sleeved shirts and use insect repellents that contain DEET or Picaridin. Care must be taken when using DEET on small children. • To control mosquito populations, drain all standing water left in open containers, such as flower pots, tires, pet dishes, or buckets, outside your home. (Source: http://www.bt.cdc.gov/disasters/ illness.asp#infectiousdisease)

This illustration of four mosquitoes shows that these bloodsucking insects vary in size, and assume different resting positions. CDC Sewage If there is flooding along with a hurricane, the waters may contain fecal material from overflowing sewage systems and agricultural and industrial waste. Although skin contact with floodwater does not, by itself, pose a serious health risk, there is risk of disease from eating or drinking anything contaminated with floodwater. (Source: http://www.bt.cdc.gov/disasters/illness.asp)

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Mold After natural disasters such as hurricanes, tornadoes, and floods, excess moisture and standing water contribute to the growth of mold in homes and other buildings. When returning to a home that has been flooded, be aware that mold may be present and may be a health risk for your family.

People at Greatest Risk from Mold People with asthma, allergies, or other breathing conditions may be more sensitive to mold. People with immune suppression (such as people with HIV infection, cancer patients taking chemotherapy, and people who have received an organ trans- plant) are more susceptible to mold infections.

Possible Health Effects of Mold Exposure People who are sensitive to mold may experience stuffy nose, irritated eyes, wheezing, or skin irritation. People allergic to mold may have difficulty in breathing and shortness of breath. People with weakened immune systems and with chronic lung diseases, such as obstructive lung disease, may develop mold infections in their lungs. If you or your family members have health problems after exposure to mold, contact your doctor or other health care provider. (Source: http://www.bt.cdc.gov/disasters/mold/protect.asp)

Smoke Smoke from wildfires is a mixture of gases and fine particles from burning trees and other plant materials. Smoke can hurt eyes, irritate respiratory system, and worsen chronic heart and lung diseases. Smoke can cause the following: • Coughing • A scratchy throat • Irritated sinuses • Shortness of breath • Chest pain • Headaches • Stinging eyes • A runny nose

Smoke may make symptoms worse for those with heart or lung disease. People who have heart disease might experience— • Chest pain • Rapid heartbeat • Shortness of breath • Fatigue

Smoke may worsen symptoms for people who have pre-existing respiratory conditions, such as respiratory allergies, asthma, and chronic obstructive pulmonary disease (COPD), in the following ways: • Inability to breathe normally • Cough with or without mucus • Chest discomfort

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• Wheezing and shortness of breath • When smoke levels are high enough, even healthy people may experience some of these symptoms. (Source: http://www.bt.cdc.gov/firesafety/wildfires/index.asp)

Chemical and Hazardous Materials What chemical emergencies are A chemical emergency occurs when a hazardous chemical has been released and the release has the potential for harming people's health. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack.

Where hazardous chemicals come from Some chemicals that are hazardous have been developed by military organizations for use in warfare. Examples are nerve agents such as sarin and VX, mustards such as sulfur mustards and nitrogen mustards, and choking agents such as phosgene. It might be possible for terrorists to get these chemical warfare agents and use them to harm people.

Many hazardous chemicals are used in industry (for example, chlorine, ammonia, and benzene). Others are found in nature (for example, poisonous plants). Some could be made from everyday items such as household cleaners. These types of hazardous chemicals also could be obtained and used to harm people, or they could be accidentally released.

Types and categories of hazardous chemicals Scientists often categorize hazardous chemicals by the type of chemical or by the effects a chemical would have on people exposed to it. The categories/types used by the Centers for Disease Control and Prevention are as follows: • Biotoxins—poisons that come from plants or animals • Blister agents/vesicants—chemicals that severely blister the eyes, respiratory tract, and skin on contact • Blood agents—poisons that affect the body by being absorbed into the blood • Caustics (acids)—chemicals that burn or corrode people’s skin, eyes, and mucus membranes (lining of the nose, mouth, throat, and lungs) on contact • Choking/lung/pulmonary agents—chemicals that cause severe irritation or swelling of the respiratory tract (lining of the nose and throat, lungs) • Incapacitating agents—drugs that make people unable to think clearly or that cause an altered state of consciousness (possibly unconsciousness) • Long-acting anticoagulants—poisons that prevent blood from clotting properly, which can lead to uncontrolled bleeding • Metals—agents that consist of metallic poisons • Nerve agents—highly poisonous chemicals that work by preventing the nervous system from working properly

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• Organic solvents—agents that damage the tissues of living things by dissolving fats and oils • Riot control agents/tear gas—highly irri- tating agents normally used by law enforcement for crowd control or by individuals for protection (for example, mace) • Toxic alcohols—poisonous alcohols that can damage the heart, kidneys, and nervous system • Vomiting agents—chemicals that cause nausea and vomiting Here, firefighters were shown battling a blaze that (Source: http://www.bt.cdc.gov/chemical/ was sparked days after hurricane Hugo made land- fall north of Charleston, South Carolina in 1989. overview.asp) CDC

SUMMARY Public health emergencies may result from a variety of sources, and it is important for behavioral health workers to have a basic understanding of the main sources to better serve populations exposed to these emergencies. Understanding if the emergency was intentional or accidental, natural or manmade, and the potential impact of the public health emergency will all help guide the behavioral health messages and services so the response will be more effective in helping individuals and the communities cope and recover.

RESOURCES

Department of Health and Human Services http://www.hhs.gov/

Terrorism and Other Public Health Emergencies: A Reference Guide for Media, Office of the Assistant Secretary for Public Affairs and the Office of Public Health Emergency Preparedness/U.S. Department of Health and Human Ser- vices (HHS), September 2005 http://www.hhs.gov/emergency/mediaguide/PDF/

Pandemic Influenza http://www.pandemicflu.gov/

Centers for Disease Control and Prevention http://www.cdc.gov/index.htm

Chemical Emergencies Overview http://www.bt.cdc.gov/chemical/overview.asp

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Implementation Plan for the National Strategy for Pandemic Influenza http://www.whitehouse.gov/homeland/nspi_implementation.pdf

United States Department of Agriculture http://www.fsis.usda.gov/home/index.asp

Emergency Preparedness: Keeping Food Safe During an Emergency http://www.fsis.usda.gov/Fact_Sheets/ keeping_food_Safe_during_an_emergency/index.asp

Virginia Department of Health, Draft Pandemic Influenza Plan http://www.vdh.virginia.gov/PandemicFlu/pdf/

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Hazmat cleanup after flooding from floods in southwest Virginia. Photo by Wade Collins, VDEM

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INTRODUCTION Response to a public health emergency will require coordination and activation of resources from the private and public sectors. Federal, State and local governments will need support of healthcare, business, faith-based organizations, schools and universities, volunteer and other groups, and individuals. Behavioral health will play an active role in many areas of a response to a public health emergency. This module describes the importance of local planning and response, how behavioral health fits into that planning and response, as well as information about state and Federal plans specifically for pandemic influenza.

One of the greatest public health threats facing the United States is pandemic influenza. Given the threat of this potential public health emergency, the President issued the National Strategy for Pandemic Influenza on November 1, 2005. The Federal response to pandemic influenza will be guided by the National Response Plan (NRP), a comprehensive, all-hazards plan to manage the response to incidents of national significance. Incidents of National Significance The NRP is based on the National Incident Management are defined in the NRP as System (NIMS), which “establishes standard incident “high-impact events that require an management processes, protocols and procedures so that extensive and well-coordinated all local, state, federal and private-sector emergency re- multi-agency response to save sponders can coordinate their responses, share a com- lives, minimize damage, and mon focus and place full emphasis on resolving the event. provide the basis for long-term All local governments and state agencies must comply community and economic with NIMS to be eligible for federal preparedness assis- recovery.” tance (National Incident Management System, State and Local Compliance Activities: Federal Fiscal Year 2006, VDEM Revision).”

Because a public health emergency, such as pandemic influenza, could require Federal government response, and because all state and local governments must comply with NIMS, it is important for Community Services Boards to have a basic understanding of both, and how behavioral health is incorporated into national, state, and local plans.

LOCAL PLANNING AND RESPONSE Like all other disasters and emergencies, the first response to a public health emergency, such as pandemic influenza, is from the community. The Implementation Plan for the National Strategy for Pandemic Influenza recognizes that: “The center of gravity of the pandemic response, however, will be in communities. The distributed nature of a pandemic, as well as the sheer burden of disease across the Nation over a period of months or longer, means that the Federal Government’s support to any particular State, Tribal Nation, or community will be limited in comparison to the aid it mobilizes for disasters such as earthquakes or hurricanes, which strike a more confined geographic area over a shorter period of time. Local communities will have to address the medical and non-medical effects of the pandemic with available resources. This means that it is essential for communities, tribes, States, and regions to have plans in place to support the full spectrum of their needs over the course of weeks or months, and for

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the Federal Government to provide clear guidance on the manner in which these needs can be met (http://www.whitehouse.gov/homeland/nspi_implementation.pdf).”

An important element of the national strategy is the recognition that the local response will be the first, and will remain the most critical throughout a pandemic. Resources that are usually available after other types of disasters may be stretched beyond the normal capacity to respond and unable to provide the same level of assistance. The planning and response to pandemic on a local level is critical, and behavioral health plays an important role in that planning and response. The following section describes the relationship between the public health response and behavioral health response to a public health emergency. The two are dependent upon each other, and working together, can ensure that information provided to response workers as well as the public are consistent and promote positive steps for self-protection and coping with the emergency. The potential demands placed on the community during a public health emergency can be tremendous. Behavioral health expertise will be necessary in many areas, as described below.

Local Response INFRASTRUCTURE AND COMMUNITY RESOURCES Employers of response workers and providers of essential services will need to educate their workers on the emotional responses they may experience, as well as potential reactions from the public. Supplement 11 of the Virginia Department of Health (VDH) draft Pandemic Influenza Plan (page 2) recommends that State and local health agencies establish workforce resilience programs that assist “deployed workers prepare for, cope with “In a crisis, the right message at the and recover from the social and psychological right time is a “resource challenges of emergency field work.” Training on multiplier”—it helps response psychosocial issues related to public health emer- officials get their job done. Many of gencies, self-care, cultural considerations, and the predictable harmful individual needs of special populations will be an important and community behaviors can be component of the workforce resilience programs. mitigated with effective crisis and emergency risk communication. The VDH draft Pandemic Influenza Plan also Each crisis will carry its own recommends establishing stress control/ psychological baggage. A leader resilience teams to assist and support employees must anticipate what mental of health care facilities and public health agen- stresses the population will be cies, as well as companies and local governments experiencing and apply appropriate that employ essential service providers. Addi- communication strategies to tional support can be provided through confiden- attempt to manage these stresses tial telephone support lines staffed by behavioral in the population health professionals. Behavioral health services Crisis & Emergency Risk should also be offered to families of employees Communication: By Leaders for who are deployed. Leaders, CDC/DHHS, page 3

Leadership Strong leadership is needed to maintain the community’s confidence that the recovery

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Community Support The response to all disasters and emergencies relies on community support to address many challenges. In a public health emergency, some of those challenges include vaccination, quarantine, and medical services. Public health emergencies will require that the community to partner with officials to contain the health risk. It also relies on the support of individuals within the community to follow the advice of public health officials in taking the appropriate steps to help contain the threat. Behavioral health workers can assist community officials in developing messages and materials that will help educate individuals and groups within the community about the steps they can take. Providing information about what to do to prepare and protect are also positive coping tools; the two are closely related in helping the public understand the risk and take appropriate steps to not only limit the spread of the disease, but to cope with it. Risk communication expert Peter Sandman states that “action binds anxiety” (see article below). As a behavioral health worker, one of your goals is to reduce anxiety among those who are experiencing stress after a disaster or public health emergency. A public that is less anxious and feels part of the planning and recovery process will be more supportive and helpful during a public health emergency. Officials will have to spend less time trying to assuage the public when the public is a partner. Maintaining community support is an interactive and ongoing process and should be a focus of both leadership and responders.

Why to encourage people to act: • Action binds anxiety. People who are doing things to protect themselves can bear their fear better and are less likely to flip into denial.

• Action reduces misery. People who are doing things to help others are less likely to sink into depression or hopeless apathy.

• Action teaches lessons. People who are doing things seek out information to make sense of what they are doing. They teach themselves that the danger is real (otherwise action would be unnecessary) and that it is manageable (otherwise action would be futile). This is exactly what we want them to learn.

• Action is useful for the situation itself. At every stage of the crisis -- before, during, and after -- people can be of genuine service to themselves, their families, their neighbors ... and you.

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How to encourage people to act: • Offer people things to do. People are more likely to take action when the action opportunities are clear.

• Ask people to do things. Some people respond better to the offer ("here's what you can do if you want"), some to the request ("here's what we hope you will agree to do"). Provide both.

• Let people do things. If many people are settling on some action of their own that helps them feel safer or less miserable, think twice before you criticize their choice. Unless it is really dangerous, you would be wiser to tolerate it.

• Support symbolic actions too. Symbolic action is a poor substitute for genuinely useful action. But almost any action is greatly preferable to no action at all. And sometimes symbolic action (flying flags, wearing buttons, etc.) can be a morale builder and a path out of paralysis.

• Model the actions you recommend. If you want people to give blood, give blood. If you want them to wear face masks, wear a face mask. Make your go-kit and your three-day supply of food into a photo-op.

• Tell people how. "Mobilizing information" is information that helps people implement a course of action: the telephone number of the volunteer center, the instructions for storing the antibiotic. People often make a tentative decision to act, then stop because they are not sure how to begin. Mobilizing information gets them over the hump.

• Offer a choice of actions. Giving people a menu of actions to choose from recruits not just their ability to act, but also their ability to decide. It is therefore even more effective in helping people bear their fear and misery.

• Bracket recommended precautions. X is the minimum precaution you consider acceptable. Y is your recommended precaution. Z is an additional precaution for people who feel especially vulnerable. Surrounding your Y with an X and a Z yields more compliance with Y. And it defines those who prefer X or Z as still part of the plan, not rebels.

• Leave some decisions to the individual. Many crisis management decisions really need to be collective. But voluntary choice gives people a greater sense of control, which reduces the probability of denial or panic. Frame some individual decisions without any recommendation.

• Seek people's advice. On decisions that need to be collective, seek public input on what the collective decision should be, sharing the dilemma and empowering the community. Go beyond pro forma public involvement to encourage public debate on difficult decisions before the decision is made.

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• Plan to use volunteers wisely. In a crisis, many people will volunteer to help. Turning them away is a lose-lose. Work on legal and logistical issues in advance, so when the crisis comes you will be ready to manage a volunteer workforce.

• Ask more of people. In a crisis, pro-social, resilient impulses vie for dominance with fear, passivity, and selfishness. Ally with the former against the latter by asking more of people at every crisis stage -- before, during, and after. People do more, and feel better, when they are asked to do more.

• Ask more of people emotionally too. People cope better when asked and expected to cope. (Of course some people also need "permission" to be unable to cope, at least for a while.) Even while validating how frightened or powerless people may feel, communicate that you know they will mostly be able to get through it and act appropriately despite their feelings.

• Tap into the social structure. Reach out now to existing organizations, from social clubs to tenants associations to service groups. Involve them in pre-crisis decision making. Ask them to organize their own networks -- to help people get ready for the crisis, and to get ready to help people if the crisis materializes. Nurture people's autonomy and interdependence, rather than their dependence on you.

• Notice and publicize examples of empowered action. Look for role models – acts of resilience and creativity and altruism. Acknowledge and validate them. Spread the word. (Source: www.psandman.com/handouts/AIHA-DVD.htm or www.psandman.com)

Cultural Factors A goal of the community response efforts should be to engage all members of the community, and ensure that resources and information are disseminated throughout the impacted areas in an impartial and evenhanded manner. Obstacles to communication and access to services need to be assessed on an ongoing basis to ensure all community members are included in the public health response efforts. Language and cultural barriers can prevent community members from receiving communication and information about health risks and precautions. The failure to address cultural and ethnic barriers can result in groups within the community being overlooked and excluded from information that may help prevent illness.

Media/Communications Communication is a key element to the response to a public health emergency. Clear and concise communication should be initiated early and continue throughout the emergency. Communication in a public health emergency may also require different types of outreach strategies than those after a natural disaster. Door-to-door outreach, workshops, and other efforts that usually make up an effective outreach program after a natural disaster may not be possible if schools are closed, events canceled, stores

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closed, and social distancing or other measures are implemented to stop or slow the spread of disease. Behavioral health workers will need to be innovative to reach people in a public health emergency, such as going to places where people are being vaccinated or treated, or conduct more paid advertising and public relations efforts. Module 8 provides more detailed information on promoting a community-wide behavioral health project.

How well the community addresses the above factors can have long lasting consequences and can influence community members’ perception of their ability to recover from the public health emergency.

The Public’s Role in Responding to a Public Health Emergency In addition to the local government and organizational planning and response, the public plays a critical role in the effectiveness of the local response. It will be important to ensure that the public is not only aware of the response efforts, but is a partner in that response. The publics’ emotional reaction, as well as the efforts they take to prepare for the public health emergency and prevent the spread of disease, is paramount to the success of the local government’s efforts. The public will need to understand not only the steps they can take to help prevent the spread of the disease, but why.

Risk communications expert Peter Sandman provides the information below about how to engage the public, and why. This information is especially important for behavioral health workers in providing guidance and assistance to officials about talking to the public, as well as in their own efforts to communicate with the public about coping with a public health emergency. This information is excerpted from Crisis Communica- tion: Guidelines for Action Planning What to Say When Terrorists, Epidemics, or Other Emergencies Strike by Peter M. Sandman, Ph.D. and Jody Lanard, M.D. It is one of several handouts about crisis communications available on the following website: http://www.psandman.com/handouts/AIHA-DVD.htm.

Crisis Communication III: Involving the Public Copyright © 2004 by Peter M. Sandman and Jody Lanard, All Rights Reserved. • Tell people what to expect. "Anticipatory guidance" -- telling people what to expect -- does raise some anxiety, especially if you're predicting bad news. But being forewarned helps us cope, it keeps us from feeling blindsided or misled, and it reduces the dispiriting impact of sudden negative events. Warning people to expect uncertainty and possible error is especially useful. So is warning people about their own likely future reactions, particularly the ones they may want to overrule: "You'll probably feel like stopping the medicine before it's all gone." • Offer people things to do. Self-protective action helps mitigate fear; victim- aid action helps mitigate misery. All action helps us bear our emotions, and thus helps prevent them from escalating into panic, flipping into denial, or declining into hopeless apathy. Plan for this well in advance; mid-crisis is a harder time to start figuring out what to offer people to do -- including the legions of volunteers who will want to help.

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• Let people choose their own actions. Offering people a choice of actions recruits not just their ability to act, but also their ability to decide. This makes it all the more empowering as a bulwark against panic or denial. Ideally, bracket your action recommendations with less and more extreme options, so people who are less concerned or more concerned than you wish they were do not need to define themselves as rebels; you have recommendations for them too. • Ask more of people. In a crisis, pro-social, resilient impulses vie for dominance with less desirable impulses: panic, passivity, selfishness. Ally with the former against the latter by asking more of people. Ask for people's help before the crisis as well as during it. Ask them to help their community and their neighbors (and your organization), not just themselves -- but do ask them to help themselves. Ask more of people emotionally too. Give us "permission" to find the situation unbearable, but make it clear that you expect we will be able to bear it. (Source: http://www.psandman.com/handouts/AIHA-DVD.htm http://www.psandman.com)

Getting the public involved in pandemic influenza planning and preparedness is so critical that the Virginia Department of Health’s draft Pandemic Influenza Plan encourages “all Virginians to be active partners in preparing for a pandemic. An informed and responsive public is essential to minimizing the health effects of a pandemic and the resulting consequences to society (Background, page 1).”

Community Services Boards Local behavioral health response for any disaster or emergency comes from the Com- munity Services Boards (CSBs). Virginia’s public mental health, mental retardation and substance abuse services system is comprised of 40 CSBs and sixteen state facilities. CSBs offer varying combinations of six core services: 1. emergency services (mandated) 2. local inpatient services 3. outpatient and case management services 4. day support services 5. residential services 6. prevention and early intervention services

The CSB responsibilities in emergencies are included in the Virginia Emergency Opera- tions Plan (EOP) under Annex G: Health and Medical Services, Attachment 5, Mental Health Services in Emergencies. The information from the Virginia EOP specific to CSBs is provided below (the Department of Mental Health, Mental Retardation and Substance Abuse Services’ (DMHMRSAS’s) responsibilities are included in the State Planning section in this module).

The state’s Community Services Boards will: 1. Provide, through the mental health centers or other programs, crisis counseling services following a major disaster. The provision of these services shall be coordinated with DMHMRSAS, local emergency management and officials, and VDEM.

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2. Maintain, on an ongoing basis, an emergency preparedness planning and response capability, which includes liaison with the state Department of Emer- gency Management, and other local emergency preparedness agencies, local Public Health Officials, contiguous Community Services Boards, appropriate professional associations and periodic revision of the Department's emergency preparedness plan and operating procedures. The CSB emergency plan should include: A. A hazard vulnerability analysis B. Specific procedures for response to each prioritized man-made or natural emergency C. Description of the CSBs role in community-wide preparedness plans and response plans D. Procedures for notifying external authorities about the emergency E. Procedures for notifying personnel when emergency response measures are initiated F. Procedures for identifying and assigning personnel to cover necessary staff positions in an emergency G. Plans should have a dated title page with record of changes and a record of plan distribution 3. Provide support and assistance to other state agencies, volunteer organizations, and federal agencies necessary to improve the Commonwealth's emergency preparedness capability. This includes the provision of technical assistance, needs assessments, training programs, and resource directories. 4. Develop procedures for responding to major disasters, including preparedness training activities, designation of community services board staff who would provide crisis counseling services, and procedures that ensure responsiveness with appropriate state and local emergency services staff. 5. Participate in the development and maintenance of local emergency services emergency operations plans in accordance with DMHMR-CSB performance agreements. 6. Coordinate with the state facilities in the development of their emergency preparedness plans. 7. Provide crisis counseling training, support, and assistance to other local agencies and volunteer organizations, according to the capability of the community services board. This includes the establishment of disaster response agreements with other agencies and volunteer associations and the identification of potential community resources to be used either during the disaster or after the emergency has passed. 8. When advised by a local government that a major disaster exists, the Commu- nity Services Board Director/designee will make personnel available for crisis counseling, initiate implementation of responsibilities under the local emergency operations plan, and notify DMHMRSAS. 9. The Commissioner/designee shall follow up with the Community Services Board (s) in the affected area to ensure that the required liaison with local emergency management officials has been accomplished and that, if necessary, personnel were made available to provide crisis counseling services. 10. The Community Services Board Director/designee should designate staff who

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will be available to provide necessary crisis counseling services at Disaster Ap- plication Centers to render immediate assistance to disaster victims and volunteers who are experiencing emotional strain. These staff should make referrals, as appropriate, to other treatment resources for follow-up care. 11. The Community Services Board Director/designee should dispatch these designated staff to the Disaster Recovery Centers according to the procedures contained in the local Emergency Operations Plan. 12. Where an ongoing need for disaster-related mental health counseling occurs and when funding becomes available, the Community Service Board(s) may provide such services in accordance with official agreements involving the Federal Emergency Management Agency and DMHMRSAS. 13. If back-up staff from other community services boards is required, the Commu- nity Services Director/designee should notify DMHMRSAS. The Department will coordinate such assistance.

AUTHORITIES AND REFERENCES: Robert T. Stafford Disaster Assistance and Emergency Assistance Act, Public Law 93-288, as amended, Section 416. (Source: Virginia Emergency Operations Plan, updated 2005, Annex G, Attach- ment 5, page G-13)

Public health emergencies are not one of the “major disasters” covered under the Staf- ford Act, defined below. That means that crisis counseling projects, awarded under individual assistance programs in response to a major disaster, may not be available under that funding source. However, public health emergencies, such as a pandemic influenza, may be declared under other authorities through which behavioral health services related specifically to that event may be funded. See Module 4 for more information.

Stafford Act definition of “major disaster:” Any natural catastrophe (including any hurricane, tornado, storm, high water, winddriven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance under this Act to supplement the efforts and available resources of States, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby. (Public Law 93-288: Robert T. Stafford Act, as amended, Section 416)

CSBs are encouraged to establish and maintain contact with public health officials and emergency managers to ensure that the behavioral health aspect of any disaster or emergency are incorporated into plans and response. CSBs are also in a unique position to help these officials and managers prepare information and messages for response workers and the public to help them cope and take proactive steps to prepare for and cope with the stress and anxiety of a public health emergency or other disaster.

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Putting Together Your Mental Health Plan to Respond to a Disaster To help CSBs put together a behavioral health plan to respond to public health emergencies and other disasters, the information below, extracted from CDC’s “Disaster Mental Health for States: Key Principles, Issues and Questions” is provided.

What Should Happen During First Four Weeks of a Disaster (Important first steps would include the following actions.) • Meet basic needs (food, shelter, clothing…) • Provide Psychological First Aid (ABCs) Arousal: Decrease excitement (provide safety, comfort, consolation) Behavior: Assist survivors to function effectively in disaster Cognition: Provide reality testing and clear information • Provide needs assessments • Monitor the recovery environment (conducting surveillance) • Provide outreach and information dissemination • Provide technical assistance, consultation and training • Foster resilience, coping and recovery • Provide triage • Provide treatment

Questions to Address in Disaster Mental Health Response Plans (Answering these questions before a disaster can help you and your team better prepare.)

Community Demographic Characteristics • Who are the most vulnerable people in the community? Where do they live? • What kinds of families live in the community (i.e., single-parent households)? • How could individuals be identified and reached in a disaster? • Are policies and procedures in place to collect, maintain, and review current demographic data for any area that might be affected by a disaster?

Cultural Groups • What cultural groups (ethnic, racial, and religious) live in the community? • Where do they live, and what are their special needs? • What are their values, beliefs, and primary languages? • Who is knowledgeable about the culture or is an informal leader in the community?

Socioeconomic Factors • Are there recognizable socioeconomic groups with special needs? • How many live in rental property? How many own their own homes? • Does the community have any special economic considerations that might affect people’s vulnerability to disaster?

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Mental Health Resources • What mental health service providers serve the community? • What skills and services does each provider offer? • What gaps, including lack of cultural competence, might affect disaster services? • How could the community’s mental health resources be used in response to different types of disasters?

Government roles and Responsibilities in a Disaster • What are the Federal, State, and local roles in disaster response? • How do Federal, State, and local agencies relate to one another? • Who would lead the response during different phases of a disaster? • What mutual aid agreements exist? • How can mental health services be integrated into the government agencies’ disaster response? • Do any subgroups in the community harbor any historical or political concerns that affect their trust of government?

Nongovernmental Organizations’ Roles in a Disaster • What are the roles of the American Red Cross (ARC), interfaith organizations, and other disaster relief organizations? • What resources do nongovernment agencies offer, and how can local mental health services be integrated into their efforts? • What mutual aid agreements exist? • How can mental health providers collaborate with private disaster relief efforts?

Community Partnerships • What resources and support would community and cultural/ethnic groups provide during or following a disaster? • Do the groups hold pre-existing mutual aid agreements with any State or county agencies? • Who are the key informants/gatekeepers of the impacted community? • Has a directory of cultural resource groups, potential volunteers, and community informants who have knowledge about diverse groups been developed? • Are the community partners involved in all phases of disaster preparedness, response, and recovery operations? (Source: CDC’s “Disaster Mental Health for States: Key Principles, Issues and Questions” www.bt.cdc.gov/mentalhealth/states.asp)

STATE PLANNING The Virginia Department of Emergency Management (VDEM) has the overall responsibility for developing, coordinating, and managing the State Emergency Operations plan. This plan, which may be viewed at http://www.vaemergency.com/library/ index.cfm, provides information about the state’s emergency response organization and policies with details about state-level emergency operations in response to any type of disaster of large-scale emergency that affects Virginia.

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According to the Virginia EOP, “Historically, major emergencies in Virginia have been floods, hurricanes, winter storms, hazardous materials accidents, gas pipeline accidents, power failures, resource shortages, drought, and environmental contamination. Such hazards are ever-increasing due to factors such as urban development in vulnerable coastal areas, industrial expansion, traffic congestion, and the widespread use and transport of hazardous materials (Virginia EOP, Basic Plan, 2004, page 1).”

The plan also states that “In Virginia, counties and independent cities have the primary responsibility for emergency operations and will commit all available resources to save lives and minimize property damage. Should local emergency response capabilities be overwhelmed, outside assistance is available, either through mutual aid agreements with nearby jurisdictions, members of the Commonwealth’s Statewide Mutual Aid Pro- gram or from the state through the Virginia Emergency Operations Center (VEOC) (Ibid, page 1) .” As a leader, you need to know that the way you normally Within the plan are details about Emergency Support communicate with your Functions, and the different agencies with primary re- community may not be effective sponsibility for those functions. Behavioral health is during and after it suffers a crisis. found within ESF #8, Health and Medical. VDH is the In a catastrophic event, your agency with primary responsibility for ESF#8, and the every word, every eye twitch and Virginia DMHMRSAS is one of the supporting agencies. every passing emotion resonates CSBs are listed under organizations that provide specific with heightened importance to a health and/or medical response teams in emergencies. public desperate for information to The chart of ESFs for the Virginia EOP, updated on Sep- help them be safe and recover tember 1, 2005, is below. It lists the function and the pri- from the crisis. In several surveys, mary agencies responsible for each. Information about the public was asked who they VDEM, VDH, and DMHMRSAS is included later in this would trust most as a spokesman section. or reliable source of information if Acronyms for following chart a bioterrorism event occurred in VDEM, Virginia Department of Emergency Manage- their community. Respondents ment trusted most the local health de- VDOT, Virginia Department of Transportation partment or a local physician or DCR, Department of Conservation and Recreation hospital. However, respondents DFP, Department of Fire Programs also trusted “quite a lot” or “a DOF, Department of Forestry great deal” their own doctor, the DSS, Department of Social Services fire chief, the director of the health DGS, Department of General Services department, the police chief, the VDH, Virginia Department of Health governor and a local religious DEQ, Department of Environmental Quality leader. VDACS, Department of Agriculture and Consumer Crisis & Emergency Risk Commu- Services nication: By Leaders for Leaders, SCC, State Corporation Commission page 3, Centers for Disease Con- DMME, Department of Mines, Minerals and Energy trol and Prevention/Department of DMA, Department of Military Affairs Health and Human Services VSP, Department of State Police

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EMERGENCY DUTIES AND RESPONSIBILITIES OF STATE DEPARTMENTS AND AGENCIES Virginia Emergency Operations Plan, April 2004 (Updated September 1, 2005)

Primary Agencies

Emergency Support Function VDEM VDOT DCR DFP DOF DSS DGS VDH DEQ VDACS SCC DMME DMA VSP

1--Transportation X 2--Communication X 3--Public Works X 4--Firefighting X X 5--I&P X 6--Mass Care X 7--Resource Support X 8--Health and Medical X 9--Search and Rescue X 10--Hazardous Materials X X 11--Food and Water X 12--Energy X X 13--Military Support X 16--Public Information X 15--Volunteers and Donations X 16--Law Enforcement X 17--Animal Care and Control X

It is important to note that all emergency plans and procedures in Virginia are to be developed in compliance with the National Incident Management System (NIMS), the National Response Plan, and in accordance with the National Preparedness Goals. Though NIMS is covered within the Federal Planning section of this module, it is critical that local governments understand NIMS and that Virginia is implementing it as “the federally required incident management system by which communities, states, and the federal government will ensure full integration of activities in response to threatened and actual emergencies and disasters of all kinds. (Virginia Executive Or- der 102, Adoption of the National Incident Management System and Use of the Na- tional Preparedness Goal for Preventing, Responding to and Recovering from Crisis Events in the Commonwealth, 2005).”

The State Coordinator of the Virginia Department of Emergency Management (VDEM) is responsible for implementing NIMS. To help other state and local agencies within Virginia comply with NIMS, there are several links on the NIMS section of VDEM’s website, located at: www.vaemergency.com/programs/nims/index.cfm.

Virginia Department of Emergency Management (VDEM) VDEM’s mission is to “protect the lives and property of Virginia's citizens from emergencies and disasters by coordinating the state's emergency preparedness, mitigation,

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response and recovery efforts.” During normal operations, VDEM coordinates the disaster planning, preparedness, and mitigation activities of state departments and agencies. It also develops, maintains, publishes, and distributes the State Emergency Opera- tions Plan, and provides guidance and assistance to cities and counties for their local emergency operations plans. During disasters and emergencies, VDEM provides coordination and communication, as well as administration of various disaster programs. VDEM reports directly to the Secretary of Public Safety and the Governor of Virginia, and works with local government, state, and federal agencies and voluntary organizations to provide resources and expertise.

The VDEM has 7 regional offices throughout the state, and a directory of local emergency managers. CSBs may consider establishing and maintaining relationships with emergency managers in their area to help coordinate response and ensure that behavioral response information is incorporated into emergency plans and recovery documents. Crisis counseling falls within the VDEM’s Recovery and Mitigation Division. This division has a major role in helping people after a disaster, assisting the Federal Emergency Management Agency (FEMA) and other organizations in administering disaster assistance programs.

CSBs may consider establishing and maintaining relationships with emergency managers in their area to help coordinate response and ensure that behavioral response information is incorporated into emergency Virginia’s Emergency Operations Center plans and recovery documents.

Virginia Department of Health (VDH) In Virginia, the primary agency responsible for public health is the VDH. Within the State EOP, VDH is responsible for ESF#8, Health and Medical Services, which includes critical services to protect the health of citizens and to provide medical, mental health and mortuary services as needed in disasters and large-scale emergencies. The Virginia EOP includes the following as VDH’s major functions in an emergency or disaster: 1. Provision of emergency health services 2. Assist with the initial damage assessment of public health and sanitation buildings and facilities, to include public water and sewage systems. 3. Assist the Department of Mental Health, Mental Retardation and Substance Abuse Services in professional counseling services to victims of major disasters in order to relieve mental health problems caused or aggravated by the disaster or its aftermath. 4. Following an emergency or major disaster, assist VDEM with damage surveys and with follow-up inspections for public assistance projects as required by the Stafford Act.

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5. Assist VDEM with the development of emergency response plans to deal with peacetime nuclear accidents/incidents, to include accident evaluation, environment monitoring, and information on protective action(s) to be taken by governmental agencies and the public when an accident occurs. 6. Develop and administer plans and programs to deal with radiation hazards of medical and dental x-ray equipment. 7. Provide technical assistance during hazardous materials incidents. 8. Assist the Department of Social Services in providing assistance to evacuees during repatriation of U.S. citizens from abroad. (Source: Virginia EOP, Basic Plan, 2004, page 59-60)

The concern about pandemic influenza has prompted the VDH to develop the draft Pandemic Influenza Plan, an appendix to the VDH Emergency Response Plan that incorporates components of the Department of Health and Human Resources Pandemic Influenza Plan. Supplement 11 of VDH’s draft Pandemic Influenza Plan addresses psychosocial issues for workers and those who are responding to the public health emergency, as well as their families. It includes recommendations for the interpandemic and pandemic alert periods, as well as the pandemic period. These recommendations include establishing workforce resilience programs, developing psychosocial support services to help responders and workers manage their stress during a pandemic, and preparing information and materials.

The VDH draft Pandemic Influenza Plan also addresses the importance of local governments in planning and response, stating that “Local jurisdictions must also be prepared to response in the context of uncertain availability of external resource and support.” The VDH draft Pandemic Influenza plan lists the principles below for responding to pandemic influenza: 1. Pandemic planning will be built on all-hazard planning, already underway at local, regional and state levels within Virginia. 2. In advance of a pandemic, VDH will work with public and private partners to coordinate preparedness activities. Advance preparations can reduce the number of people who become ill or die and can minimize the economic and community impact. 3. Federal, state and local governments will not be able to address all pandemic influenza needs or meet all resource requests. Responsibility for preparing for and responding to a pandemic spans all levels and sectors. In addition to government entities, healthcare, business, faith-based organizations, schools and universities, volunteer and other groups, and individuals have critical roles to play in pandemic preparedness. VDH encourages all Virginians to be active partners in preparing for a pandemic. An informed and responsive public is essential to minimizing the health effects of a pandemic and the resulting consequences to society. 4. Sustained human-to-human transmission anywhere in the world will be a triggering event to initiate a pandemic response by federal and state responders. (Source: VDH Draft Pandemic Influenza Plan, Revised March 2006, page 1)

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The draft VDH Pandemic Influenza Plan also includes the following assumptions: 1. Susceptibility to the pandemic influenza subtype will be universal. 2. The typical incubation period for influenza is one to three days. It is assumed that this would be the same for a novel strain that is transmitted between people by respiratory secretions. Persons who become ill may shed virus and can transmit infection for up to one day before the onset of illness. Viral shedding and risk for transmission will be the greatest during the first two days of illness. 3. Although pandemic influenza strains have emerged mostly from areas of East- ern Asia, variants with pandemic potential could emerge in Virginia or elsewhere in the U.S. 4. In an affected community, a pandemic outbreak will last about six to eight weeks. At least two pandemic disease waves are likely. Many geographic areas within Virginia and its neighboring jurisdictions may be affected simultaneously. Localities should be prepared to rely on their own resources to respond. 5. The seasonality of a pandemic cannot be predicted with certainty. The largest waves in the U.S. during 20th century pandemics occurred in the fall and winter. Experience from the 1957 pandemic may be instructive in that the first U.S. cases occurred in June, but no community outbreaks occurred until August and the first wave of illness peaked in October. 6. An influenza pandemic will present a massive test of the emergency preparedness system. Advance planning for Virginia's emergency response could save lives and prevent substantial economic loss. 7. There may be critical shortages of health care resources such as staffed hospital beds, mechanical ventilators, morgue capacity, temporary holding sites with refrigeration for storage of bodies, and other resources. 8. Healthcare workers and other first responders may be at higher risk of exposure and illness than the general population, further straining the healthcare system. 9. Widespread illness in the community could increase the likelihood of sudden and potentially significant shortages of personnel in other sectors who provide critical public safety services. 10. Effective preventive and therapeutic measures (e.g., vaccines and antiviral medications) will be delayed and in short supply. 11. Assuming that prior influenza vaccination(s) may offer some protection, even against a novel influenza variant, the annual influenza vaccination program, supplemented by pneumococcal vaccination when indicated, will remain a cornerstone of prevention. 12. Surveillance of influenza disease and virus will provide information critical to an effective response. 13. It is likely that public health will take the lead in distributing influenza vaccine. Health departments will work in partnership with health care providers to facilitate distribution. 14. An effective response to pandemic influenza will require coordinated efforts of a wide variety of organizations, both public and private, and health as well as non- health related. Influenza, or flu, is a viral infection of the lungs. There are two main types of flu virus, A and B. Each type includes many different strains, and new strains emerge periodically. Influenza outbreaks occur most often in late fall and winter. Seasonal outbreaks of influenza are caused by strains of flu virus

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similar to those of past years. Some people may have built up immunity, and there is also a vaccine for each year’s flu season. (Source: Ibid, page 2)

The VDH is dedicated to protecting and promoting the health of Virginians. The central office is in Richmond, and there are 35 local health districts which, according to the VDH website at www.vdh.virginia.gov, work together to “promote healthy lifestyle choices that can combat chronic disease, to educate the public about emergency preparedness and threats to their health, and to track disease outbreaks in Virginia.” VDH has five offices, including the Offices of the Commissioner, Ad- Photo of smallpox vaccination, ministration, Public Health, Community Health Services, and VDH Website Emergency Preparedness and Response. The Deputy Commis- sioner for Emergency Preparedness and Response (EP&R) is designated as the Coordi- nator for VDH emergency response.

Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services The Virginia DMHMRSAS’s Central Office has responded to virtually all major natural disasters in the Commonwealth for almost 20 years. The Department’s mission is to “provide leadership and service to improve Virginia’s system of quality treatment, ha- bilitation, and prevention services for individuals and their families whose lives are affected by mental illness, mental retardation, or substance use disorders (alcohol or other drug dependence or abuse). The Department seeks to promote dignity, choice, recovery, and the highest possible level of participation in work, relationships, and all aspects of community life for these individuals (http://www.dmhmrsas.virginia.gov/ Default.htm).”

As mentioned before, information about mental health services is included in the Vir- ginia Emergency Operations plan, with information about responsibilities of the DMHMRSAS as well as the CSBs. Information specific to the DMHMRSAS from the EOP, Appendix 5, is provided below (CSB responsibilities are earlier in this module).

A. The Director of the Federal Emergency Management Agency (FEMA) is authorized, pursuant to Section 416 of The Stafford Act, to allow financial assistance to state or local agencies or private mental health organizations to provide professional counseling services to victims of major disasters or training of disaster workers in order to relieve mental health problems caused or aggravated by such disasters. B. An individual may be eligible for crisis counseling services if he/she was a resident of the designated disaster area(s) or was located in the area at the time of the disaster event and if he/she has a mental health problem which was caused or aggravated by the major disaster or its aftermath, or if he/she may benefit from preventive care techniques. C. The Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) will:

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a. Assure that the state’s DMHMRSAS facilities and community services boards are aware of their responsibilities in the event of a major disaster, participate in local emergency services planning activities, and have in place necessary procedures and plans for responding to major disasters. b. In the event of a major disaster, direct the state’s DMHMRSAS facilities to implement their emergency preparedness plans, to include provisions for re- locating patients/residents as required. c. In the event of a major disaster, direct the state’s DMHMRSAS facilities and community services boards to establish liaison with local governments and to assist with local emergency operations as appropriate. Implement crisis counseling services as agreed in local Emergency Operations Plans. d. Provide back-up assistance, on a standby basis, to those community services board staff who are providing crisis counseling services during a major disaster. If needed, community services board(s) in the disaster area should request DMHMRSAS to coordinate with other community services boards in unaffected areas of the state in order to send additional crisis counseling staff to help in designated disaster area(s). e. Provide additional assistance as requested by the Virginia Department of Emergency Management (VDEM), within the capability of the Department, to include on-site visits to assess service needs and the provision of needed technical assistance. f. DMHMRSAS will implement the following procedures in response to a major disaster. i. The Commissioner/designee of the Department will, upon notification by the state Department of Emergency Management of a disaster and the need for emergency services, determine the need (and location) for evacuation/relocation for emergency operations by the Central Office. ii. The Commissioner/designee of the Department will direct, as required, implementation of disaster plans by state facilities for the provision of crisis counseling and other emergency assistance. iii. The Commissioner/designee of the Department will instruct the directors of state facilities to cooperate fully with VDEM and local government officials. iv. The Commissioner/designee will notify the directors of community services boards in the affected area and that they may be contacted to provide crisis counseling services. v. The Commissioner/designee, at the request of the Community Services Board Director/designee, located in the affected area, will contact other DMHMRSAS facilities or community services boards in unaffected areas to identify supplemental crisis counseling staff who could be dispatched to the disaster area. vi. The Commissioner/designee will be available to respond to specific requests from state facilities and community services boards affected by a disaster. D. There are ten DMHMRSAS psychiatric facilities and five mental retardation training centers statewide. Each will: a. Develop and maintain a facility emergency response plan which sets forth

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procedures to be followed in time of emergency such as a lock-out for security purposes, a temporary evacuation as with a fire drill, or a longer-term relocation to another pre-designated facility. Coordinate with local emergency management officials and prepare to assist with local emergency operations as appropriate. b. In the event of a major disaster, provide for the safety and health of all persons at the facility as appropriate and in accordance with the facility emergency response plan. Assist with local emergency operations, as appropriate, providing such services as crisis counseling to disaster victims, space for emergency hospitals, or temporary housing for displaced persons. c. Facilities in unaffected areas of the state may be requested to assist facilities in the disaster area(s) by providing such services as staffing support or the reception and care of relocated patients/residents. Such assistance will be coordinated by DMHMRSAS. d. Develop procedures for responding to major disasters affecting the facility, including preparedness training in hospital, communication, and recording procedures. e. Prepare and routinely update facility emergency response plans and procedures, which include: i. Procedures for coordinating with the emergency management staff of local governments and with the State EOC. ii. Responsibilities and procedures affecting the facility that are contained in the local emergency operations plans. iii. Circumstances and procedures under which the facility would initiate evacuation and relocation of facility patients and residents. iv. Procedures for the housing of disaster victims and volunteer workers and providing additional supportive services on the facility grounds. v. Procedures for alerting and communicating with facility personnel and volunteer workers for assisting victims during the disaster. vi. Procedures for keeping records of disaster-related events and actions. vii. Procedures for transmitting situation reports to, and for requesting assistance from, the State EOC. viii.Procedures for accessing disaster response resources and assistance from other state facilities, and the Department during major disasters. ix. Establishment of lines of succession of key facility personnel during the disaster and procedures for implementing such succession, including notification of the appropriate personnel of local and state agencies. f. Provide support and assistance to community services boards and other local agencies, volunteer associations, and federal agencies, according to the capability of the facility, during emergency operations. g. Inform local government emergency management personnel of the responsibilities of the state facility during a major disaster and of procedures in place for accessing the resources of the facility. h. Coordinate, to the extent possible, with local institutions of higher learning, mental health associations, and other volunteer agencies in establishing disaster response agreements and identifying potential resources to be used during a major disaster.

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i. When directed by the Governor or Commissioner of DMHMRSAS that a major disaster exists, the Director/designee of a facility shall establish liaison with local government, make his facility available for relief assistance, and initiate implementation of the facility emergency response plan. j. Upon an emergency declaration by local government, the Director/designee shall notify the Commissioner of DMHMRSAS to make his facility available for relief assistance, and implement the facility emergency response plan. During and after the event, the facility should maintain liaison with local government(s) and provide emergency mental health services as needed. k. The Director/designee, in conjunction with the Commissioner/designee, shall determine whether or not the nature of the disaster requires evacuation and relocation of facility patients or residents. If a total or partial evacuation is necessary, the Director/designee shall inform the Commissioner (or his designee), the local emergency services staff, and the receiving facility and proceed with the evacuation according to the procedures contained in the facility emergency response plan. l. The Director/designee will be available to federal emergency response staff and keep accurate records of victims and treatment in order to support applications for federal assistance in accordance with instructions received from the state Department of Emergency Management. m. The Director/designee will provide periodic reports to the Commissioner/ designee on the situation and any problems that may require state-level intervention. (Source: Virginia EOP, updated 2005, pages G-13 through G-17)

In addition to the responsibilities included in the Virginia EOP, the DMHMRSAS has its own plan. Covering the period 2004 – 2010, the Comprehensive State Plan of the Virginia DMHMRSAS, includes goals, objectives and action steps for preparing for and responding to disasters and terrorism. The full plan may be viewed at: http:// www.dmhmrsas.virginia.gov/documents/reports/OPD-StatePlan2004% 20thru2010.pdf. The goals for responding to disasters and terrorism are provided below. Goal 48: Enable Virginia’s mental health, mental retardation, and substance abuse services system to better understand and prepare for the heightened threat potential facing the Commonwealth. Objectives: 1. Provide training to all CSBs and state mental health and mental retardation facilities in crisis counseling and all hazards disaster response. Action Steps: a. Develop a multi-media training package that incorporates information on all hazard disaster response and incorporates the lessons learned from Virginia’s response to the terrorism of 9/11/01, the serial sniper incident, and Hurricane Isabel, including risk communication and mass media strategies for intervention. b. Provide sufficient copies of this training package to all CSBs and state facilities to enable them to share this training with local response partners. c. Provide copies of this training package to other state agency responders

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such as the Virginia Department of Emergency Management and Virginia Department of Health as well as other public and private responders. d. Provide at least one live all hazard training session per health planning region utilizing Community Resilience Project Managers as trainers for their CSB peers in conjunction with the Virginia Department of Health.

Goal 49: Establish structures and relationships that will assure an immediate, effective, and coordinated response to terrorism-related and other major disasters by the mental health, mental retardation, and substance abuse services system. Objectives: 1. Link CSBs, state and private facilities, school systems, public health departments, faith communities, professional organizations, academic institutions and others into planning and response to disasters and terrorism–related events. Action Steps: a. Develop formal memoranda of understanding between contiguous CSBs to provide mutual support and response to disasters. b. Encourage and assist CSBs to develop strong supportive working relationships with other local mental health and substance abuse providers and first responders. c. Develop plans for regional state facility evacuation plans. d. Assure that all state mental health and mental retardation facility disaster plans meet Joint Commission on the Accreditation of Healthcare Organi- zations standards. 2. Improve Central Office disaster response infrastructure and communication capabilities. Action Steps: a. Seek funds to provide disaster preparedness and recovery training, assistance, and support to state facilities and CSBs. (Source: Comprehensive State Plan of the Virginia DMHMRSAS, page 147)

FEDERAL PLANNING State and local plans are based upon the Federal plans for responding to public health emergencies and disasters. To understand how they all fit together, below is information about the National Response Plan (NRP) and the National Incident Management System (NIMS). The information within the this section has been extracted from three primary sources: the National Response Plan brochure, the Quick Reference Guide for the National Response Plan, and the Terrorism and Other Public Health Emergencies: A Reference Guide for Media, Office of the Assistant Secretary for Public Affairs and the Office of Public Health Emergency Preparedness at the U.S. Department of Health and Human Services (HHS), September 2005.

National Response Plan The National Response Plan (NRP), which supersedes the Federal Response Plan, was adopted by the Federal government in December 2004. DHS’s brochure about the NRP describes it as “an all-discipline, all-hazards plan that establishes a single, comprehen-

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sive framework for the management of domestic incidents. It provides the structure and mechanisms for the coordination of Federal support to State, local, and tribal incident managers and for exercising direct Federal authorities and responsibilities. The NRP assists in the important homeland security mission of preventing terrorist attacks within the United States; reducing the vulnerability to all natural and man-made hazards; and minimizing the damage and assisting in the recovery from any type of incident that occurs (http://www.dhs.gov/xlibrary/assets/NRP_Brochure.pdf).”

EMERGENCY SUPPORT FUNCTIONS (ESFS) The NRP includes Emergency Support Functions (ESFs), which group capabilities and resources into functions most likely needed during an incident and describe the responsibilities of primary and support agencies involved. According to the Quick Refer- ence Guide for the National Response Plan, ESFs may be selectively activated by the Secretary of Homeland Security for both Stafford Act and non-Stafford Act incidents. ESFs may also be activated by the ESF Coordinators (see chart). For example, a large- scale natural disaster or significant terrorist incident may require the activation of all ESFs. A localized flood or tornado might only require activation of a few ESFs. (Quick Reference Guide for the National Response Plan, page 14, http://www.dhs.gov/ xlibrary/assets/NRP_Quick_Reference_Guide_5-22-06.pdf)

Behavioral health and disaster mental health are included within ESF #6, Mass Care, Housing, and Human Services, and ESF#8, Public Health and Medical Services. The behavioral health and disaster mental health elements of both ESFs are described below.

Disaster Mental Health within ESF#6 The coordinator for ESF#6 is Emergency Preparedness and Response, FEMA, DHS. Primary agencies for this ESF include the coordinating agency as well as the American Red Cross. The purpose of ESF#6 is to support State, regional, local, and tribal government and nongovernmental organization (NGO) efforts to address the non-medical mass care, housing, and human services needs of individuals and/or families impacted by Incidents of National Significance. The Human Services element of this ESF implements programs and provides services to assist victims, which includes “services that impact individuals and households, including a coordinated system to address victims’ incident-related recovery efforts through crisis counseling and other supportive services (National Response Plan, 2004, page ESF 6-1 through ESF 6-2).”

Behavioral Health within ESF#8 The U.S. Department of Health and Human Services is the primary agency for ESF#8. It “provides the mechanism for coordinated Federal assistance to supplement State, local, and tribal resources in response to public health and medical care needs (to include veterinary and/or animal health issues when appropriate) for potential or actual Incidents of National Significance and/or during a developing potential health and medical situation.” There are four core functional areas: 1) assessment of public health/ medical needs (including behavioral health); 2) public health surveillance; 3) medical care personnel; and 4) medical equipment and supplies. When notified of the activa-

Module 3 66 tion of a potential or actual Incident of National Significance, HHS will consult with the appropriate ESF#8 organizations to determine the need for assistance according to the functional areas, which includes behavioral health. Behavioral health in ESF#8 is described as follows: “HHS may task its components to assist in assessing mental health and substance abuse needs; providing disaster mental health training materials for workers; providing liaison with assessment, training, and program development activities undertaken by Federal, State, local, and tribal mental health and substance abuse officials; and providing additional consultation as needed (National Response Plan, 2004, page ESF 8-1 through ESF 8-6).”

National Incident Management System (NIMS) DHS’s brochure about the NRP described is as “a specific application of the National Incident Management System (NIMS). The NIMS provides the doctrine, concepts, principles, terminology, and organizational processes needed for effective, efficient, and collaborative incident management at all levels. While the NIMS provides the template, it is not an operational incident management or resource allocation plan. The NRP, using the comprehensive framework of the NIMS, provides the coordinating structure and mechanisms for national-level policy and operational direction for Federal support to State, local, and tribal incident managers, Federal-to-Federal support and for exercising direct Federal authorities and responsibilities as appropriate under the law (http:// www.dhs.gov/xlibrary/assets/ NRP_Brochure.pdf).” The executive briefing room of the CDC’s new Emergency Op- erations Center (EOC), which is a separate room designed for NIMS is a federally mandated incident manage- meetings, briefings and planning purposes. The new center will promote quicker, better-coordinated responses to public health ment system which State and local governments emergencies across the country and around the globe. CDC/ are required to adopt to help ensure coordination EOC, Greg Knobloch among all levels of government in response to disasters and emergencies that have occurred or are a threat.

Federal Planning and Response for Public Health or Medical Emergencies According to the NRP, “the Homeland Security Act of 2002 established the DHS to prevent terrorist attacks within the United States; reduce the vulnerability of the United States to terrorism, natural disasters, and other emergencies; and minimize the damage and assist in the recovery from terrorist attacks, natural disasters, and other emergencies (National Response Plan, 2004, page 9).” To protect the health of all Americans, the HHS is the U.S. government’s principal agency. The overall goal of HHS’ preparedness and response program is to ensure sustained public health and medical preparedness within our communities and our nation in defense against terrorism, infectious disease outbreaks, medical emergencies, and other public health threats.

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In a public health emergency, HHS’ responsibilities include: • Monitoring, assessing, and following up on people’s health • Ensuring the safety of workers responding to an incident • Ensuring that the food supply is safe • Providing medical, public health, and mental/behavioral health advice • Establishing and maintaining a registry of people exposed to or contaminated by a given agent

To fulfill this role, HHS works closely with state, local, and tribal public health departments; DHS; other federal agencies; and medical partners in the private and nonprofit sectors. Under the Public Health Service Act, HHS has the authority to: • Declare a public health emergency • Make and enforce regulations (including isolation and quarantine) to prevent the introduction, transmission, or spread of communicable diseases into the United States or from one state or possession into another • Conduct and support research and investigation into the cause, treatment, or prevention of a disease or disorder • Direct the deployment of officers of the Public Health Service, a division of HHS, in support of public health and medical operations • Provide public health and medical services and advice • Provide for the licensure of biological products (Source: Terrorism and Other Public Health Emergencies: A Reference Guide for Media, Office of the Assistant Secretary for Public Affairs and the Office of Public Health Emergency Preparedness at the U.S. Department of Health and Human Services (HHS), September 2005, page 142-143)

There are several organizations within HHS that assist with emergency response. Behavioral health is covered under the Substance Abuse and Mental Health Services Administration or SAMSHA (http://www.samhsa.gov/). SAMSHA addresses the psychosocial factors, such as mental health, substance abuse, and related concerns, in preparedness, response, and recovery for natural and manmade disasters. SAMSHA may staff interagency emergency operations centers; deploy personnel; and provide grants, services, and technical assistance to local and state jurisdictions.

HHS’S ROLE IN PUBLIC HEALTH EMERGENCIES BY TYPE OF INCIDENT Since HHS is the primary agency for protecting the health of Americans, and behavioral health/disaster mental health is the responsibility of this Federal agency, it is important for CSBs to understand HHS’s role in responding to public health emergencies, from those that occur as a result of a natural disaster to acts of bioterrorism. This next section, extracted from Terrorism and Other Public Health Emergencies: A Reference Guide for Media, Office of the Assistant Secretary for Public Affairs and the Office of Public Health Emergency Preparedness at the U.S. Department of Health and Human Services (HHS), September 2005, provides that information.

State, local, or tribal governments have the initial responsibility for responding to an emergency and protecting the people, property, and environment within their

Module 3 68 jurisdiction. The federal government generally supports the state, local, and tribal response when one or more of the following occurs: • A state requests assistance from the federal government and the President • The President declares a state of emergency • An incident takes place in areas that are owned or controlled by the federal government • Federal response is coordinated through DHS.

IN ALL EMERGENCY SITUATIONS In all disasters, HHS’s Secretary’s Operations Center becomes operational immediately upon notification and begins the collection, analysis, and dissemination of requests for medical and public health Dr. Taronna Maines, a microbiologist in the Influenza Branch at the Centers for assistance. Disease Control and Prevention, while she was conducting an experiment that was part of a study to investigate the pathogenicity and transmissibility of newly emerging H5N1 viruses. Information gained from this study is important for HHS operates under the NRP in all pandemic preparedness. CDC/ Taronna Maines, Greg Knobloch situations involving an “Incident of National Significance.” This is defined in the NRP as an actual or potential high- impact event that requires a coordinated and effective response by an appropriate combination of federal, state, local, tribal, and nongovernmental and/or private sector entities in order to save lives and minimize damage and provide the basis for long-term community recovery and mitigation activities.

Incidents of national significance are declared by the Secretary of Homeland Secu- rity under these criteria: • A federal department or agency acting under its own authority has requested the assistance of the Secretary of DHS • The resources of state and local authorities are overwhelmed and federal assistance has been requested by the appropriate state and local authorities • More than one federal department or agency has become substantially involved in responding to an incident • The Secretary of Homeland Security has been directed to assume responsibility for managing a domestic incident by the President

IN A NATURAL DISASTER DHS coordinates the federal response to a natural disaster, which may include floods, earthquakes, hurricanes, tornadoes, droughts, and epidemics. As in all crises, the Secretary’s Operations Center will coordinate medical and public health support to local and state governments. HHS will also gather and analyze data to help identify, monitor, and manage medical and health consequences for the public. HHS’s activities will be closely coordinated with several other agencies and organizations, including the Federal Emergency Management Agency under DHS, the Na- tional Guard and Reserve, and the American Red Cross.

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IN A NATURAL OUTBREAK As the primary public health agency in the nation, HHS will, through its Centers for Disease Control and Prevention (CDC), work closely with local and state public health officials to identify, track, and monitor outbreaks of diseases. Disease surveillance and detection systems, including the National Electronic Disease Surveil- lance System, provide the framework for communication of public health information throughout the nation and help public health officials detect and fight outbreaks. CDC has also provided funding and other support to develop additional epi- demiological and laboratory capacity for states and territories to address infectious disease. In coordination with DHS, HHS will provide direct public health support— both staff and medical supplies—to a state, if requested by its leadership. Many federal agencies would play a role in the management of an outbreak considered to be an Incident of National Significance, such as pandemic influenza or serious emerging infectious disease. HHS will coordinate all federal response for such an incident.

IN A BIOTERROR ATTACK HHS has primary responsibility for federal public health and medical response in a bioterrorist incident because response and recovery efforts will rely on public health and medical emergency response. The Assistant Secretary for Public Health Emer- gency Preparedness will coordinate responses with DHS and other federal and state agencies from the Secretary’s Operations Center. HHS will coordinate the federal public health and medical response to a bioterror attack.

IN A CHEMICAL INCIDENT If a chemical attack or other chemical incident occurs, HHS will work as part of the emergency management team in the emergency operations center of the agency with primary responsibility, the Environmental Protection Agency or the DHS/U.S. Coast Guard, in the event that the emergency activates ESF #8. CDC, through its Agency for Toxic Substances and Disease Registry and National Institute for Occu- pational Safety and Health, will assume roles in evaluating chemical spills and environmental contamination and providing safety and health recommendations to responders (e.g., the wearing of personal protective equipment). HHS will determine whether illnesses, diseases, or complaints may be attributed to exposure to a hazardous substance. It will establish disease exposure registries, conduct appropriate testing, and provide information on the health effects of toxic substances.

WHEN RADIOLOGICAL MATERIALS HAVE BEEN RELEASED DHS is responsible for the overall coordination of incident management activities for all radiological or nuclear Incidents of National Significance. If radiological materials have been released, HHS will work in cooperation with the emergency operations center of DHS and/or the agency it appoints as the coordinating agency. For example: • Radiological terrorism incidents would be initially coordinated by the U.S. De- partment of Energy (DOE), unless the material or facilities were either owned or operated by the U.S. Department of Defense (DOD) or licensed by the Nuclear Regulatory Commission. In those cases, the respective agency would serve as the coordinating agency. Radiological terrorism incidents include:

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• Radiological Dispersal Device, e.g., radioactive material plus conventional explosives • Improvised Nuclear Device, e.g., “suitcase bomb,” crude nuclear bomb • Radiation-Emitting Device, e.g., hidden (not exploded) radiological materials used to expose people to radiation (sometimes referred to as a “silent” source) • Management of an incident at a nuclear facility would be coordinated by the agency that licenses, owns, or operates the facility; this would be the Nuclear Regulatory Commission, DOD, or DOE. For nuclear facilities not licensed, owned, or operated by a federal agency, the Environmental Protection Agency would coordinate incident management. • In the event of a nuclear weapon accident/incident, DOD or DOE would serve as the coordinating agency, based on custody at the time of the event.

HHS will assess, monitor, and follow people’s health; ensure the safety of workers and responders involved in the incident; Arlington, VA, September 20, 2001 -- A FEMA Urban Search and Rescue member from New Mexico Task Force-1 is pictured outside ensure that the food supply is safe; and of the Pentagon. Photo by Jocelyn Augustino/ FEMA News Photo provide medical and public health advice. If there is a mass casualty situation, the American Red Cross will take a lead role in management as well. (Source: Terrorism and Other Public Health Emergencies: A Reference Guide for Media, Office of the Assistant Secretary for Public Affairs and the Office of Public Health Emergency Preparedness at the U.S. Department of Health and Human Services (HHS), September 2005, page 149-150)

PANDEMIC INFLUENZA Currently, one of the public health threats causing a tremendous amount of concern is pandemic influenza. The National Strategy for Pandemic Influenza states that seasonal influenza results in about 36,000 deaths and more than 200,000 hospitalizations each year in the United States, with an annual cost of more than $10 billion. It goes on to state that “a pandemic, or worldwide outbreak of a new influenza virus, could dwarf this impact by overwhelming our health and medical capabilities, potentially resulting in hundreds of thousands of deaths, millions of hospitalizations, and hundreds of bil- lions of dollars in direct and indirect costs (National Strategy for Pandemic Influenza, 2005, page 1).”

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The introduction to the National Strategy for Pandemic Influenza says that there have been three pandemics in the last century: 1918, 1957, and 1968. Respectively, they killed 40 million, 2 million, and 1 million people worldwide. It goes on to say that both science and history suggest that we will face one or more pandemics in this century and that “the current threat stems from an unprecedented outbreak of avian influenza in Asia and Europe caused by the H5N1 strain of the Influenza A virus.” (Ibid, page 1). Because influenza viruses do not respect the distinctions of age, race, sex, profession or nationality, not are they constrained by geographic boundaries, preparing for a pandemic requires coordinated action by all segments of government and society, including individuals. “While a pandemic will not damage power lines, banks, or computer networks, it will ultimately threaten all critical infrastructure by removing essential personnel from the workplace for weeks or months (Ibid, page 1).” The next pandemic is likely to come in waves, each lasting months and passing through communities of all size across the nation and the world.

The Federal government’s National Strategy for Pandemic Influenza is guided by the NRP, which is the primary mechanism for coordinating the Federal Government’s response to Incidents of National Significance. Because of the potential impact of pandemic influenza, this strategy not only addresses the health and medical aspect of this threat, but also includes strategies to sustain critical infrastructure, private-sector activities, the movement of good and services across the nation and the globe, as well as economic and security considerations (Source: Ibid, page 2). In the context of response to a pandemic, the Secretary of DHS will coordinate overall non-medical support and response actions, and ensure necessary support to the Secretary of HHS’s coordination of public health and medical emergency response efforts. The HHS also has a pandemic influenza plan, and one of the activities in this plan includes psychosocial support services, which focuses on “the institutionalization of psychosocial support services that will help healthcare workers manage emotional stress during the response to an influenza pandemic and resolve related personal, professional, and family issues (HHS Pandemic Influenza FactSheet, http://www.hhs.gov/pandemicflu/plan/ factsheet.html).”

It is important to note that the designation of the phase of pandemic influenza, as well as movement from one phase to another, is made by General-Director of the World Health Organization (WHO).

Working with Others Responding to a Public Health Emergency If there is a public health emergency, such as pandemic influenza, CSBs will be involved in the overall response effort. There will be several agencies and organizations involved, which are outlined in the following chart, taken from Helping to Heal, A Training on Mental Health Response to Terrorism.

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Other Organizations that May Be Responding

Local Response-- Fire and rescue department Public Agencies Law enforcement Local emergency management Public works Emergency medical services Hospitals Local officials Survivor services Human services Local Response-- American Red Cross Private Agencies and Civilians Salvation Army Unmet Needs Committee Community action groups Good Samaritans Clergy Media Employee assistance programs Funeral homes State Response State emergency management State medical examiner’s office Public works National Guard Highway patrol Public health Governor’s office State attorney’s office State crime survivor compensation program Consumer Protection Agency *Federal Response Federal Bureau of Investigation (FBI)

Bureau of Alcohol, Tobacco, and Firearms (ATF) Office for Victims of Crime (OVC)

Federal Emergency Management Agency (FEMA) Public Health Service (PHS)

Centers for Disease Control and Prevention (CDC) Center for Mental Health Services (CMHS) General Services Administration (GSA) Small Business Administration (SBA)

*Note that many agencies are from a larger unit. CMHS and PHS, for example, are part of DHHS. Onsite, workers will probably identify themselves as being from CMHS or PHS, not DHHS.

(Source: Helping to Heal: A Training on Mental Health Response to Terrorism, 2003, page 31-32)

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NATIONAL VOLUNTEER ORGANIZATIONS ACTIVE IN DISASTER (NVOAD)

National National Volunteer Organizations Active in Disaster (NVOAD) coordinates planning efforts by many voluntary organizations responding to disaster. Member organizations provide more effective and less duplication in service by getting together before disasters strike. Once disasters occur, NVOAD or an affiliated state VOAD encourages members and other voluntary agencies to convene on site. This cooperative effort has proven to be the most effective way for a wide variety of volunteers and organizations to work together in a crisis (www.nvoad.org).

NVOAD is a support agency of the ESF#6: Mass Care, Housing, and Human Services of the NRP and is responsible for the following activities: • Facilitate and encourages collaboration, communication, cooperation, and coordination, and build relationships among members while groups plan and prepare for emergencies and disaster incidents. • Assists in communicating to the government and the public the services provided by its national member organizations. • Facilitates information-sharing during planning and preparedness and after a disaster incident. • Provides members information pertaining to the severity of the disaster, needs identified, and actions of “helpers” throughout the response, relief and recovery process. • Provides guidance in client information-sharing, spiritual and emotional care management of unaffiliated volunteers, and unsolicited donated goods, as needed. (Source: National Response Plan, 2004, Annex 6, page ESF 6-8)

State Information about the Virginia Voluntary Organizations Active in Disaster (VOAD) in Virginia may be found at the following website: www.vaemergency.com/business/ recovering/na_voad.cfm. Information included on this website provides the following information about what VOAD members can do: • Provide clean-up in workplaces affected by disaster. • Guide you through the recovery process if your business has no insurance coverage. • Coordinate efforts among volunteer and government organizations to better assist businesses in the response and recovery process. • Identify ways businesses can mitigate potential damage before and after disaster strikes. • Provide crisis counseling to people affected by the disaster.

Additionally, Annex E, Human Needs and Shelter Operations/Attachment 4 of the Vir- ginia Emergency Operations Plan includes more details about the Virginia Voluntary

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Organizations Active in Disaster. See below for more about Virginia VOAD.

The mission of the Virginia Voluntary Organizations Active in Disaster is “to provide a liaison with the voluntary organizations that provide disaster services in Vir- ginia, so that their capabilities and resources will be effectively coordinated with other local, state and federal agencies to meet the needs of disaster victims.”

Organization A. The Virginia Voluntary Organizations Active in Disaster (VVOAD) is an organization whose purpose is to coordinate the interaction between voluntary disaster relief agencies and government disaster response activities in accordance with the local, state and federal disaster response plans. The VVOAD is an affiliate of the National Voluntary Organizations Active in Disaster (NVOAD). B. Member organizations of the VVOAD include the major organizations that have resources, developed plans and implemented preparatory actions to provide assistance in disasters that occur in Virginia. (see Tab A) The capabilities of these organizations include sheltering, mobile and fixed feeding, repair and recon- struction of homes, clean-up, counseling, storage and distribution of bulk food, clothing and household goods, child care, and many other services. They are frequently called on by their parent organizations to respond to disasters in neighboring states, and often provide funding and relief supplies for disaster victims worldwide.

Concept of Operations A. During Normal Operations, the VVOAD will participate in statewide exercises to assist in the development of local and state disaster response capabilities. B. The VVOAD will receive all situation reports, weather briefings, notifications and alerts that are distributed by the State EOC to state agencies. C. During the Initial Alert Level, the VVOAD contact designates a liaison to continue communication with the State EOC during the readiness phase and report to the State EOC if necessary. D. Each member organization maintains contact persons and resource lists to respond to requests from the liaison at the State EOC. Each member organization coordinates the response of its services and provides status reports to the liaison at the State EOC. E. The VVOAD functions in the State EOC as part of the Human Services Branch and works closely with the Mass Care and Food support functions. F. The VVOAD liaison will link member organizations with local emergency managers, local voluntary agencies, and state and federal agencies that are providing assistance in the affected areas. G. The VVOAD liaison will coordinate with other support functions in the State EOC to provide assistance to member organizations (i.e. transportation, communication resources, information on road conditions, etc.) H. The VVOAD will collect, compile and report information on the status of activities and resources of VVOAD member organizations in accordance with State EOC requirements. I. When there is no government disaster declaration, the VVOAD will continue to

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assist member organizations that provide additional assistance in meeting disaster-caused needs that are beyond the resources of the individual disaster victims. J. When the President declares a major disaster and the Federal Emergency Man- agement Agency implements a range of assistance programs available to individuals and families, the VVOAD will continue its liaison role with member organizations active in the disaster area. K. When the response and recovery phases of the disaster operation are completed, VVOAD will participate in evaluation procedures initiated by the Department of Emergency Services.

The Member Organizations of the VVOAD include (as of April 1, 2004): • Adventist Community Services • American Red Cross • Baptist General Association of Virginia • Catholic Diocese of Arlington • Catholic Diocese of Richmond • Christian Church, Disciples of Christ • Church of Jesus Christ of Latter Day Saints • Church of the Brethren • Church World Service • Episcopal Church • Evangelical Lutheran Church in America • Federation of Virginia Foodbanks • Friends Disaster Services • Humane Society of the United States • Jewish Community Federation • Lions Club of Virginia • Mennonite Disaster Service • Operation Blessing International • Presbyterian Church, USA • Psychiatric Society of Virginia Buena Vista, Va., Sept 26, 2003 -- The Salvation • The Salvation Army Army sets up an Emergency Disaster Service truck • Southern Baptist Conservatives of Virginia along South River Road near Lexington. The truck distributes food, water and ice to those in need. Most • United Church of Christ of the road and homes were destroyed by flooding • United Methodist as a result of Hurricane Isabel. Photo by Melissa Ann Janssen/FEMA photo • United States Air Force Auxiliary • United States Service Command • United Way of Virginia • Virginia Council of Churches • Virginia Department of Emergency Management • Virginia Disaster Recovery Taskforce • Virginia Jaycees • Virginia Office of Volunteerism (Source: Virginia EOP, 2004, Annex E, page E-24 through E-26)

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CSBs may coordinate with these voluntary organizations to help identify and reach more people impacted by the public health emergency, and to assess individual and community needs. It helps also to establish and maintain contact with members of the Virginia VOAD before a disaster.

SUMMARY Preparing for and responding to any disaster or emergency starts with the local government. Though other resources may be available should the local jurisdiction become overwhelmed, the local government will remain an active and critical part of the response. Behavioral health workers will also play an important role in the response and recovery from disasters and emergencies, and need to establish and maintain relationships with other response organizations before emergencies and disasters strike to be prepared to respond. Behavioral health is an important part in restoring the overall well-being of people in communities impacted by public health emergencies or other disasters, and to help individuals and communities recover.

RESOURCES

Department of Health and Human Services www.hhs.gov

HHS Pandemic Influenza Plan http://www.hhs.gov/pandemicflu/plan

Disaster Mental Health for States: Key Principles, Issues and Questions www.bt.cdc.gov/mentalhealth/states.asp

Risk and Emergency Communication: By Leaders for Leaders, CDC http://www.cdc.gov/communication/emergency/leaders.pdf

National Response Plan National Response Plan www.dhs.gov/interweb/assetlibrary/NRP_FullText.pdf

National Response Plan Fact Sheet www.dhs.gov/interweb/assetlibrary/NRP_FactSheet_2005.pdf

Quick Reference Guide to the National Response Plan www.vaemergency.com/library/plans/Quick_Ref_Guide052206.pdf)

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National Response Plan Brochure http://www.dhs.gov/interweb/assetlibrary/NRP_Brochure.pdf

National Incident Management System National Incident Management System http://www.fema.gov/emergency/nims/index.shtm

Virginia Department of Emergency Management Virginia Department of Emergency Management www.vaemergency.com/index.cfm

Virginia Department of Emergency Management, Plans and Procedures www.vaemergency.com/library/plans/index.cfm

Virginia Emergency Operations Plan Annex G: Health and Medical Services http://www.vaemergency.com/library/plans/coveop/eopvol1/eopvol1_c.pdf

Virginia Department of Emergency Management, Agency Strategic Plan www.vaemergency.com/library/plans/vdemstratplan2006.pdf

National Incident Management System, State and Local Compliance Activities, Fiscal Year 2006, VDEM Revision www.vaemergency.com/programs/nims/ State_Local_Compliance_VDEMrev.pdf

Commonwealth of Virginia Office of the Government Executive Order http://www.vaemergency.com/programs/nims/ExecutiveOrder102.pdf

National Incident Management System, State and Local Compliance Activities: Federal Fiscal Year 2006, VDEM Revision; www.vaemergency.com/programs/ nims/State_Local_Compliance_VDEMrev.pdf

VDEM’s NIMS and state compliance activities and information: www.vaemergency.com/programs/nims/index.cfm

Virginia Department of Health www.vdh.virginia.gov

Draft Pandemic Influenza Plan www.vdh.virginia.gov/pandemicflu/

Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services www.dmhmrsas.virginia.gov/Default.htm

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Comprehensive State Plan, 2004-2010, Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services, December 12, 2003 www.dmhmrsas.virginia.gov/documents/reports/OPD-StatePlan2004% 20thru2010.pdf

Community Services Boards www.dmhmrsas.virginia.gov/SVC-CSBs.asp

Helping to Heal, A Training on the Mental Health Response to Terrorism http://www.dmhmrsas.virginia.gov/CWD-HelpingToHeal.htm

Miscellaneous Information Peter Sandman, Risk Communications Expert www.psandman.com

National Volunteer Organizations Active in Disaster www.nvoad.org

Virginia Volunteer Organizations Active in Disaster www.vaemergency.com/business/recovering/na_voad.cfm

Hazmat cleanup after floods in southwest Virginia. Photo by Suzanne Simmons, VDEM

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INTRODUCTION Federal laws and regulations governing homeland security and public health emergencies as described in Module 3 clearly define behavioral health as an integral element of the national response. Yet, there is currently no established Federal program and legis- lation like the CCP of the Stafford Act covering reimbursement of State and local government expenditures related to behavioral health care following a large-scale public health emergency, such as Pandemic Influenza. Module 4: Funding for Behavioral Health Services after a Public Health Emergency describes the existing Federal programs for disasters and other precipitating events that include some, but not all types of public health emergencies.

The Federal government, through supplemental appropriations, has funded behavioral health response to terrorism. A summary of the initial DHHS funding for the Septem- ber 11, 2001, terrorist attacks is provided to illustrate the scope of supplemental grant awards for a past incident of national significance. The September 11, 2001 terrorist attack on the Pentagon demonstrated that the Virginia DMHMRSAS and the CSBs will be expected to quickly assess needs and submit multiple grant applications to Federal agencies in order to access funds for behavioral health services following a public health emergency that is an incident of national significance. Since, there is currently no one established Federal program for funding behavioral health services after a public health emergency that is unrelated to a natural disaster or act of terrorism, the amount of available funds and time period to be covered cannot be predicted.

TYPES OF FUNDING Federal funding to State and local governments are generally provided through three types of funding: Formula (or Block), Discretionary, and Congressional Earmarks.

Formula (or Block) • Awarded to State and local governments based on a predetermined formula (might be based on a jurisdiction's crime rate, population, or other factors). • Awarded to an agency in each State designated by the governor. • Generally requires States to pass awards to local agencies and organizations via subgrants.

Discretionary • Awarded on a competitive basis to public and private non-profit organizations. • Funding ranges from single awards for research, evaluation, and technical assistance to multi-site awards for program development. • Awarded on a competitive basis, consistent with congressional earmarks, to certain discretionary programs.

Congressional Earmarks • Hard Earmarks: Congress directs the Federal agency to provide certain funds to specific programs it has identified.

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• Soft Earmarks: Congress identifies a program and directs the Federal agency to: • Evaluate the program. • Fund the program, if warranted.

Most funding for the Homeland Security initiative is discretionary spending and provided through regular appropriations, supplemental appropriations or fee-funded activities (Congressional Budget Office, Economic and Budget Issue Brief, Federal Funding for Homeland Security: An Update, July 20, 2005). The Homeland Security budget for 2006 was $54 billion and the 2007 request is $58 billion with $5 billion for emergency preparedness and response (White House, Analytical Perspectives, Budget of the United States Government, 2007). The greatest increase in funding since 2001 has been for the Department of Health and Human Services (Congressional Budget Office, 2005).

Behavioral health has not been a major focus of the current spending. The need to involve behavior health has been consistently identified in planning efforts and guidance, but preparedness and response funding from Homeland Security for behavioral health initiatives has been sporadic.

EXISTING PROGRAMS There are three established Federal grant programs that fund behavioral health services following a mass crisis, these programs are limited on the type of disaster or emergency that may be funded:

Agency/Department Program Type of Event FEMA, U.S. Department of Crisis Counseling Assistance and Any natural catastrophe Homeland Security Training (including any hurricane, tornado, storm, high water, wind driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of cause, any fire, flood, or explosion Office for Victims of Crime, U.S. Antiterrorism and Emergency Terrorist act or mass violence Department of Justice Assistance Program Substance Abuse and Mental Emergency Response Grant Natural disasters, technologi- Health Services Administration, cal disasters and criminal acts U.S. Department of Health and including terrorism Human Services

States are eligible to apply for CCP funding from FEMA for Presidentially declared natural or manmade disasters, and to Office of Victims of Crime (OVC) for terrorist acts or mass violence. Public health emergencies that are not due to major disasters as defined in the Stafford Act or acts of terrorism and other mass violence as defined in OVC guidance, are not eligible for funding from these two Federal programs. SAMSHA Emergency Response Grants are “funds of last resort,” but have the least limitations on type of precipitating event.

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FEMA CRISIS COUNSELING ASSISTANCE AND TRAINING Background The Federal Emergency Management Agency (FEMA) of the Department of Homeland Security (DHS) administers the Crisis Counseling Assistance and Training Program (more commonly referred to as the Crisis Counseling Program or CCP). The CCP is a Disaster Assistance Program authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, and funded by the President’s Disaster Relief Fund.

The Center for Mental Health Services (CMHS) within the Substance Abuse and Men- tal Health Services Administration (SAMHSA) of the Department of Health and Hu- man Services (DHHS) assists FEMA in administering the CCP. CMHS Project Officers review CCP funding applications, monitor grants, and provide technical assistance to States, territories, Tribal Nations, and local mental health authorities. FEMA and CMHS both play an active role in the administration and oversight of the grant application and program delivery.

Supplemental Funding The purpose of the CCP is to provide supplemental funding to States, territories, and Tribal Nations for short-term crisis counseling services to eligible victims of Presiden- tially-declared major disasters.

CCP is a supplemental program that funds costs beyond State and local resources. The State is expected to make an in-kind contribution, such as office space, senior management, consultation, etc.

Eligible applicants Only a State or Federally recognized territory or Tribal Nation may apply for a CCP grant. The CSB submits an application request to DMHMRSAS for CCP funds. DMHMRSAS combines all CSB applications into one State application, which is submitted to FEMA through VDEM.

Eligible recipients CCP services are not dependent on registration for other forms of Federal or State disaster assistance. All CCP services are provided free to disaster survivors. Eligibility for crisis counseling services is defined in 44 CFR 206.171 (h)(1) as follows:

1. Services to Disaster Survivors. A person may be eligible for crisis counseling services if he or she was a resident of the designated area or located in the area at the time the disaster occurred and: a. Has a mental health problem which was caused or aggravated by the disaster or its aftermath; or b. May benefit from services provided by the program as a result of the disaster. 2. Training for Mental Health Workers. Mental health workers specified in the grant application are eligible for training that will enable them to provide crisis counseling services to people affected by the disaster. 3. Training for Disaster Workers. FEMA and other disaster workers are eligible for general instruction designed to enable them to deal effectively and humanely with

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people affected by the disaster, and to alleviate the stress which may result from disaster work.

BEHAVIORAL HEALTH ASSISTANCE Immediate Services There are two separate portions of the CCP, which can be funded: (1) Immediate Ser- vices (IS); and (2) Regular Services (RS). The IS portion is intended to enable the State or local agency to respond to the immediate mental health needs with crisis counseling services. IS may be funded for up to 60 days after the Presidential declaration. If an RS application has been submitted, the program period for the IS may be extended for an additional 30 days. The funding level may be increased to cover the costs accrued during the extension. A longer extension may be approved by FEMA if the review process of the RS exceeds 30 days. Costs incurred from the date of the incident to the date of the declaration are reimbursable under the IS portion.

Included in the IS application process is a needs assessment conducted by the State or local mental health agency to determine the approximate size, cost, and length of the program. The assessment must be initiated within ten calendar days of the date of the disaster declaration. If requested by the State, a CMHS Project Officer can provide technical assistance and guidance on the needs assessment. The CMHS Project Officer may provide technical assistance on-site or by telephone depending on the needs of the State.

The State must submit an application for IS funding within 14 days of the declaration. Separate applications are submitted for IS and RS. Both applications are submitted by the Governor’s Authorized Representative. DMHMRSAS has developed a separate guidance manual on how to develop an IS and RS application.

One of the greatest challenges of implementing an IS grant is to recruit and hire staff quickly. Most programs rely heavily on newly hired staff with some involvement of existing staff. On-going service demands often preclude the extensive use of existing staff. Many of the activities of the CCP do not require licensed mental health professionals. A blend of paraprofessionals and mental health professionals may be used to provide the needed services to the impacted communities. A paraprofessional does not necessarily have to have a degree in a related field. They are people who are well connected with the community and are good listeners. The paraprofessionals receive training through the CCP before they are allowed to interact with disaster survivors. The training includes identifying people who need to be referred to a mental health professional. Funding may be awarded for training of paraprofessionals and professionals involved in the CCP.

Regular Services The Regular Services (RS) program provides up to 9 months of crisis counseling services, community outreach, and consultation and education services to people affected by the disaster. Funding for the RS is separate from IS. The State may apply for either or both portions of the CCP. The application for RS funding is due within 60 days of the declaration. The intent of RS is to help disaster survivors recognize typical reactions and emotions that occur following a disaster, and to regain control over themselves and their environment.

RS funding may be approved for up to nine months, and that time period has become the standard practice. The program period begins when CMHS awards the grant using

Module 4 84 a PHS-5152-3 Notice of Grant Award (NOGA). The official program period is provided in block 6 of the NOGA.

The RS program period may be extended up to 90 days because of extenuating circumstances. Additional funds may be awarded to cover the costs incurred during the extension. States may ask for a no-cost extension if additional funds are not needed. The extension may be used to provide additional services or to complete the final report.

Virginia received two extensions for the Community Resilience Project, which responded to the September 11, 2001 terrorist attacks. Services were funded through March 2004.

Scope of the CCP The CCP regulations currently include the following services: screening, diagnostic, and counseling techniques, as well as outreach services such as public information, community networking, consultation, and education which can be applied to meet mental health needs immediately after a major disaster declaration. The CCP helps disaster survivors recognize typical reactions and emotions that occur following a disaster, and regain control over themselves and their environment. Crisis counseling is not treatment for psychiatric or developmental disabilities. Screening and diagnostic services are limited and used to refer disaster victims to traditional mental health or other services as needed. Psychiatric diagnosis is not an approved activity of the CCP. Mental health workers specified in the CCP grant application are eligible for training designed to enable them to deal effectively with people impacted by the disaster.

Possible Amendments to the Stafford Act The following amendment to the Stafford Act has been introduced in the Senate and is scheduled for debate as of August 2006. If the law changes, the President will have the authority to extend Regular Services grants beyond 90 days for catastrophic disasters. The new law also changes crisis counseling services to mental health services and requires Federal agencies and state and local authorities to develop response plans that include a survey of needs and a strategy for meeting those needs.

S.3721, Post Katrina Emergency Management Reform Act of 2006 (Introduced in Senate) SEC. 219. MENTAL HEALTH SERVICES. (a) In General- The Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5121 et seq.) is amended by striking section 416 and inserting the following:

`SEC. 416. MENTAL HEALTH SERVICES. `(a) In General- The President is authorized to provide mental health and substance abuse services to individuals affected by a major disaster (including children and other vulnerable populations, and emergency response providers responding to a major disaster) to relieve or prevent mental health or substance abuse problems caused or aggravated by such major disaster or its aftermath.

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`(b) Types of Assistance- The assistance provided under subsection (a) may include providing financial assistance to Federal, State, or local government agencies or private mental health or substance abuse organizations to provide mental health or substance abuse services or train individuals to provide such services. `(c) Duration of Assistance- The President may provide an award of financial assistance described in this section for a period of no more than 9 months after the date of notice of the grant award. The President may extend the period of such an award for 90 days because of documented extraordinary circumstances. In limited circumstances, such as disasters of a catastrophic nature, the President may extend the period of such an award beyond 90 days if the President determines it is in the public interest.'. (b) Response Plan- Not later than 180 days after the date of enactment of this Act, the Substance Abuse and Mental Health Services Administration and other Federal agencies providing mental health or substance abuse services, in coordination with the Administrator and State and local government officials with responsibilities for providing mental health or substance abuse prevention and services, shall-- (1) conduct a survey of mental health or substance abuse services and any applicable support services available to individuals affected by major disasters and to emergency response providers responding to major disasters; and (2) develop a strategy for the adequate provision of mental health and substance abuse services to individuals affected by major disasters and to emergency response providers responding to major disasters.

Office for Victims of Crime ANTITERRORISM AND EMERGENCY ASSISTANCE PROGRAM Background The threat of terrorism and criminal mass violence against Americans, both in the United States and abroad, has increased in recent years. Such acts leave victims with serious physical and emotional wounds and challenge government officials and communities to respond immediately with appropriate resources. Victim assistance and compensation providers face the daunting task of coordinating effective and timely responses, providing information and assistance to victims, and working closely with other agencies and victim service organizations.

Following the bombing of the federal office building in Oklahoma City on April 19, 1995, congress amended the Victims Crime Act of 1984 to authorize the OVC Direc- tor to provide support to jurisdictions and assistance to victims of terrorism and mass violence crimes using moneys that were deposited into to Crime Victims Fund and set aside for the Antiterrorism Emergency Reserve. Funding from the Reserve has been used to provide support to victims of the Oklahoma City bombing, the bombing of Pan Am Flight 103, the bombing of the U.S. embassies in Kenya and Tanzania, the two cases of mass violence resulting from school shootings in Oregon and Colorado, and the September 11, 2001, terrorist attacks on America, among others.

Supplemental Funds The funds available through the Application may supplement other resources and

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services available to jurisdictions responding to acts of terrorism and mass violence. Specifically, Antiterrorism and Emergency Assistance Program support may be granted if any of the following exist:

• The jurisdiction cannot adequately provide needed services with its existing resources • The provision of services and assistance to terrorism or mass violence victims by the jurisdiction will result in undue financial hardship on the jurisdiction, im- pairing its ability to respond to general population crime victims in a comprehensive and timely manner. • A response by the jurisdiction will impede its ability to respond to other crime victims.

Eligible Applicants Applicants eligible for funding include state victim assistance and victim compensation programs, public agencies including federal, state, and local governments; and victim service and nongovernmental organizations.

In cases within the United States, applications will be accepted only from the jurisdictions in which the crime occurred unless a statute establishes a special authori- zation and appropriation supporting allocations to other jurisdictions, or a compel- ling justification can be provided to the OVC Director supporting requests from other jurisdictions.

Eligible Recipients In cases of terrorism and mass violence within the United States, the term “victim” has the same meaning as “victim” in 42 USCA 10603c, as amended. (As of the publication of these Guidelines, 42 U.S.C. 10603c defines “victim” as a person who has suffered direct physical or emotional harm as a result of the commission of a crime.) Because of the nature of terrorist incidents, the term victim will also include individuals who are likely to Fort Eustis, Va., Sept. 25, 2003 -- The US Army Corps of Engineers suffer traumatic effects of the incident, for (USACE) assist in the logistics of generator, ice, water distribution example people in direct proximity to the throughout Virginia. Photo by Melissa Ann Janssen/FEMA crime and emergency responders. In addition, OVC requires that consistent with other portions of VOCA, no individual who is criminally culpable for the terrorist act or mass violence may receive either assistance or compensation either directly or on behalf of a victim. (Source: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi? dbname=2002_register&docid=02-2299-filed)

(Note: OVC denied Virginia’s request to provide services to the general population for 9-11.)

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Behavioral Health Assistance Of the five types of assistance available through OVC, two are for behavioral health services, described below.

Crisis Response Grant (emergency/short-term up to 9 months) Funding to help rebuild adaptive capacities, decrease of stressors, and reduce symptoms of trauma immediately following a terrorism or mass violence incident.

Allowable Activities: • Crisis counseling • Intervention with employers & creditors • Child & dependent care • Assistance securing compensation • Emergency food, housing & clothing • Toll-free telephone lines • Emergency travel & transportation • Needs assessment (limited) • Outreach, awareness, and education • Automated telephone services • Coordination

Consequence Management Grant (0ngoing/longer-term, up to 18 months) Funding to help victims adapt to the trauma event and to restore the victims’ sense of equilibrium.

Allowable Activities: • Counseling & group therapy • Intervention with employers & creditors • Information Web sites for victims • Rehabilitation expenses • Emergency travel & transportation • Vocational rehabilitation • Automated telephone services • Temporary housing, per diem & relocation • Needs assessment (expanded) • Coordination • Outreach, awareness & education (Source: http://www.ojp.usdoj.gov/ovc/fund/pdftxt/ antiterrorapplication.pdf)

OVC awarded the Commonwealth of Virginia a $12 million Antiterrorism and Emer- gency Assistance Program grant. DMHMRSAS submitted a request for $4.7 million of the $12 million to be used continue the Community Resilience Project after the FEMA funding ended. The request was denied, because OVC funding is limited to direct victims. OVC would not accept a plan to provide services to the general population.

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SAMHSA The following information has been taken directly from the SAMHSA Emergency Re- sponse Grant (SERG) Q&A Fact Sheet::

Emergency Response Grant (SERG) Background Funding for the SAMHSA Emergency Response Grant (SERG) is designed to meet emergency substance abuse and mental health needs in local communities which are a direct consequence of a precipitating event. SERG funding enables public entities to address these needs when existing resources are overwhelmed and other resources are unavailable or inadequate. SERG monies are considered “funds of last resort.”

Supplemental Funding Immediate awards are funded up to $50,000. Intermediate awards have no prede- fined budget limit. Submission of a Pre-Application Letter of Intent provides the applicant with the opportunity to consult with a SERG project officer who can comment on the appropriateness of the funding request for an intermediate award…

The immediate SERG application is due as soon as possible following the emergency event and funds 90 days of services from the date of the emergency. The intermediate SERG applications is due within 90 days of the date of the emergency and may fund up to one year of services. An immediate SERG is not prerequisite to apply for an intermediate SERG.

As a time-limited, emergency response grant, the SERG is intended to bolster, not replace, existing individual, community and behavioral health supports. Applicants must show that a specific mental health or substance abuse need directly resulting from the emergency exists, that existing systems for mental health or substance abuse services are overwhelmed, and that all other resources to address the need have been exhausted. The SERG typically does not fund traditional services, such as long-term mental health or substance abuse treatment, medications, or hospitalization.

Eligible Applicants Eligible applicants are limited to public entities, which are defined as a State or Ter- ritory, political subdivision of a State, federally recognized Native American tribal government, or tribal organization. These entities may partner with other organizations to respond to the emergency situation; however, the eligible entity must submit the application.

The governor is required to certify the emergency need; however, local governments are eligible to seek the grant and must sign the application as the responsible fiscal party. For tribal entities, the principal elected official, or his or her designee, is required to certify the emergency need.

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Precipitating Event A precipitating event must have a sudden, rapid onset and a definite conclusion. Examples include the following: • Natural disasters (e.g., hurricane, tornado, storm, flood, earthquake, fire, drought); • Technological disasters (e.g., chemical spill, major industrial accident, transportation accident); and • Criminal acts (e.g., act of terrorism, hostage situation, riot, incident of mass violence, such as a school shooting).

Such incidents typically result in significant death, injury, exposure to life- threatening circumstances, hardship, suffering, loss of property, or loss of community infrastructure.

Behavioral Health Assistance As a time-limited, emergency response grant, the SERG is intended to bolster, not replace, existing individual, community, and behavioral health supports. Appli- cants must show that a specific mental health or substance abuse need directly resulting from the emergency exists, that existing systems for mental health or substance abuse services are overwhelmed, and that all other resources to address the need have been exhausted. The SERG typically does not fund traditional services, such as long-term mental health or substance abuse treatment, medications, or hospitalization.

Note: The Fact Sheet is available through the SAMHSA Disaster Technical Assis- tance Center

OTHER FUNDING SOURCES How Will Behavioral Health Services for Pandemic Influenza be Funded? Congress can award supplemental appropriations to respond to emergency situations. An Emergency Response Supplemental Appropriation awarded over $28 million to the States impacted by the September 11, 2001 terrorist attacks. The following HHS press release summarizes the initial funding that was awarded following the September 11th terrorist attack. Additional funding was awarded at a later date.

Emergency Grants Awarded Provide $6.8 Million for Disaster Areas

HHS Secretary Tommy G. Thompson announced the award of 23 grants, totaling $6.8 million, to help eight states and the District of Columbia support crisis mental health services and to supplement existing mental health and substance abuse systems in the areas affected by the September 11 terrorist-inflicted disaster.

The grants are the first wave of awards by the Substance Abuse and Mental Health Services Administration (SAMHSA) from a total of $28 million in funding made available to the agency under the emergency response supplemental appropriation,

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all part of a total of $5.1 billion in disaster-related funds released by President Bush on Sept. 21.

The SAMHSA program dollars respond directly to the significant actual and potential psychosocial effects of the attacks and devastation on adults, adolescents and children in the affected communities.

"The nation has been responding in remarkable ways to the needs of their communities through financial contributions and donations of all kinds. The people of HHS, too, have been lending a helping hand," Secretary Thompson said. "We have sped the wheels of the department's funding capacity to help identify and meet the overwhelming long-term human needs for counseling, support, and recovery in the wake of this man-made tragedy. The grants being made today are just the beginning of the department's ongoing commitment to help America's citizens heal."

The nine mental health-focused grants will support state mental health needs assessments to enable affected states to identify gaps in mental health service capacity that cannot be filled through existing regular and emergency funding mechanisms.

SAMHSA's substance abuse prevention- and treatment- supported grants -- 14 in all -- will supplement current hotline crisis counseling capacities and enhance current resilience-building, family-strengthening and substance abuse prevention activities in affected communities.

"The foremost aim of these grants is to ensure that needed psychosocial supports for affected Americans are identified and made available for as long as anyone affected by this tragedy may need them," said Joseph H. Autry III, M.D., SAMHSA's acting administrator. "While the dollars may be small, their impact can be measured in reclaimed health and well-being of many." The $6.8 million, allocated by state, is as follows: New York, $2.2 million; Connecticut, $1.1 million; Pennsylvania, $650,000; New Jersey, $1.05 million; Virginia, $465,000; Maryland, $250,000; Massachusetts, $50,000; Rhode Island, $50,000; and the District of Columbia, $987,000. (Source: http://www.hhs.gov/news/press/2001pres/20011029.html)

Additional grants were awarded through the CCP and supplemental appropriations during the subsequent years. The following is the total funding for Virginia’s behavioral health response to September 11, 2001: • SAMHSA substance abuse $1,040,547 • SAMHSA mental health $991,453 • FEMA immediate services $2,160,498 • FEMA regular services $ 10,707,990

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SUMMARY It is impossible to predetermine the level of potential funding available to CSBs for a behavioral health response to a public health emergency of national significance. Past experience in Virginia suggests the DMHMRSAS and CSBs should be prepared to develop a comprehensive needs assessment and submit grant applications to multiple Federal authorities.

RESOURCES

Congressional Budget Office, Economic and Budget Issue Brief, Federal Funding for Homeland Security: An Update, July 20, 2005 FEMA http://www.fema.gov

Office for Victims of Crime http://www.ojp.usdoj.gov/ovc

Substance Abuse and Mental Health Services Administration http://www.samhsa.gov

White House, Analytical Perspectives, Budget of the United States Govern- ment, 2007)

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Overturned Tractor Trailer, Suffolk (2003); Due to a 30-inch gouge in this overturned tanker, responders had to burn off the propane inside using a flare stand. Though experts expected it to take two to three days to burn off the propane, VDEM Hazmat Officer Ray Haring's approach of burning propane in its liquid rather than gaseous state cut that time in half. Two heavy-duty tow trucks then lifted the propane rig and set it up- right on the ramp. Photos by R.C. Powell, Virginia State Police

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INTRODUCTION Public health emergencies may be naturally caused or human-caused. They may be the primary event, such as a pandemic, or the result of another disaster. Though it is difficult to identify all of the characteristics and impacts of a pandemic, state and Federal planning documents offer information about those that are anticipated. This information is summarized in Module 5 to help behavioral health workers prepare to respond with information about how to cope with any public health emergency, and coordinate with public health officials before, during, and after an event to provide information to disaster workers and to the public within impacted communities about what to expect and how to cope.

CHARACTERISTICS OF A PUBLIC HEALTH EMERGENCY There is a lot of speculation about the characteristics and challenges of responding to a public health emergency, particularly pandemic influenza. The focus in this section is on pandemic influenza, as there is currently a great deal of attention on this particular public health threat.

The Implementation Plan for the National Strategy for Pandemic In- fluenza addresses the psychosocial concerns and characteristics of the response to a pandemic: “During a pandemic, psychosocial issues may play significantly contribute to, or hinder, the effectiveness of the response. Public anxiety and subjective perception of risk during the initial phases will impact the degree of medical surge; overall compliance with quarantine, snow days, and other control procedures; participation of the workforce, including health care workers, in response efforts. In later stages of the epidemic, other psychosocial factors may also emerge. During the 1918-1919 “Spanish flu,” for example, people experienced significant distress due to loss of family members and anxiety about work, food, transportation, and basic infrastructure, while the SARS outbreak in 2003 led to psychological distress for health care workers and the general public because of social isolation, stigmatization of groups perceived to be high risk, and general fears about safety and health (Implementation Plan for the National Strategy for Pandemic Influenza, White House, Homeland Security Council, 2004, page 111).”

Characteristics and challenges of a pandemic Rapid Worldwide Spread • When a pandemic influenza virus emerges, its global spread is considered inevitable. • Preparedness activities should assume that the entire world population would be susceptible. • Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but cannot stop it.

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Health Care Systems Overloaded • Most people have little or no immunity to a pandemic virus. Infection and illness rates soar. A substantial percentage of the world’s population will require some form of medical care. • Nations unlikely to have the staff, facilities, equipment and hospital beds needed to cope with large numbers of people who suddenly fall ill. • Death rates are high, largely determined by four factors: the number of people who become infected, the virulence of the virus, the underlying characteristics and vulnerability of affected populations and the effectiveness of preventive measures. • Past pandemics have spread globally in two and sometimes three waves.

Medical Supplies Inadequate • The need for vaccine is likely to outstrip supply. • The need for antiviral drugs is also likely to be inadequate early in a pandemic. • A pandemic can create a shortage of hospital beds, ventilators and other supplies. Surge capacity at non-traditional sites such as schools may be created to cope with demand • Difficult decisions will need to be made regarding who gets antiviral drugs and vaccines.

Economic and Social Disruption • Travel bans, closings of schools and businesses and cancellations of events could have major impact on communities and citizens. • Care for sick family members and fear of exposure can result in significant worker absenteeism.

(Source: http://www.pandemicflu.gov/general/whatis.html)

The emergence of an easily transmissible novel strain of influenza into a human population anywhere poses a threat to societies everywhere. Influenza does not respect geographic or political boundaries. When pandemic strains emerge they sweep through communities and nations with frightening velocity. The three pandemics of the 20th century each encircled the globe, sparing few if any communities, within months of their emergence into human populations. The cumulative and concentrated mortality of a pandemic can be appalling. The 1918 pandemic, for example, killed more people in 6 months than acquired immunodeficiency syndrome (AIDS) has killed in the last 25 years and more than were killed in all of World War I. Implementation Plan for the National Strategy for Pandemic Influenza, 2006, page 99

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HOW DOES SEASONAL FLU DIFFER FROM PANDEMIC FLU?

Seasonal Flu Pandemic Flu

Outbreaks follow predictable seasonal pat- Occurs rarely (three times in 20th century - terns; occurs annually, usually in winter, in last in 1968) temperate climates

Usually some immunity built up from previ- No previous exposure; little or no ous exposure pre-existing immunity

Healthy adults usually not at risk for serious complications; the very young, the elderly Healthy people may be at increased risk for and those with certain underlying health con- serious complications ditions at increased risk for serious complications

Health systems can usually meet public and Health systems may be overwhelmed patient needs

Vaccine developed based on known flu Vaccine probably would not be available in strains and available for annual flu season the early stages of a pandemic

Adequate supplies of antivirals are usually Effective antivirals may be in limited supply available

Average U.S. deaths approximately 36,000/ Number of deaths could be quite high (e.g., yr U.S. 1918 death toll approximately 675,000)

Symptoms: fever, cough, runny nose, muscle Symptoms may be more severe and compli- pain. Deaths often caused by complications, cations more frequent such as pneumonia.

May cause major impact on society (e.g. Generally causes modest impact on society widespread restrictions on travel, closings of (e.g., some school closing, encouragement of schools and businesses, cancellation of large people who are sick to stay home) public gatherings)

Manageable impact on domestic and world Potential for severe impact on domestic and economy world economy

(Source: PandemicFlu.gov, 2006, http://www.pandemicflu.gov/general/ season_or_pandemic.html)

Phases of a Pandemic Six distinct phases have been defined (see chart below) to facilitate pandemic preparedness planning, with roles defined for governments, industry, and WHO. The present situation is categorized as phase 3: a virus new to humans is causing infections, but does not spread easily from one person to another.

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Phases of a Pandemic Given the widespread and enormous impact a pandemic will have, it is critical that behavioral health workers be involved in the planning and response of all phases of a pandemic. The World Health Organization (WHO) offers the chart below about the phases of a pandemic, which is also included in the VDH draft Pandemic Influ- enza Plan.

Phase Definition

No new influenza virus subtypes have been detected in human. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human Interpandemic Phase 1 infection is considered to be low.

No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk1 2 of human disease.

Human infection(s) with a new subtype, but no human-to-human spread, or at most rare in- 3 stances of spread to a close contact2

Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well-adapted to hu- Pandemic Alert 4 mans2

Larger cluster(s) but human-to-human spread is still localized, suggesting that the virus is becoming increasing better adapted to humans, but may not yet be fully transmittable (substantial 5 pandemic risk)

Pandemic: increased and sustained transmission Pandemic 6 in general population2

Post-Pandemic Period Return to the Interpandemic Period (phase 1)

1 The distinction between Phase 1 and Phase 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, and/or other scientific parameters.

2 The distinction between Phase 3, Phase 4 and Phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered (e.g., rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains [if derived from an animal strain], and/or other scientific parameters).

(Source: World Health Organization, Global Influenza Preparedness Plan, 2005, page 2)

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According to the WHO website, experts at WHO and elsewhere believe that the world is now closer to another influenza pandemic than at any time since 1968. The General- Director of WHO makes the designation of phases as well as when to move from one phase to another.

How a Pandemic is Different from Other Disasters According to the Virginia Department of Health’s (VDH) draft Pandemic Influenza Plan, several features set pandemic influenza apart from other emergencies or community disasters: • Outbreaks can be expected to occur simultaneously throughout much of the U.S., preventing shifts in human and material resources that usually occur in response to other disasters; • Effects on individual communities will be relatively prolonged (weeks to months) in comparison to other disasters; • Healthcare workers and other first responders may be at higher risk of exposure and illness than the general population, further straining the healthcare system; • Preventive and therapeutic medicines (e.g., vaccine and antiviral agents) will be delayed and in short supply; and • Widespread illness in the community could increase the likelihood of sudden and potentially significant shortages of personnel in other sectors who provide critical public safety services. • Additional planning is needed on the local, state and national levels to address some of the unique issues surrounding pandemic influenza. Examples of issues that require further discussion and planning include:

Vaccine Delivery Because a shortage of vaccine is anticipated early in the pandemic, prioritization of persons receiving the initial doses of vaccine will be necessary. Issues will arise, such as: • What populations should receive the vaccine in the event of a shortage? • How will decisions be made about sub-groups in each of the priority populations (e.g., how to define a ‘healthcare worker’)? • How will vaccine be distributed to priority groups? • How will vaccination of priority groups be enforced and will people have to ‘prove’ that they fit into a priority group (for example, by providing documentation of their diabetes)? • How will security of the vaccine be maintained?

Antiviral Medications Because vaccine will likely not be available when the virus first affects communities, antiviral medications may play an important role for the prevention and control of influenza, especially during the period before vaccine is available. Some issues that will arise include: • What populations should receive antivirals in the event of a shortage? • Should antiviral use be recommended for either prophylaxis or treatment or both?

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• Should antiviral medication required by persons with certain diseases (e.g., Parkinson’s disease) be reserved for this indication?

Healthcare Facilities Healthcare facilities will encounter many issues regarding both the treatment of patients and the protection of their workers. Some issues that may arise include: • Will public health provide any guidance to healthcare facilities regarding patient prioritization or triage of patients (e.g., cancellation of elective admissions and surgeries)? • How will facilities make decisions about prioritization of scarce resources (e.g., ventilators)? • What steps will be taken to address staffing shortages at hospitals? • What steps will be recommended to protect healthcare workers when personal protective equipment is in short supply?

Community Transmission Widespread occurrence of influenza in the community will create many concerns, including: • What are the essential services that cannot be stopped in any event (e.g., water, electricity, nuclear power plants)? • What steps will be taken to ensure that essential service workers are prioritized to receive vaccine and/or antiviral medications? • At what stages in the pandemic will recommendations to minimize community transmission be made (e.g., through cancellation of sports events, school closures)? • Will the recommendations be enforced? • At what stages in the pandemic will isolation and quarantine be used as tools to reduce transmission? (Source: VDH Draft Pandemic Influenza Plan, 2006, page 9)

The VDH draft Pandemic Influenza Plan also provides the following information about the impact of a pandemic in Virginia: “Influenza A viruses periodically cause worldwide epidemics, or pandemics, with high rates of morbidity and mortality. Unlike other public health emergencies, an influenza pandemic will affect multiple communities across Virginia, and the entire nation, simultaneously. It is estimated that during eight weeks of pandemic activity in Virginia, as many as 1,137,850 outpatient visits, 24,090 hospitalizations, and 5,380 deaths could occur across the state. The Centers for Disease Con- trol and Prevention estimates that pandemic activity could continue for as long as 18 months, which would greatly increase the number of individuals affected (Ibid, Execu- tive Summary).”

Additional characteristics of a public health emergency may include the following: • Fear of illness and death; fear for the safety of individuals and family; fear about the impacts of a pandemic such as financial, employment, food and water, social disruption, etc. • Unpredictable, as it is impossible to know when or if a pandemic will occur or where it will start

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• Duration: a pandemic is predicted to come in waves lasting 2 to 3 months; the entire pandemic period may last up to 18 months (CDC) • Contagious/susceptibility: the first planning assumption in the Implementation Plan for the National Strategy for Pandemic Influenza is that susceptibility to the pandemic influenza virus will be universal;” and that individuals may spread the disease before they even know they are sick (Implementation Plan for the National Strategy for Pandemic Influenza, 2006, page 25) • Transmission from person-to-person will be “efficient and sustained,” making it easy for people to get sick (Implementation Plan for the National Strategy for Pan- demic Influenza, 2006, page 25) • Quarantine, isolation, and other social distancing measures may be required Unlike geographically and temporally bounded to slow the transmission of the disease, disasters, a pandemic will spread across the causing a significant impact on work, globe over the course of months or over a year, travel, social events, and other factors possibly in waves, and will affect communities of • Mass illness and casualties that result all sizes and compositions. In terms of its scope, from a pandemic may be high; coping the impact of a severe pandemic may be more with potentially high number of deaths comparable to that of war or a widespread eco- could present additional concerns nomic crisis than a hurricane, earthquake, or act about other diseases, dealing with re- of terrorism. mains effectively and swiftly, and han- Implementation Plan for the National Strategy for dling the remains respectfully Pandemic Influenza, 2006, page 2 • Vaccines, treatment and medication, the availability of which may limited (VDH draft Pandemic Influenza Plan, 2006, page 9) and cause anger among those who are unable to receive them for themselves or their families • Stigmitization of those who are or have been infected, of those who work with those who are ill, and families of those individuals (VDH draft Pandemic Influenza Plan, 2006, Supplement 11, page 1)

Quarantine, Isolation, and Other Definitions and Processes In a public health emergency such as pandemic influenza, measures to contain the disease or to reduce the spread of disease may be necessary. Below is information from CDC’s Crisis and Emergency Risk Communications: By Leaders for Leaders about specific definitions and processes to help reduce the spread of disease.

Detention is the temporary holding of a person; ship; aircraft; or other carrier, animal, or thing. The length and location of detention is determined by the CDC director.

Isolation is the separation of a person or group of persons from other persons except the health care staff on duty in such a manner as to prevent the spread of infection. This isolation is for the period of communicability of infected persons or animals from others in such placed and under such conditions as to prevent or limit the direct or indirect transmission of the infectious agent from those who are susceptible or those who may spread the agent to others.

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Quarantine restricts the activities of well persons or animals exposed to communicable disease during its period of communicability in order to prevent disease transmission during the incubation, if infection should occur. There are two types of quarantine:

Absolute or complete quarantine limits the freedom of movement of those exposed to a communicable disease for a period of time not longer than the longest usual incubation period of that disease, in such a manner as to prevent effective contact with those not so exposed.

Modified quarantine is the selective, partial limitation of freedom of movement of contacts, commonly on the basis of known or presumed differences in susceptibility and related to the danger of disease transmission. This type is designed to meet such specific situations as the exclusion from school, exemption of those known to be immune, restriction of military to post, etc. This includes personal surveillance and segregation, defined as the following:

Surveillance of a person is the temporary supervision of someone who may have or has been exposed to a communicable disease. It is the practice of close medical or other supervision of contacts in order to permit prompt recognition of infection or illness but without restricting their movements.

A surveillance order is a notification delivered to a person who may have been exposed to a communicable disease, advising him or her of the potential exposure, the need for surveillance of the individual, the authority to perform the surveillance, and providing compliance instructions for the person being placed under surveillance. Instructions may include information about the symptoms, actions should symptoms occur, who to contact if the person relocates, time period of surveillance, penalty for noncompliance, etc.

Segregation is the separation of some part of a group, persons, or domestic animals from others for special consideration, control, or observation. Segregation includes removal of susceptible children to the homes of immune persons, or the establishment of a sanitary boundary (to protect the uninfected from infected portions of a population).

A cordon sanitaire is a sanitary cord or line around a quarantined area guarded to prevent the spread of disease by restricting passage into or out of the area. These concepts may be critical in the response to suspected or confirmed large-scale bioterrorist events. Questions about people with active cases of illness and those who may be incubating the disease and infectious agent would have to be considered to protect non-exposed healthy people.

The public health response, timing, and degree of the response would depend on the following aspects of the outbreak: • Number of cases and exposed persons • Associated illness and death from the disease (severity of the disease)

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• Ease and rapidity of the spread of the disease (some spread so easily that these disease control measures may not be feasible). • The degree of movement in and out of a community (how isolated the community may or may not be). • Resources needed to separate sick or exposed people from well people • Risk for public panic.

For individuals who are sick, the appropriate response may be isolation (home or congregate settings) and respiratory isolation. Sick people would need to be moni- tored to detect new cases and monitor disease treatment. (Source: Crisis and Emergency Risk Communications: By Leaders for Leaders, CDC, pages 44-45)

DISRUPTION, LOSS, AND CONCERNS OF A PUBLIC HEALTH EMERGENCY The impact of a pandemic will depend on its severity. However, information available now about the potential impact of a pandemic shows that virtually no community will remain untouched. The VDH website provides the following information:

If a new and severe strain of flu were to begin spreading across the globe, Virginia would not be spared from its impact. The severity of the next pandemic cannot be predicted, but modeling studies suggest that its effect in the United States could be severe. In the absence of any control measures (vaccination or drugs), it has been estimated that in the United States a "medium-level" pandemic could cause: • 89,000 to 207,000 deaths • 314,000 to 734,000 hospitalizations • 18 to 42 million outpatient visits • 20 to 47 million people becoming sick • An economic impact ranging between $71.3 and $166.5 billion

In Virginia, pandemic flu impact estimates include: • 2,700 to 6,300 deaths • 12,000 to 28,500 hospitalizations • 575,000 to 1.35 million outpatient visits • 1.08 million to 2.52 million people becoming sick (Source: VDH website: http://www.vdh.virginia.gov/PandemicFlu/index.asp)

Below is information about individual and family planning for the impact and disruption caused by a pandemic, extracted from the Pandemic Flu website.

Essential Services May Be Disrupted • Plan for the possibility that usual services may be disrupted. These could include services provided by hospitals and other healthcare facilities, banks, restaurants, government offices, telephone and cellular phone companies, and post offices. • Stores may close or have limited supplies. The planning checklists can help you

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determine what items you should stockpile to help you manage without these services • Transportation services may be disrupted and you may not be able to rely on public transportation. Plan to take fewer trips and store essential supplies. • Public gatherings, such as volunteer meetings and worship services, may be canceled. Prepare contact lists including conference calls, telephone chains, and email distribution lists, to access or distribute necessary information. • Consider that the ability to travel, even by car if there are fuel shortages, may be limited. • You should also talk to your family about where family members and loved ones will go in an emergency and how they will receive care, in case you cannot communicate with them. • In a pandemic, there may be widespread illness that could result in the shut down of local ATMs and banks. Keep a small amount of cash or traveler's checks in small denominations for easy use.

Food and Water Supplies May Be Interrupted and Limited • Food and water supplies may be interrupted so temporary shortages could occur. You may also be unable to get to a store. To prepare for this possibility you should store at least one to two weeks supply of non-perishable food and fresh water for emergencies.

Food • Store two weeks of nonperishable food. • Select foods that do not require refrigeration, preparation (including the use of water), or cooking. • Insure that formulas for infants and any child's or older person's special nutritional needs are a part of your planning.

Water • Store two weeks of water, 1 gallon of water per person per day. (2 quarts for drinking, 2 quarts for food preparation/sanitation), in clean plastic containers. Avoid using containers that will decompose or break, such as milk cartons or glass bottles.

Being Able to Work May Be Difficult or Impossible • Ask your employer how business will continue during a pandemic. • Discuss staggered shifts or working at home with your employer. Discuss tele- commuting possibilities and needs, accessing remote networks, and using port- able computers. • Discuss possible flexibility in leave policies. Discuss with your employer how much leave you can take to care for yourself or a family member • Plan for possible loss of income if you are unable to work or the company you work for temporarily closes.

Schools and Daycare Centers May Be Closed for an Extended Period of Time • Schools, and potentially public and private preschool, childcare, trade schools,

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and colleges and universities may be closed to limit the spread of flu in the community and to help prevent children from becoming sick. Other school-related activities and services could also be disrupted or cancelled including: clubs, sports/sporting events, music activities, and school meals. School closings would likely happen very early in a pandemic and could occur on short notice. • Talk to your teachers, administrators, and parent-teacher organizations about your school's pandemic plan, and offer your help. • Plan now for children staying at home for extended periods of time, as school closings may occur along with restrictions on public gatherings, such as at malls, movie theaters. • Plan home learning activities and exercises that your children can do at home. Have learning materials, such as books, school supplies, and educational computer activities and movies on hand. • Talk to teachers, administrators, and parent-teacher organizations about possible activities, lesson plans, and exercises that children can do at home if schools are closed. This could include continuing courses by TV or the internet. The economic and societal disruption of an influenza pandemic could be significant. • Plan entertainment and recreational activities that your children can do at Absenteeism across multiple sectors related to home. Have materials, such as read- personal illness, illness in family members, fear ing books, coloring books, and games, of contagion, or public health measures to limit on hand for your children to use. contact with others could threaten the functioning of critical infrastructure, the movement of Medical Care for People with Chronic goods and services, and operation of Illness Could be Disrupted institutions such as schools and universities. A • In a severe pandemic, hospitals and pandemic would thus have significant doctors' offices may be overwhelmed. implications for the economy, national security, • If you have a chronic disease, such as and the basic functioning of society. heart disease, high blood pressure, Implementation Plan for the National Strategy diabetes, asthma, or depression, you for Pandemic Influenza, 2006, page 1 should continue taking medication as prescribed by your doctor. • Make sure you have necessary medical supplies such as glucose and blood- pressure monitoring equipment. • Talk to your healthcare provider to ensure adequate access to your medications. • If you receive ongoing medical care such as dialysis, chemotherapy, or other therapies, talk with your health care provider about plans to continue care during a pandemic. (Source: A Guide for Families and Individuals, http://www.pandemicflu.gov/ plan/individual/familyguide.html)

According to the Implementation Plan for the National Strategy for Pandemic Influ- enza (2006, page 1), these and other disruptions have “signification implications for the economy, national security, and the basic functioning of society.” The Implementa- tion Plan also states the following: “The economic repercussions of a pandemic could be significant. The Congressional Budget Office has estimated that a pandemic on the scale of the 1918 outbreak could result in a loss of 5 percent of gross domestic product,

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or a loss of national income of about The Federal Government recommends that $600 billion. These effects will oc- government entities and the private sector plan cur through two main channels. A with the assumption that up to 40 percent of their pandemic will affect the economy staff may be absent for periods of about 2 weeks directly through illness and mortal- at the height of a pandemic wave with lower ity caused by the disease, and the levels of staff absent for a few weeks on either associated lost output. A pandemic side of the peak. These absences may be due to will also generate indirect costs, employees who: care for the ill; are under from actions taken to prevent and voluntary home quarantine due to an ill house- control the spread of the virus. Some of these actions will be taken hold member; care for children dismissed from by the government. Others will be school; feel safer at home; or are ill or taken by institutional leaders and incapacitated by the virus. employers, while still others will be Implementation Plan for the National Strategy for the Pandemic Influenza, 2006, page 13 result of uncoordinated individual responses to avoid infection. These latter reactions will reflect public perceptions and fears (Implementation Plan for the National Strategy for Pandemic Influenza, 2006, page 15-16).”

Additionally, the Implementation Plan for the National Strategy for Pandemic Influ- enza, provides the following information about the potential disruption and impact of pandemic influenza: • A pandemic will differ from most natural or manmade disasters in nearly every respect. Unlike events that are discretely bounded in space or time, a pandemic will spread across the globe over the course of months or over a year, possibly in waves, and will affect communities of all sizes and compositions. The impact of a severe pandemic may be more comparable to that of a widespread economic crisis than to a hurricane, earthquake, or act of terrorism. It may present as a particularly severe influenza season, or it may overwhelm the health and medical infrastructure of cities and have secondary and tertiary impacts on the stability of institutions and the economy. These consequences are impossible to predict before a pandemic emerges because the biological characteristics of the virus and the impact of our interventions cannot be known in advance. • A pandemic will present unique challenges to the coordination of the U.S. Gov- ernment response. First and foremost, the types of support that the Federal Government will provide to the Nation are of a different kind and character than those it traditionally provides to communities damaged by natural disasters. Second, although it may occur in discrete waves in any one locale, the national impact of a pandemic could last for many months. Finally, a pandemic is a sustained public health and medical emergency that will have sustained and profound consequences for the operation of critical infrastructure, the mobility of people and freight, and the global economy. Health and medical considerations will affect foreign policy, international trade and travel, domestic disease containment efforts, continuity of operations (COOP) within the Federal Govern- ment, and many other aspects of the Federal response.

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• Unlike many other catastrophic events, an influenza pandemic will not directly affect the physical infrastructure of an organization. While a pandemic will not damage power lines, banks, or computer networks, it will ultimately threaten all critical infrastructure by its impact on an organization’s human resources by removing essential personnel from the workplace for weeks or months. Employers should include considerations for protecting the health and safety of employees during a pandemic in their business continuity planning. (Source: Implementation Plan for the National Strategy for Pandemic Influ- enza, 2006, pages 27, 28, and 165)

More information about pandemic influenza and the potential impact of a pandemic is offered by the World Health Organization. Among the information included on the WHO’s website is the list below of entitled “Ten things you need to know about pandemic influenza,” dated October 14, 2005.

1. Pandemic influenza is different from avian influenza. Avian influenza refers to a large group of different influenza viruses that primarily affect birds. On rare occasions, these bird viruses can infect other species, including pigs and humans. The vast majority of avian influenza viruses do not infect humans. An influenza pandemic happens when a new subtype emerges that has not previously circulated in humans.

For this reason, avian H5N1 is a strain with pandemic potential, since it might ultimately adapt into a strain that is contagious among humans. Once this adaptation occurs, it will no longer be a bird virus--it will be a human influenza virus. Influenza pandemics are caused by new influenza viruses that have adapted to humans.

2. Influenza pandemics are recurring events. An influenza pandemic is a rare but recurrent event. Three pandemics occurred in the previous century: “Spanish influenza” in 1918, “Asian influenza” in 1957, and “Hong Kong influenza” in 1968. The 1918 pandemic killed an estimated 40–50 million people worldwide. That pandemic, which was exceptional, is considered one of the deadliest disease events in human history. Subsequent pandemics were much milder, with an estimated 2 million deaths in 1957 and 1 million deaths in 1968.

A pandemic occurs when a new influenza virus emerges and starts spreading as easily as normal influenza – by coughing and sneezing. Because the virus is new, the human immune system will have no pre-existing immunity. This makes it likely that people who contract pandemic influenza will experience more serious disease than that caused by normal influenza.

3. The world may be on the brink of another pandemic. Health experts have been monitoring a new and extremely severe influenza virus – the H5N1 strain – for almost eight years. The H5N1 strain first infected humans in Hong Kong in 1997, causing 18 cases, including six deaths. Since mid-2003, this virus has caused the largest and most severe outbreaks in poultry on record. In De- cember 2003, infections in people exposed to sick birds were identified.

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Since then, over 100 human cases have been laboratory confirmed in four Asian countries (Cambodia, Indonesia, Thailand, and Viet Nam), and more than half of these people have died. Most cases have occurred in previously healthy children and young adults. Fortunately, the virus does not jump easily from birds to humans or spread readily and sustainably among humans. Should H5N1 evolve to a form as contagious as normal influenza, a pandemic could begin.

4. All countries will be affected. Once a fully contagious virus emerges, its global spread is considered inevitable. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but cannot stop it. The pandemics of the previous century encircled the globe in 6 to 9 months, even when most international travel was by ship. Given the speed and volume of international air travel today, the virus could spread more rapidly, possibly reaching all continents in less than 3 months.

5. Widespread illness will occur. Because most people will have no immunity to the pandemic virus, infection and illness rates are expected to be higher than during seasonal epidemics of normal influenza. Current projections for the next pandemic estimate that a substantial percentage of the world’s population will require some form of medical care. Few countries have the staff, facilities, equipment, and hospital beds needed to cope with large numbers of people who suddenly fall ill.

6. Medical supplies will be inadequate. Supplies of vaccines and antiviral drugs – the two most important medical interventions for reducing illness and deaths during a pandemic – will be inadequate in all countries at the start of a pandemic and for many months thereafter. Inadequate supplies of vaccines are of particular concern, as vaccines are considered the first line of defense for protecting populations. On present trends, many developing countries will have no access to vaccines throughout the duration of a pandemic.

7. Large numbers of deaths will occur. Historically, the number of deaths during a pandemic has varied greatly. Death rates are largely determined by four factors: the number of people who become infected, the virulence of the virus, the underlying characteristics and vulnerability of affected populations, and the effectiveness of preventive measures. Accurate predic- tions of mortality cannot be made before the pandemic virus emerges and begins to spread. All estimates of the number of deaths are purely speculative.

WHO has used a relatively conservative estimate – from 2 million to 7.4 million deaths – because it provides a useful and plausible planning target. This estimate is based on the comparatively mild 1957 pandemic. Estimates based on a more virulent virus, closer to the one seen in 1918, have been made and are much higher. However, the 1918 pandemic was considered exceptional.

8. Economic and social disruption will be great. High rates of illness and worker absenteeism are expected, and these will contribute

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to social and economic disruption. Past pandemics have spread globally in two and sometimes three waves. Not all parts of the world or of a single country are expected to be severely affected at the same time. Social and economic disruptions could be temporary, but may be amplified in today’s closely interrelated and inter- dependent systems of trade and commerce. Social disruption may be greatest when rates of absenteeism impair essential services, such as power, transportation, and communications.

9. Every country must be prepared. WHO has issued a series of recommended strategic actions for responding to the influenza pandemic threat. The actions are designed to provide different layers of defense that reflect the complexity of the evolving situation. Recommended actions are different for the present phase of pandemic alert, the emergence of a pandemic virus, and the declaration of a pandemic and its subsequent international spread.

10. WHO will alert the world when Emergency hospital during influenza epidemic, Camp Funston, Kansas. the pandemic threat increases. Photo courtesy of the National Museum of Health and Medicine, Armed WHO works closely with ministries of Forces Institute of Pathology, Washington, D.C., NCP 1603 health and various public health organizations to support countries' surveillance of circulating influenza strains. A sensitive surveillance system that can detect emerging influenza strains is essential for the rapid detection of a pandemic virus. (Source: World Health Organization, “Ten things you need to know about pandemic influenza,” dated October 14, 2005. http://www.who.int/csr/disease/influenza/pandemic10things/en/index.html)

SUMMARY The characteristics and disruption that may be caused by a public health emergency such as pandemic influenza, may last much longer and be wider spread than a natural disaster or an act of terrorism. It is critical that local officials work with other jurisdictions, organizations, states, and the Federal government to prepare to respond to what could be a devastating event. It is important for behavioral health workers to understand the potential impacts to be prepared to not only help the individuals and communities affected, but also to help community leaders understand reactions and help people cope more effectively with them.

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RESOURCES

CDC http://www.cdc.gov

Pandemic Flu website www.pandemicflu.gov

Characteristics and challenges of a pandemic http://www.pandemicflu.gov/general/whatis.html

Individuals and Families Planning http://www.pandemicflu.gov/plan/tab3.html

Questions and Answers on the Executive Order Adding Potentially Pandemic Influ- enza Viruses to the List of Quarantinable Diseases http://www.cdc.gov/ncidod/dq/qa_influenza_amendment_to_eo_13295.htm

Implementation Plan for the National Strategy for Pandemic Influenza http://www.whitehouse.gov/homeland/nspi.pdf

Virginia Department of Health (VDH) draft Pandemic Influenza Plan http://www.vdh.virginia.gov/PandemicFlu/pdf/ DRAFT_Virginia_Pandemic_Influenza_Plan.pdf

World Health Organization www.who.int

“Ten things you need to know about pandemic influenza” http://www.who.int/csr/disease/influenza/pandemic10things/en/index.html

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Street car conductor in Seattle not allowing passengers aboard without a mask. 1918. Source: www.wikipedia.com, taken from http://www.archives.gov/exhibits/influenza-epidemic/

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INTRODUCTION This module discusses how people react to crisis. The Implementation Plan for the National Strategy for Pandemic Influenza tasks public health to train behavioral health staff to help people cope with the grief, stress, exhaustion, anger and fear during the emergency. The plan describes the potential reactions to a pandemic:

While most people are resilient and will need minimal psychological support to cope with catastrophic events such as an influenza pandemic, it is imperative that planning for behavioral health reactions be undertaken to support affected populations and possibly reduce the occurrence of long-term psychological distress. Such planning should involve efforts to recruit, credential, and mobilize mental health and substance abuse personnel (as part of personnel efforts discussed above), along with the development of materials on psychological self-care and related topics, including a plan for dissemination of such materials. (Source: White House, Homeland Security Council, 2006, page 111)

Many behavioral health responders across the nation have received training on responding to natural disasters. After the 9-11 terrorist attacks, there was a lot of attention given to psychological consequences of terrorism. Information is available on reactions to 9-11 and the Oklahoma City bombing. Far fewer behavioral health personnel have been trained to respond to the needs of people following public health emergencies, such as infectious disease, chemical emergencies, radiation emergencies, and other public health risks. This module attempts to adapt guidance for natural disasters and terrorist incidents to public health emergencies.

DIFFERENCES BETWEEN REACTIONS TO PUBLIC HEALTH EMERGENCIES AND OTHER TYPES OF DISASTERS Witnessing a Crisis The public can observe the devastation and destruction to the environment from natural disasters and terrorist bombings, such as the Oklahoma City bombing or the attacks of September 11, 2001. The media brings graphic illustrations of the event into homes via television and print media. In contrast, public health emergencies, such as infectious disease, bioterrorism, chemical emergencies, and radiation emergencies are silent killers that do not leave a visible trail of destruction. The public’s reaction will be based on their perception of their personal risk to the emergency rather than on physical destruction. The media may portray the grief, disruption to services, and long lines at medical facilities and vaccination sites. These images may result in increased levels of anxiety and fear among the general population.

Perception of Risk The perception of risk can greatly impact how the person reacts to a crisis or traumatic event. the current events. By October 2002, The Community Resilience Project of

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Northern Virginia had been responding to 9-11 for over a year and demand for services was beginning to decline when the sniper attacks in shopping areas and gas stations resulted in a new surge in demand for services. People receiving individual services reported being anxious, fearful, and hypervigiliant during this time. A recurring theme was people were afraid to leave their homes and maintain normal daily routines. The new perception of risk that anyone could be targeted going about their daily routines generated the surge in demand for behavioral health services. The perception of risk can have a substantial impact on demand for behavioral services following public health emergencies. More information about the perception of risk, from the CDC’s CD-ROM on Crisis and Risk Emergency Communication, is below.

■ Voluntary versus involuntary: Voluntary risks are more readily accepted than imposed risks.

■ Personally controlled versus controlled by others: Risks controlled by the individual or community are more readily accepted than risks outside the individual’s or community’s control.

■ Familiar versus exotic: Familiar risks are more readily accepted than unfamiliar risks. Risks perceived as relatively unknown are perceived to be greater than risks that are well understood.

■ Natural origin versus manmade: Risks generated by nature are better tolerated than risks generated by man or institution. Risks caused by human action are less well tolerated than risks generated by nature.

■ Reversible versus permanent: Reversible risk is better tolerated than risk perceived to be irreversible.

■ Statistical versus anecdotal: Statistical risks for populations are better tolerated than risks represented by individuals. An anecdote presented to a person or community, i.e., “one in a million,” can be more damaging than a statistical risk of one in 10,000 presented as a number.

■ Endemic versus epidemic (catastrophic): Illnesses, injuries, and deaths spread over time at a predictable rate are better tolerated than illnesses, injuries, and deaths grouped by time and location (e.g., U.S. car crash deaths versus airplane crashes).

■ Fairly distributed versus unfairly distributed: Risks that do not single out a group, population, or individual are better tolerated than risks that are perceived to be targeted.

■ Generated by trusted institution versus mistrusted institution: Risks generated by a trusted institution are better tolerated than risks that are generated by a mistrusted institution. Risks generated by a mistrusted institution will be perceived as greater than risks generated by a trusted institution.

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■ Adults versus children: Risks that affect adults are better tolerated than risks that affect children.

■ Understood benefit versus questionable benefit: Risks with well- understood potential benefit and the reduction of well-understood harm are better tolerated than risks with little or no perceived benefit or reduction of harm. (Source: CDC, Crisis and Emergency Risk Communication CDCynergy, 2003, pages 17-18)

High Risk Exposure Public health emergencies have the potential for mass casualty numbers that far exceed natural disasters and terrorist bombings. The 1918 pandemic influenza killed 675,000 Americans, which is ten times the number of American casualties during World War I (http://virus.stanford.edu/uda/). Research and experience have found that exposure to mass casualties is a high risk factor for traumatic responses.

The National Center for Post Traumatic Stress Disorder’s (NCPTSD) review of disaster research found a 4-5% prevalence rate of PTSD following natural disasters. The percentage of the population that will have longer term problems or develop PTSD is dependent on the severity of the exposure to the traumatic incident. NCPTSD identifies the following types of high risk exposure types: • Exposure to mass destruction or death • Toxic contamination • Sudden violent death of a love one • Loss of home or community

(Source: NCPTSD, Effects of Traumatic Stress in a Disaster Situation in www.ncptsd.va.gov/facts/disasters/fs_effects_disasters.html

Crisis Reactions A public health emergency has the potential of impacting entire communities, regions, or the country. Behavioral health workers can assist community leaders and officials to understand the emotional reactions. A leader in the area of risk communication is Dr. Peter Sandman. His following article on the reactions to crisis describes the range of reactions to crises:

Public Reactions and Teachable Moments Peter M. Sandman Ph.D.

The public can react to crises in a wide variety of ways, but let me start with the least common public reaction to a crisis: panic. Panics are truly horrific when they happen — but they don't happen often, especially in the West and in the absence of intoxicating substances.

In the stairwells of the World Trade Center on September 11, 2001, survivors tell us, many people felt panicky, but their behavior was calm, orderly, helpful to others,

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sometimes even heroic. The panic attacks came later, when the crisis and the need for urgent action were over.

The impression that people are panicking and the prediction that they are likely to panic aren’t just mistakes, they’re dangerous mistakes. The impulse to “avert” panic too often leads authorities (and sometimes even journalists) to sound over- reassuring, withholding or shrugging off information they consider too alarming for the public to tolerate. Paradoxically, this may actually increase the probability of panic, as people come to feel that those in charge are “handling” and misleading them instead of leveling with them.

Denial and Apathy While panic is rare, another extreme reaction, denial, is fairly common. Denial, in fact, is why panic is rare; people at risk of panicking usually trip a mental circuit- breaker and go into denial instead. The dangerous thing about denial is that people in denial often do not take precautions in a crisis (or the run-up to a crisis), and this leads to more harm to themselves and others.

Apathetic people, of course, also fail to take precautions. In communication terms, the problem with denial is that it looks a lot like apathy. The difference is that apathy responds well to scary warnings — but that’s a devastatingly wrong prescription for denial, since it only forces us deeper into denial. Nor will over-reassurance work for denial; it colludes with the denial and thus deepens it.

The strongest antidote to denial is, paradoxically, the legitimization of fear. If it’s okay to be afraid, then I don’t have to deny my fear and can find ways to tolerate it instead.

Crisis managers often find even modest levels of public fear intolerable, which may be why they interpret the fear as panic. The public, on the other hand, can usually tolerate its own fear fairly well, especially if there are things we can do to protect ourselves (as psychiatrists and soldiers have long recognized, action binds anxiety). We’re hard-wired to respond fearfully to new dangers; that response is more conducive to survival than fearlessness would be. In fact, it’s arguable that we tend to recover rather too easily from fear. We quickly get used to the New Normal, relaxing our vigilance and our sense of shared urgency.

Finally, note that when people become suddenly afraid of X, they typically become less afraid of Y and Z, and less vulnerable to free-floating anxiety. For the most part, each individual is as anxiety-prone and fear-prone as he or she is wired to be. We allocate our fear. During a crisis, we are temporarily more afraid — we draw on a reservoir of untapped fearfulness. But very quickly we revert to our normal level of fearfulness — but with more of our normal fear attached to the new risk, and less of it available for other risks.

What level of public fear should be the goal of crisis managers? Panic, denial, and apathy are all undesirable extremes. So is terror; that’s the terrorists’ goal. But if

Module 6 116 terror is too strong a response, mere interest or concern is too weak. In a crisis, we want people to put their ordinary concerns aside, to be vigilant, to take precautions, to tolerate inconveniences. Fear isn’t the problem in a crisis. It is part of the solution.

Empathy and Its Siblings But of course fear isn’t the only emotional response to crisis. Just as important is the empathy/misery/depression complex of emotions. One of the principal reactions to September 11 was and still is a sense of shared misery. Most people expect to survive whatever the terrorists throw at us. But we expect to have to watch a succession of terrorist attacks on CNN. Whether or not life got scarier after 9/11, it cer- tainly got more miserable. To a lesser but significant extent, all calamities provoke misery.

It is important to distinguish empathic over-reactions — misery, even depression — from fear and its relatives. For officials to tell a miserable person to calm down misses the point; we’re calm already. There is a prescription for misery, however: • Acknowledge and help us acknowledge that misery is part of what we’re feeling. • Affirm that in a situation like this misery is appropriate to feel. • Let us know you feel it too. • Expect us (and yourself) to bear it, and in time to get past it. • Suggest empathic actions, ways we can help others. (One important corollary: Planning to make suitable use of volunteers is a crucial aspect of emergency preparedness.)

Anger, Hurt, and Guilt Anger is also an appropriate reaction to crisis, especially to terrorism. It is functional; it fuels resolve, vigilance, and precaution-taking. Of course it can also fuel scapegoating and harassment. Not all angry behaviors are useful, though the anger itself is. But when anger escalates into rage or flips into denial, it is no longer functional. Legitimizing the anger is one important way to keep this from happening.

Hurt is often underrated as a response to crisis. I’m talking about injured self- esteem: “Why did this happen to me?”

Once again terrorism crises are an extremely vivid example. After 9/11, virtually everyone was asking the bewildered question, “Why do they hate us so?” This is an important question to ask and try to answer. But not everyone was looking for answers; many just wanted to express their hurt feelings. We preserve our sense of goodness with overly simple answers: they’re evil; they envy our good life; they hate our freedoms. Hurt, too, can flip into denial; it’s hard to hold onto the idea that people actually hate you so much they want to kill you.

Guilt also plays an important role — caretaker guilt (“I feel powerless to protect my family, my community, my constituents”); survivor guilt (which results largely from projected relief: “I’m okay and they’re not”), and above all guilt at continuing to be preoccupied with our own mundane concerns.

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A Minnesota County Commissioner who is also a florist told me about all his wed- ding customers in the days and weeks after 9/11. Shipments of flowers (among other things) were disrupted, and his customers were worried about the flowers for their weddings. But they also felt guilty about worrying about such things. So he learned that he not only needed to reassure them that they’d have their flowers; he had to reassure them that we all need beauty right now, that their floral worries were not wrong or selfish.

The Value of “Over-Reacting” Fear, misery, anger, hurt, and guilt are all normal responses to crisis (for crisis managers as well as the public!). But we bear them and we get beyond them — perhaps not immediately, perhaps not easily, but we do it. Resilience is also a normal response to a crisis. Call it post-traumatic growth.

Strong emotional reactions are especially likely, and especially important, at the start of a crisis. This is particularly true of fear; the other emotions tend to come later. Many crises start small or distant. They may stay small or distant, or die out altogether — or they may get bigger and closer. Like a hurricane or a forest fire, they capture our attention before we are actually in danger.

That’s good; it’s a survival trait to worry about possible crises before they engulf you. One way people tend to worry about possible crises is to imagine that they are already crises. Thus, people may be “over-reacting” to what is currently happening to them as a way of getting ready for what may soon happen to them. This is especially appropriate for the sorts of crises that tend to grow quickly and without much warning. Infectious diseases, for example, can suddenly make the transition from a small localized problem to a serious epidemic, even a pandemic.

Terrorist attacks are like infectious diseases in this way, especially if you consider that terrorists may begin with a pilot project. One of the main reasons many people over-reacted to the 2001 anthrax attacks was in anticipation of more serious bioterrorist attacks to come. (People overreacted, but notice that they didn’t panic.) Most experts similarly expect another and much tougher bioterrorism challenge sooner or later. Reassurances about the low risk of the 2001 attacks very seldom acknowledged this, and so they sounded hollow.

The Adjustment Reaction When someone first learns about a new serious risk, in other words, the natural and healthy and useful reaction is, in a sense, an over-reaction:

• You pause and stop what you’re doing. In particular, you stop doing the things that might have suddenly become dangerous (spending time in tall buildings, for example) while you wait to see what’s going to happen. • You become hyper-vigilant — watching CNN for hours, checking Google News periodically, even scrutinizing strange-looking people in nearby cars and restau- rant booths. • You personalize the risk — treating a risk that is already hurting others and may

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be coming your way as if it were actually here already. • You take precautions that are perhaps unnecessary, or at least unnecessary so far. You decide to go out for Mexican food instead of Chinese food (because you’re worried about SARS) — or Chinese food instead of Mexican food (because you’re worried about hepatitis) — or either one instead of a hamburger (because you’re worried about mad cow disease).

These responses are what psychiatrists call an “adjustment reaction,” a short-term phenomenon as you get used to the New Normal. They are functional psychologically, an emotional rehearsal that gets you ready to cope if you have to. But they’re a logistical rehearsal too. People who have gone through this adjustment reaction cope better with an actual crisis and recover better when the crisis (or the threat of crisis) is past.

From a risk communication perspective, this adjustment reaction period is the teachable moment. Officials should encourage people’s efforts to come to grips with the potential crisis, their struggle to figure out how to feel and how to act. They should guide the adjustment reaction toward effective and pro-social behaviors. They shouldn’t give in to their temptation to disparage or ridicule it.

Peter M. Sandman, Ph.D., is a risk communication consultant based in Princeton, NJ. This column is based on his essay in a soon-to-be-published manual for journalists entitled “Terrorism and Other Public Health Emergencies” (U.S. Depart- ment of Health and Human Services, 2005). Jody Lanard, M.D., Dr. Sandman’s wife and colleague, collaborated in the development of many of the ideas in this article. For more information on crisis communication and public reactions to crisis situations, see http://www.psandman.com, especially http:// www.psandman.com/articles/beyond.pdf. (Source: Peter Sandman, www.psandman.com, published in Homeland Protection Professional, May 2005, vol. 4, no. 4, pp.14–16, Posted: 22 August 2005)

EMOTIONAL RESPONSE TO A CRISIS The following guidance developed through a joint Center for Disease Control (CDC) and U.S. Department of Health and Human Services (DHHS) initiative describes how leaders can respond to the crisis reactions and promote cooperation and support from the public:

During a disaster, what are people feeling inside? People are feeling a lot of different emotions. Each person may or may not feel any or all of a range of emotions. However, patterns do emerge in a crisis and a leader needs to expect these and understand that is why communicating in a crisis is different.

There are a number of psychological barriers that could interfere with the cooperation and response from the public. Many of them can be mitigated through the work of a leader with an empathetic and honest communication style.

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Fear, Anxiety, Confusion and Dread In a crisis, you can expect people in your community are feeling fear, anxiety, confused and, possibly, dread. Your job as a leader is not to make these feelings go away. If that’s the goal, failure is a certainty. Instead, these are the emotions that you should acknowledge in a statement of empathy. “We’ve never faced anything like this before in our community and it can be frightening.”

Hopelessness and helplessness Looking for a communication goal in a crisis? Here’s the number one objective. If the community, its families, or individuals let their feelings of fear, anxiety, confusion and dread grow unchecked during a crisis, psychologists can predict they will begin to feel hopeless or helpless. What leader needs a community of hopeless and helpless victims?

So, a reasonable amount of fear is OK. Instead of striving to “stop the panic” and eliminate the fears, help the community manage their fears and set them on a course of action. Action helps overcome feelings of hopelessness and helplessness.

Give people things to do. People want things to do. As much as possible, give them relevant things to do: things that are constructive and relate to the crisis they’re facing. Anxiety is reduced by action and a restored sense of control.

The actions may be symbolic (e.g., put up the flag), or preparatory (e.g., donate blood or create a family check-in plan). Some actions need to be put into context. Be careful about telling people things they should do without telling them when to do it. Phrase these preparatory actions in an “if—then” format. For example, “Go buy duct tape and plastic sheeting to have on hand, and if (fill in the blank) occurs, then seal up one interior space in your house and shelter in place.”

The public must feel empowered and in control of at least some parts of their lives if you want to reduce fear and victimization. Plan ahead the things you can ask people to do, even if it’s as simple as “checking on an elderly neighbor.”

What about panic? Contrary to what one may see in the movies, people seldom act completely irration- ally or panic during a crisis. We do know that people have run into burning buildings, have refused to get out of a car stuck on the tracks with a train speeding close, and have gone into shock and become paralyzed to the point of helplessness. The overwhelming majority of people can and do act reasonably during an emergency. How people absorb or act on information they receive during an emergency may be different from non-emergency situations. Research provides some clues about the receiver of information during an emergency. Research has shown that in a dire emergency, people or groups may exaggerate their responses as they revert to more rudimentary or instinctual “ flight or fight” reasoning, caused in part by the increase of adrenaline and cortisol in the blood system.

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In other words, that primitive part of our brains that we can credit for the survival of the human species kicks in. One can not predict whether someone will choose fight or flight. However, everyone will fall at some point on the continuum. “Fighters” may resist taking actions to keep them safe. “Fleers” may overreact and take additional steps to make them extra safe. Those extremes are what most of us see reflected back in the media. However, the overwhelming majority of people do not engage in extreme behavior. It just feels like they do when you’re the one responsible for getting a recommended response from the community.

During the 2001 anthrax incident, media reported local shortages of the antibiotic known as “cipro” because people began to seek out prescriptions anticipating the threat of anthrax. Question. If I want a prescription of cipro in my back pocket even though I live on the other side of the country, is that a panic behavior? No, it’s my survival instinct kicking into overdrive. If I hear my community leader saying “don’t panic,” I think that doesn’t apply to me. While I’m chasing down a cipro prescription I think I’m rationally taking steps to ensure my survival, and someone else must be panicking. If you describe individual survival behaviors as “panic,” you’ve lost the very people you want to talk to. Acknowledge their desire to take steps and redirect them to an action they can take and explain why the unwanted behavior is not good for them or for the community. You can call on people’s sense of community to help them resist individual grabs for protection.

When people are swamping your emergency hotline with calls, they are not panicking. They want the information they believe they need and you have. As long as people are seeking information, they may be fearful but they are not acting helpless, nor are they panicking.

Physical and mental preparation will relieve anxiety despite the expectation of potential injury or death. An “action message” can provide people with the feeling that they can take steps to improve a situation and not become passive victims of the threat. Action messages should not be an afterthought. Reduce the level of extreme reactions by reaching out early with a message of empathy and action.

Uncertainty Have you ever had to wait over the weekend for the results of a life or death medical test? The not knowing quickly seems worse than dealing with a bad result. People hate uncertainty. We all spend a great deal of our time in life working to reduce uncertainty. The uncertainty that is inherent in most crises, especially early in the event, will challenge even the greatest communicator. Early in a crisis, typically there are more questions than answers. The full magnitude of the problem is unknown. Perhaps the cause of the disaster is unknown. Even, what people can do to protect themselves may be unclear.

A danger, early in a crisis, especially if you’re responsible for fixing the problem, is to promise an outcome outside your control. Never utter a promise, no matter how heartfelt, unless it’s in your absolute power to deliver. We can hope for certain out-

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comes, but most we can’t promise. Instead of offering a “knee jerk” promise, “we’re going to catch the SOBs who did this,” promise “we’re going to throw everything we have at catching the bad guys, or stopping the spread of disease, or preventing further flood damage.”

People can manage the anxiety of the uncertainty if you share with them the process you are using to get the answers. “I can’t tell you today what’s causing people in our town to die so suddenly, but I can tell you what we’re doing to find out. Here’s the first step . . .”

Remember, in a crisis, people believe any information is empowering. Tell them what you know and most important tell them what you don’t know and the process you’re using to try and get some answers. Mayor Giuliani cautioned, “Promise only when you’re positive. This rule sounds so obvious that I wouldn’t mention it unless I saw leaders break it on a regular basis.” (Giuliani, 2002, p. 165) (Source: Center for Disease Control and the U.S. Department of Health and Hu- man Services. Crisis & Emergency Risk Communication: By Leaders for Leaders. Pages 13-15.)

COMMON REACTIONS Even though each public health emergency is unique, there are common thoughts, feelings and behaviors experienced by people exposed to a traumatic event: • Concern for basic survival • Grief over loss of loved ones and loss of valued and meaningful possessions • Fear and anxiety about personal safety and the physical safety of loved ones • Sleep disturbances, often including nightmares and imagery from disaster • Concerns about relocation and related isolation or crowded living conditions • Need to talk about events and feelings associated with the disaster, often repeatedly • Need to feel one is a part of the community and its disaster recovery (Source: DeWolfe, D.J. Training Manual for Mental Health and Human Services Workers in Major Disasters, Rockville, MD: 2000, page 17.)

Behavioral health can serve as a bridge between the individuals and the community. Behavioral health services can provide the opportunity for people come together as a group to share their thoughts, feelings, and experiences and help one another recover from the trauma.

Reactions to Trauma and Suggestions for Intervention Most people experience common reactions to trauma. Behavioral health responders can assist the public in understanding that people have a wide range of experiences and most people recovering from the trauma will require little or no intervention.

The following charts describe common behavioral, physical and emotional reactions to trauma and intervention options:

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Age Behavioral Physical Emotional Intervention Options

Give verbal reassur- Clinging to parents 1 to 5 Loss of appetite Anxiety ance and physical or familiar adults comfort Helplessness and Clarify misconcep- Stomach aches Generalized fear passive behavior tions repeatedly

Resumption of bed Provide comforting wetting or thumb Nausea Irritability bedtime routines sucking Sleep problems, Help with labels for Fear of the dark Angry outbursts nightmares emotions Avoidance of sleep- Avoid unnecessary Speech difficulties Sadness ing alone separations Permit child to sleep Increased crying Tics Withdrawal in parents' room temporarily Demystify reminders

Encourage expression regarding losses (deaths, pets, toys) Monitor media expo-

sure

Encourage expression through play activities

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Age Behavioral Physical Emotional Intervention Options

Give additional Decline in school 6 to 11 Change in appetite Fear of feelings attention and performance consideration Relax expectations of Withdrawal from performance at home School avoidance Headaches friends, familiar ac- and at school tivities temporarily Set gentle but firm Aggressive behavior Reminders triggering Stomach aches limits for acting out at home or school fears behavior Provide structured but undemanding Hyperactive or silly Sleep disturbances, Angry outbursts home chores and behavior nightmares rehabilitation activities

Encourage verbal Whining, clinging, Preoccupation with and play expression acting like a younger Somatic complaints crime, criminals, of thoughts and child safety, and death feelings

Increased competi- Listen to child's tion with younger Self-blame repeated retelling of siblings for parents' traumatic event attention

Clarify child's Traumatic play and Guilt distortions and re-enactments misconceptions Identify and assist

with reminders

Develop school program for peer support, expressive activities, education

on trauma and crime, preparedness planning, identifying at-risk children

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Age Behavioral Physical Emotional Intervention Options

Loss of interest in Give additional Decline in academic 12 to 18 Appetite changes peer social activities, attention and performance hobbies, recreation consideration

Relax expectations of Rebellion at home or Sadness or performance at home Headaches school depression and at school temporarily

Encourage discus- Anxiety and Decline in previous Gastrointestinal sion of experience of fearfulness about responsible behavior problems trauma with peers, safety significant adults

Agitation or decrease Avoid insistence on Resistance to in energy level, Skin eruptions discussion of feelings authority apathy with parents

Feelings of Complaints of vague Address impulse to Delinquent behavior inadequacy and help- aches and pains recklessness lessness Guilt, self-blame, Link behavior and Risk-taking behavior Sleep disorders shame, and self- feelings to event consciousness Encourage physical Social withdrawal Desire for revenge activities

Encourage Abrupt shift in resumption of social

relationships activities, athletics, clubs, etc.

Encourage participa- Use of alcohol or tion in community

illegal drugs activities and school events

Develop school programs for peer support and debriefing at risk-student support groups, telephone hotlines, drop-in centers, and identification of at-risk teens

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Age Behavioral Physical Emotional Intervention Options

Shock, disorienta- Protect, direct, and Adults Sleep problems Nausea tion, and numbness connect

Avoidance of Ensure access to Headaches Depression, sadness reminders emergency services

Provide supportive Excessive activity listening and oppor- Fatigue, exhaustion Grief level tunity to talk about experience and losses

Provide frequent res- Protectiveness Gastrointestinal cue and recovery Irritability, anger toward loved ones distress updates and resources for questions

Assist with prioritiz- Crying easily Appetite change Anxiety, fear ing and problem solving

Assist family to Despair, hopeless- facilitate communi- Angry outbursts Somatic complaints ness cation and effective functioning

Provide information on traumatic stress Increased conflicts Worsening of chronic Guilt, self-doubt and coping, with family conditions children's reactions, and tips for families

Provide information on criminal justice Hypervigilance Mood swings procedures, roles of primary responder groups

Isolation, with- Provide crime victim drawal, shutting services down

Increased use of alco- Access and refer

hol or illegal drugs when indicated

Provide information

on referral resources

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Age Behavioral Physical Emotional Intervention Options

Provide strong and Older Withdrawal and Worsening of chronic Depression persistent verbal Adults isolation conditions reassurance Reluctance to leave Provide orienting Sleep disorders Despair about losses home information Ensure physical needs are addressed Mobility limitations Memory problems Apathy (water, food, warmth)

Use multiple assess- Relocation Confusion, disorien- ment methods as Somatic symptoms adjustment problems tation problems may be underreported

Increased suscepti- Assist with recon- bility to hypo and Suspicion necting with family hyperthermia and support systems

Physical and sensory Assist in obtaining limitations (sight, Agitation, anger medical and financial hearing, interfere assistance with recovery)

Encourage discussion of traumatic Fears of institution- experience, losses, alization and expression of emotion

Anxiety with unfa- Provide crime victim

miliar surroundings assistance

Embarrassment about receiving handouts

(Source: http://mentalhealth.samhsa.gov/publications/allpubs/SMA05-4025/ chapter5.asp#table1)

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Disasters can particularly be difficult for children who do not have the life experiences to understand what is happening to their world. FEMA offers the following guidance on assisting children.

Disasters can leave children feeling frightened, confused, and insecure. Whether a child has personally experienced trauma, has merely seen the event on television, or has heard it discussed by adults, it is important for parents and teachers to be informed and ready to help if reactions to stress begin to occur.

Children may respond to disaster by demonstrating fears, sadness, or behavioral problems. Younger children may return to earlier behavior patterns, such as bed- wetting, sleep problems, and separation anxiety. Older children may also display anger, aggression, school problems, or withdrawal. Some children who have only indirect contact with the disaster but witness it on television may develop distress.

Who is at Risk? For many children, reactions to disasters are brief and represent normal reactions to "abnormal events." A smaller number of children can be at risk for more endur- ing psychological distress as a function of three major risk factors:

• Direct exposure to the disaster, such as being evacuated, observing injuries or death of others, or experiencing injury along with fearing one’s life is in danger. • Loss/grief: This relates to the death or serious injury of family or friends. • On-going stress from the secondary effects of disaster, such as temporarily living elsewhere, loss of friends and social networks, loss of personal property, parental unemployment, and costs incurred during recovery to return the family to pre-disaster life and living conditions.

What Creates Vulnerabilities in Children? In most cases, depending on the risk factors above, distressing responses are temporary. In the absence of severe threat to life, injury, loss of loved ones, or problems such as loss of home, moves, etc., symptoms usually diminish over time. For those that were directly exposed to the disaster, reminders of the disaster such as high winds, smoke, cloudy skies, sirens, etc. may cause upsetting feelings to return. Having a prior history of some type of traumatic event or severe stress may contribute to these feelings.

The way children cope with disaster or emergencies is often tied to the way parents cope. They can detect adults’ fears and sadness. Parents and adults can make disasters less traumatic for children by taking steps to manage their own feelings and having plans for coping. Parents are almost always the best source of support for children in disasters. One way to establish a sense of control and to build confidence in children before a disaster is to engage and involve them in preparing a family disaster plan. After a disaster, children can contribute to a family recovery plan.

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A Child’s Reaction to Disaster by Age Below are common reactions in children after a disaster or traumatic event.

Birth through 2 years. When children are pre-verbal and experience a trauma, they do not have the words to describe the event or their feelings. However, they can retain memories of particular sights, sounds, or smells. Infants may react to trauma by being irritable, crying more than usual, or wanting to be held and cud- dled. The biggest influence on children of this age is how their parents cope. As children get older, their play may involve acting out elements of the traumatic event that occurred several years in the past and was seemingly forgotten.

Preschool - 3 through 6 years. Preschool children often feel helpless and powerless in the face of an overwhelming event. Because of their age and small size, they lack the ability to protect themselves or others. As a result, they feel intense fear and insecurity about being separated from caregivers. Preschoolers cannot grasp the concept of permanent loss. They can see consequences as being reversible or permanent. In the weeks following a traumatic event, preschoolers’ play activities may reenact the incident or the disaster over and over again.

School age - 7 through 10 years. The school-age child has the ability to understand the permanence of loss. Some children become intensely preoccupied with the details of a traumatic event and want to talk about it continually. This preoccupation can interfere with the child’s concentration at school and academic performance may decline. At school, children may hear inaccurate information from peers. They may display a wide range of reactions— sadness, generalized fear, or specific fears of the disaster happening again, guilt over action or inaction during the disaster, anger that the event was not pre- vented, or fantasies of playing rescuer.

Pre-adolescence to adolescence - 11 through 18 years. As children grow older, they develop a more sophisticated understanding of the disaster event. Their responses are more similar to adults. Teenagers may become involved in dangerous, risk-taking behaviors, such as reckless driving, or alcohol or drug use. Others can become fearful of leaving home and avoid previous levels of activities. Much of adolescence is focused on moving out into the world. After a trauma, the view of the world can seem more dangerous and unsafe. A teenager may feel overwhelmed by intense emotions and yet feel unable to discuss them with others.

Meeting the Child’s Emotional Needs Children’s reactions are influenced by the behavior, thoughts, and feelings of adults. Adults should encourage children and adolescents to share their thoughts and feelings about the incident. Clarify misunderstandings about risk and danger by listening to children’s concerns and answering questions. Maintain a sense of calm by validating children’s concerns and perceptions and by discussing concrete plans for safety.

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Listen to what the child is saying. If a young child is asking questions about the event, answer them simply without the elaboration needed for an older child or adult. Some children are comforted by knowing more or less information than others; decide what level of information your particular child needs. If a child has difficulty expressing feelings, allow the child to draw a picture or tell a story of what happened.

Try to understand what is causing anxieties and fears. Be aware that following a disaster, children are most afraid that: • The event will happen again. • Someone close to them will be killed or injured. • They will be left alone or separated from the family.

Monitor and Limit Your Family’s Exposure to the Media News coverage related to a disaster may elicit fear and confusion, and arouse anxiety in children. This is particularly true for large-scale disasters or a terrorist event where significant property damage and loss of life has occurred. Particularly for younger children, repeated images of an event may cause them to believe the event is happening over and over.

If parents allow children to watch television or use the Internet where images or news about the disaster are shown, parents should be with them to encourage communication and provide explanations. This may also include parent’s monitoring and appropriately limiting their own exposure to anxiety-provoking information.

Use Support Networks Parents help their children when they take steps to understand and manage their own feelings and ways of coping. They can do this by building and using social support systems of family, friends, community organizations and agencies, faith-based institutions, or other resources that work for that family. Parents can build their own unique social support systems so that in an emergency situation or when a disaster strikes, they can be supported and helped to manage their reactions. As a result, parents will be more available to their children and better able to support them. Parents are almost always the best source of support for children in difficult times. But to support their children, parents need to attend to their own needs and have a plan for their own support. (Source: FEMA, Helping Children Cope with Disaster (2006, http:// www.fema.gov/rebuild/recover/cope_child.shtm#2).

Preparing for disaster helps everyone in the family accept the fact that disasters do happen, and provides an opportunity to identify and collect the resources needed to meet basic needs after disaster. Preparation helps; when people feel prepared, they cope better and so do children.

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RISK FACTORS There are some people who are more susceptible to having a problematic stress response to a traumatic event. The following risk factors presented by Dr. Rony Berger of Natal Israel Trauma Center for Victims of Terror and War at a 9-11 training in Vir- ginia can be used to help identify individuals who may benefit from immediate outreach and intervention.

Personal Risk Factors Pre-Trauma • Past history of Post-Traumatic Stress Disorder • History of childhood abuse • Early attachment issues • Family history of trauma • Psychological difficulties • History of substance abuse • Female gender, younger age, low socioeconomic status • Lower intelligence

Personal Risk Factors During Trauma & 24 Hours Post • Degree and intensity of exposure • Dissociation • Intrusion and avoidance • Depression • Hyper-arousal • Negative self talk • Lack of immediate social support

Personal Risk Factors Post-Trauma • Lack of societal acknowledgement • Lack of ongoing social support • Stressful life events • Unproductive family patterns ( Source: Adapted from Rony Berger, Psy.D., Natal Israel Trauma Center for Vic- tims of Terror and War handout)

Reactions to a trauma can change over time. The dynamics of reactions over time are described below.

Dynamics of Reactions Over Time Post-event traumatic reactions may be: • Intense or mild • Immediate or delayed • Cumulative in intensity • Reactivated by • Subsequent traumatic experiences • Reminders of the event • Anniversaries • Area or object associated with the event (e.g., planes, building)

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Symptoms may also be activated by vicarious trauma, such as media exposure or contact with people involved in the terrorist event. (Source: Adapted from Rony Berger, Psy.D., Natal Israel Trauma Center for Vic- tims of Terror and War handout)

Group Risk Factors Behavioral health will need to determine potential vulnerabilities and other risk factors of groups within the community. Specific groups may be more vulnerable to or have greater exposure to the health risk. Community leaders and gatekeepers can assist to gain insight to the needs of a particular group with regard to the following factors: • Race/ethnicity • Refugee and immigrant status • Age • Gender • Religion • Attitudes • Lifestyles and customs • Interests • Values • Beliefs • Physical or mobility impairments • Psychiatric disability • Family frameworks • Income levels • Professions and unemployment rate • Language and dialects • Education and literacy levels (Source: Virginia, 2004, Helping to Heal: A Training Manual for Mental Health Response to Terrorism, page 67)

PROBLEMATIC STRESS RESPONSES The National Center for PTSD Fact Sheet Effects of Traumatic Stress in a Disaster Situation identified the following stress responses that may indicate a person will require assistance from a medical or behavioral health professional: • Severe dissociation (feeling as if the world is unreal, not feeling connected to one's own body, losing one's sense of identity or taking on a new identity, amne- sia) • Severe intrusive re-experiencing (flashbacks, terrifying screen memories or nightmares, repetitive automatic reenactment) • Extreme avoidance (agoraphobic-like social or vocational withdrawal, compul- sive avoidance) • Severe hyper-arousal (panic episodes, terrifying nightmares, difficulty controlling violent impulses, inability to concentrate) • Debilitating anxiety (ruminative worry, severe phobias, unshakeable obsessions, paralyzing nervousness, fear of losing control/going crazy) • Severe depression (lack of pleasure in life, feelings of worthlessness, self-blame, dependency, early wakenings)

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• Problematic substance use (abuse or dependency, self-medication) • Psychotic symptoms (delusions, hallucinations, bizarre thoughts or images) • Some people will be more affected by a traumatic event for a longer period of time than others, depending on the nature of the event and the nature of the individual who experienced the event. One of the most debilitating effects of traumatic stress is a condition known as Post-traumatic Stress Disorder (PTSD). The current trauma literature suggests that many factors are related to the increased or decreased risk for PTSD. The likelihood of developing PTSD and the severity and chronicity of symptoms experienced is a function of many variables, the most important being exposure to a traumatic event. It is therefore important to bear in mind that, even among vulnerable individuals, PTSD would not exist without exposure to a traumatic event (Source: National Center for PTSD Fact Sheet at www.ncptsd.va.gov/facts/ disasters/fs_effects_disaster.html).

Factors that have been found to aggravate stress reactions and increases the survivor risk of developing outcomes include: • Lack of emotional and social support • Presence of other stressors such as fatigue, cold, hunger, fear, uncertainty, loss, dislocation, and other stressful experiences • Difficulties at the scene • Lack of information about the nature and reasons for the event • Lack of, or interference with, self-determination and self-management • Treatment [given] in an authoritarian or impersonal manner • Lack of follow-up support in the weeks following the exposure (Source: Emergency Management Australia, 1999 from Disaster Mental Health Response Handbook, page 36, in Ibid)

CMHS presentations on CCP include the following other factors that contribute to or aggravate stress reactions: • Anxiety and vigilance • Anger, resentment, and conflict • Uncertainty about the future • Prolonged mourning of losses • Diminished problem-solving • Isolation and hopelessness • Health problems • Lifestyle changes (Source: Nelson, B., (2001) PowerPoint Presentation on the Crisis Counseling As- sistance and Training Program.)

Protective factors that may mitigate negative effects include: • Social support • Higher income and education • Successful mastery of past disasters and traumatic events • Limitation or reduction of exposure to any of the aggravating factors listed above

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• Provision of information about expectations and availability of recovery services • Care, concern and understanding on the part of the recovery services personnel • Provision of regular and appropriate information concerning the emergency and reasons for action (Source: Emergency Management Australia, 1999, Disaster Mental Health Re- sponse Handbook, page 36 in National Center for PTSD, Fact Sheet: Effects of Traumatic Stress in a Disaster Situation at http://www.ncptsd.va.gov/facts/ disasters/fs_effects_disaster.html)

DISASTER SURVIVOR RESILIENCY FACTORS Resiliency Literature on trauma and disaster reactions often focuses on the fear that is experienced during the warning and impact of the disaster, as well as immediately following a disaster. What is often overlooked in the literature is the courage and resiliency that is even more prevalent than the fear. Most people will take action to protect themselves, their families, and others. Even though Americans generally do not prepare for catastrophic events, the majority will follow directions given by emergency management, public health, and other local officials during an emergency. Virginians have demonstrated remarkable survival skills and resiliency regardless of the intensity or duration of the traumatic event. Behavioral health workers should assume that the stress reactions experienced by most people are short-term and that recovery will occur with or without assistance.

A recent World Health Organization article (Publication: Bulletin of the WHO; Type: Research Article ID:06-033019’ Article DOI: 10.247/BLT.06.033019) states that a post-Katrina survey found a 5.2% increase (11.3% after Katrina versus 6.1% before) in the prevalence of serious mental illness and a 10.2% increase in mild to moderate mental illness (19.9 % after Katrina versus 9.7% before).

Final reports for Virginia Crisis Counseling Programs for both natural disasters and terrorist events have not reported significant incidence of PTSD or other serious mental illnesses. Very few Virginians have been referred for services beyond crisis counseling after a natural disaster or after the 9-11 terrorist attack. The prevalence of problematic reactions following a public health emergency could surpass what has been previously experienced in Virginia. It is important that behavioral health responders are trained on common and problematic reactions, so appropriate referrals can be made for those in need of additional assistance.

The American Psychological Association in 2004 developed the following guidance on resiliency following a hurricane disaster. The article was written for a natural disaster, but the information is also appropriate for other types of emergencies and traumatic events. The article is provided here in its entirety as guidance on developing behavioral health responses that build on the individual’s strengths:

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Resilience: After the Hurricanes The devastation the hurricanes left behind can leave people with strong emotions and a strong sense of uncertainty.

Yet people generally adapt well over time to life-changing situations and stressful conditions. What enables them to do so? It involves resilience, an ongoing process that requires time and effort and engages people in taking a number of steps.

What Is Resilience? Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress -- such as family and relationship problems, serious health problems, or workplace and financial stressors. It means "bouncing back" from difficult experiences.

Research has shown that resilience is ordinary, not extraordinary. People commonly demonstrate resilience. Examples of resilience in the face of the hurricanes abound. One woman, looking over the wreckage of what used to be her home, told news crews that she was tough and that the only thing that mattered was the lives of her loved ones.

Being resilient does not mean that a person doesn't experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. In fact, the road to resilience is likely to involve consid- erable emotional distress.

Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts, and actions that can be learned and developed in anyone.

Resilience Factors & Strategies Factors in Resilience A combination of factors contributes to resilience. Many studies show that the primary factor in resilience is having caring and supportive relationships within and outside the family.

Relationships that create love and trust, provide role models, and offer encouragement and reassurance help bolster a person's resilience.

Several additional factors are associated with resilience, including: • The capacity to make realistic plans and take steps to carry them out • A positive view of yourself and confidence in your strengths and abilities • Skills in communication and problem solving • The capacity to manage strong feelings and impulses All of these are factors that people can develop in themselves.

Strategies For Building Resilience Developing resilience is a personal journey. People do not all react the same to traumatic and stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies.

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Some variation may reflect cultural differences. A person's culture might have an impact on how he or she communicates feelings and deals with adversity -- for example, whether and how a person connects with significant others, including extended family members and community resources. The hurricanes cut a wide enough swath that several different distinct cultures felt the impact.

The good news about resilience is that it can be built using approaches that make sense within each culture.

Some or many of the ways to build resilience that follow may be appropriate to consider in developing your personal strategy.

10 Ways to Build Resilience Make connections. Good relationships with close family members, friends, or others are important. Even for those separated from their families, connections can be built among new acquaintances. There are several tales, for instance, of people evacuating from New Orleans accompanied by – and emotionally attached to – fel- low evacuees whom they had just met during the flood. Accepting help and support from those who care about you and will listen to you strengthens resilience. Some people find that even though they themselves have suffered losses during Katrina and Rita, helping others makes them feel good about themselves.

Avoid seeing crises as insurmountable problems. You can't undo the waters or winds of the hurricanes, but you can change how you interpret the hurricanes. Try to see beyond the current crisis to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.

Accept that change is a part of living. Certain goals may no longer be attain- able as a result of the hurricanes. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter. Move toward your goals. Develop some realistic goals. Do something regularly - - even if it seems like a small accomplishment -- that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"

Take decisive actions. Act on adverse situations as much as you can. Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away. Although the hurricanes uprooted people from their normal routines, establish new routines as soon as you can, even if they may have to change again if you are moved.

Look for opportunities for self-discovery. People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vul-

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Nurture a positive view of yourself. Reframe how you think about yourself. If you were in the hurricanes, you are a survivor, not a victim of the hurricanes. Ac- knowledging your own strength and resourcefulness in dealing with difficult conditions can help you develop confidence in yourself.

Keep things in perspective. Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective.

Maintain a hopeful outlook. An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.

Take care of yourself. Pay attention to your own needs and feelings. Although you may not be up to your usual level of activity, try to get some exercise and try to find something to do that will relax you, whether it be telling a story to your child or meditating. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.

Additional ways of strengthening resilience may be helpful. For example, some people write about their deepest thoughts and feelings related to trauma or other stressful events in their life. Meditation and spiritual practices help some people build connections and restore hope.

The key is to identify ways that are likely to work well for you as part of your own personal strategy for fostering resilience.

Learning From Your Past Some Questions to Ask Yourself Focusing on past experiences and sources of personal strength can help you learn about what strategies for building resilience might work for you. By exploring answers to the following questions about yourself and your reactions to challenging life events, you may discover how you can respond effectively to difficult situations in your life.

Consider the following: • What kinds of events have been most stressful for me? • How have those events typically affected me? • Have I found it helpful to think of important people in my life when I am distressed? • To whom have I reached out for support in working through a traumatic or stressful experience?

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• What have I learned about myself and my interactions with others during difficult times? • Has it been helpful for me to assist someone else going through a similar experience? • Have I been able to overcome obstacles, and if so, how? • What has helped make me feel more hopeful about the future?

Staying Flexible Resilience involves maintaining flexibility and balance in your life as you deal with stressful circumstances and traumatic events. This happens in several ways, including: • Letting yourself experience strong emotions, and also realizing when you may need to avoid experiencing them at times in order to continue functioning • Stepping forward and taking action to deal with your problems and meet the demands of daily living, and also stepping back to rest and reenergize yourself • Spending time with loved ones to gain support and encouragement, and also nurturing yourself • Relying on others, and also relying on yourself

Places To Look For Help Getting help when you need it is crucial in building your resilience. Beyond caring family members and friends, people often find it helpful to turn to:

• Self-help and support groups. Such community groups can aid people struggling with hardships such as the death of a loved one. By sharing information, ideas, and emotions, group participants can assist one another and find comfort in knowing that they are not alone in experiencing difficulty.

• Books and other publications by people who have successfully managed adverse situations such as surviving cancer. These stories can motivate readers to find a strategy that might work for them personally.

• Online resources. Information on the web can be a helpful source of ideas, though the quality of information varies among sources.

• For many people, using their own resources and the kinds of help listed above may be sufficient for building resilience. At times, however, an individual might get stuck or have difficulty making progress on the road to resilience.

• A licensed mental health professional such as a psychologist can assist people in developing an appropriate strategy for moving forward. It is important to get professional help if you feel like you are unable to function or perform basic activities of daily living as a result of the hurricane or other traumatic or other stressful life experience.

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Different people tend to be comfortable with somewhat different styles of interaction. A person should feel at ease and have good rapport in working with a mental health professional or participating in a support group.”

Documents from apahelpcenter.org may be reprinted in their entirety with credit given to the American Psychological Association. Any exceptions to this, including requests to excerpt or paraphrase documents from apahelpcenter.org, must be presented in writing to [email protected] and will be considered on a case-by-case basis. Permission for exceptions will be given on a one-time-only basis and must be sought for each additional use of the document. (Source: APA, 2004 at http:// www.apahelpcenter.org/articles/article.php? id=113)

SUMMARY Behavioral health responders need to understand both how people are reacting to the traumatic event and what factors influence both resiliency and vulnerability to problematic stressors. The underlying assumption is most people will recover on their own without assistance. Psychoeducation about common reactions can help disaster survivors—whether they have survived a natural disaster, terrorist attack, or public health emergency—understand and cope with the stress reactions they experience. A smaller number of individuals will need assistance to recover from the trauma. Behavioral health responders can assist community leaders in understanding and responding to the reactions of the public. Additionally, community-wide outreach is necessary to identify those most vulnerable and in need of services and make referrals as needed.

RESOURCES

American Red Cross Publications and guidance on behavioral health response to disasters http://www.redcross.org/services/disaster/0,1082,0_319_,00.html

American Psychological Association Publications and guidance on behavioral health response to disasters http://www.apa.org/

Centers for Disease Control and Prevention Publications and guidance on health emergencies and disasters http://www.bt.cdc.gov/mentalhealth/

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Center for Mental Health Services Publications, handouts and guidance on disasters, terrorism and emergencies http://nmhicstore.samhsa.gov/cmhs/EmergencyServices/pubs.aspx http://mentalhealth.samhsa.gov/cmhs/EmergencyServices/progguide.asp

Commonwealth of Virginia Department of Mental Health, Mental Retarda- tion and Substance Abuse Services Helping to Heal: A Training Manual on Mental Health Response to Terrorism http://www.dmhmrsas.virginia.gov/CWD-default.htm

National Center for PTSD Research, publications and fact sheets on l behavioral health interventions for disasters and terrorism and other related topics www.ncptsd.va.gov

SAMHSA Disaster Technical Assistance Center Publications and information on disasters and emergencies http://mentalhealth.samhsa.gov/dtac/default.asp

World Health Organization Research, publications and guidance on health emergencies http://www.who.int/en/

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This historic photograph depicted a ceremony crowning a Virginia “health queen”. Note the sign to the left calling for 100% vaccination. The original image was scanned from a glass lantern slide donated by the Minnesota De- partment of Health, and is one of a historical collection of documents and photographs devoted to observances of Child Health Day in the United States. CDC/ Minnesota Department of Health, R.N. Barr Library; Librarians Melissa Rethlefsen and Marie Jones

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INTRODUCTION A great deal of attention has been given to the field of disaster behavioral health since the 9-11 terrorist attacks. While there are still gaps in the research about the effectiveness of early interventions, some research has been conducted on the effectiveness of intervention approaches and a range of services have been found to be appropriate. Be- havioral health experts and practitioners agree that there is not one best behavioral health intervention; the interventions must be tailored to the unique experiences and the needs of the impacted individuals and communities.

Psychological debriefing is a group intervention that has been used with a wide range of groups including first responders, survivors, and community groups. CMHS has advised that, based on current findings, psychological debriefing is not an eligible service under Federal funding for behavioral health services. Psychological debriefing is not included as an intervention in this manual.

The behavioral health providers from the CSB or other systems that are responding to a public health emergency may have a wide range of emergency and community services experience, and may already be familiar with much of the material presented here. What may be new is the context in which these services are provided, the population served, as well as the approach of outreaching to the community to relieve stress and anxiety related to invisible threats, such as infectious disease, exposure to radiation or biological weapons.

The information on specific interventions in this section has been adapted from Help- ing to Heal: A Training Manual on Mental Health Response to Terrorism (Virginia, 2004) and CMHS manuals and guidance, as well as extracted from pandemic influenza planning documents.

PHASES OF SUPPORT SERVICES During the interpandemic and pandemic alert periods, the CSBs will be coordinating with public health officials, first responders, businesses, corporations, and other private sector interests to develop resources and train behavioral health professionals in disaster response strategies and interventions. During the Pandemic Period and Post Pandemic period, the CSB will be providing a range of services that are described in this module. The Health and Human Services (HHS) Pandemic Influenza Plan (2005) includes the Checklist of Workforce Support Services/Resources that summarizes preparedness and response activities:

Interpandemic and Pandemic Alert Periods • Incorporate psychosocial support services into emergency preparedness planning for an influenza pandemic. • Coordinate with business, corporations and other private sector interests in planning for behavioral health response and consequences. • Develop plans to prepare and support emergency services responders (e.g. police, fire, hospital emergency department staff, mortuary workers) during and following deployment.

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• Prepare for a significant surge of individuals who fear they may be infected, but aren’t, who may present at emergency departments or other healthcare locations, or contact health information hotlines. • Develop a demographic picture of the community (e.g., ethnic, racial, and religious groups; most vulnerable; special needs; language minorities: and plan for how they might be reached in a disaster. • Identify rest and recuperation sites for responders. These sites can be stocked with health snacks and relaxation materials (e.g., music, relaxation tapes, movies), as well as pamphlets or notices about workforce support services. • Develop confidential telephone support lines to be staffed by behavioral health professionals. • Use behavioral health expertise to develop public health messages, train staff on the psychological impact of personal protective equipment (PPE) and conduct other relevant activities.

Identify and access existing resources • Work with community-based organizations and nongovernmental organizations to determine the types of psychological and social support services and training courses available in their jurisdictions. • Establish public-sector links with private mental health resources such as Red Cross and other national voluntary organizations active in disasters. • Develop a plan to manage offers of assistance and invited/uninvited volunteers. • Identify gaps, such as culturally and multilingual providers, that might affect disaster services.

Train behavioral health and related professionals in disaster response strategies • Train behavioral health staff in hospitals, clinics and related agencies in techniques to help people cope with grief, stress, exhaustion, anger and fear during an emergency. • Train non-behavioral health professionals (e.g., primary-care clinicians, safety and security personnel, community leaders, and staff of cultural- and faith- based organizations) in basic psychological support services. • Establish links to health and medical entities for purposes of assisting in screening potential victims for mental disorders and psychogenic symptomatology, functional impairment, substance abuse, etc.

Develop resource and materials • Prepare educational and training materials on psychosocial issues for distribution to workers during an influenza pandemic.

Pandemic Period During the first 4 weeks • Meet basic needs such as food, shelter, and clothing. • Provide basic psychological support (psychological first aid). • Provide needs assessments. • Monitor the recovery environment (conducting survelliance). • Provide outreach and information dissemination.

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• Provide technical assistance, consultation, and training. • Foster resilience, coping and recovery. • Provide triage. • Provide treatment. • Provide psychological and social support service for employees and their families. • Address stigmatization issues that might be associated with participation in such services. • Implement workforce resilience programs. • Work with communications experts to shape messages that reduce the psychological impact of the pandemic. • Provide medical, public health, and community partners with educational and training materials.

During subsequent weeks • Provide continued outreach, triage, and services. • Monitor workforce for signs of chronic or severe psychological distress. • Provide assistance in reintegration for workers who were deployed or isolated from work and family. (Source: HHS Pandemic Influenza Plan, 2005, S11-12, Appendix 2)

UNIQUE CHALLENGES Behavioral health may be called upon to assist with community initiatives to protect and support the public in response to unique challenges, such as evacuation, mass vaccination, quarantine, and mass fatalities that require the public to trust and follow the directions of community officials.

Evacuation A public health emergency may require individuals or communities to be moved away from the potential health danger. Local officials will plan and coordinate the evacuation procedures. Clear communication that is accessible to everyone is crucial to a successful evacuation. The following are examples of how behavioral health workers can support local officials and the community during an evacuation:

• Assist officials to develop risk communication messages that consider the psychological implications of the evacuation and the demographics of the community including cultural and language considerations • Deploy staff to provide behavioral health services at shelters or other sites evacuees are congregating • Distribute psychoeducation information on staying in a shelter, assessing the public health risk and taking appropriate actions, reactions to a traumatic event, coping strategies, self-care and other topics to the general population and emergency workers • Establish an emergency hotline

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Mass Vaccination In the event of a bio-terror attack, virus outbreak or epidemic, a mass immunization program may be launched. An important question for considerations is how willing is the public to participate in a mass vaccination? A survey conducted by the Center for the Advancement of Collaborative Strategies in Health of the New York Academy of Medi- cine revealed that following an outbreak of smallpox, 38% of the population would be afraid of catching smallpox from other people at a vaccination site. This same study also found that 48% of the population’s

Historical glimpse of Malaria eradication in the US in the 1940's and anxiety level can be reduced if officials gave 50's CDC them a choice of protective actions for a smallpox outbreak (Lasker RD. Redefining Readiness: Terrorism Planning Through the Eyes of the Public. New York, NY: The New York Academy of Medicine, 2004, http://www.cacsh.org/pdf/ RedefiningReadinessStudy.pdf). Behavioral health can assist officials to understand the importance of communicating the risk and benefits of mass vaccination to reduce fear and anxiety among the general population.

The following are examples of behavioral health services that can support a mass vaccination initiative: • Assist officials to develop risk communication messages that consider the psychological implications of mass vaccination • Deploy behavioral health workers to mass vaccination sites • Distribute information on psychological reactions, coping strategies, and self- care

Quarantine Isolation, quarantine, and other activity restrictions that separate exposed or potentially exposed people from the general public may be imposed on individuals, groups, or whole communities. Community leaders may promote social distancing or community containment to prevent transmission of a virus outbreak or epidemic. A study of the psychological effects on 129 people quarantined for exposure to severe acute respiratory syndrome (SARS) in Toronto, Canada observed symptoms of post-traumatic stress disorder (PTSD) in 28.9% and depression in 31.2% of the respondents, respectively. The prevalence of PTSD increased with the duration of the quarantine. The study also found PTSD and depressive symptoms were reported by people who were acquainted with or directly exposed to someone with SARS (Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, and Styra R. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis [serial on the Internet]. 2004 Jul. Available from: http://www.cdc.gov/ncidod/EID/vol10no7/03-0703.htm).

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The quarantine of children poses unique requirements and challenges. It is very difficult for parents and children to be separated, especially during a crisis:

There are two sets of people that are affected by quarantine when children are involved. Both the child victim and their parents must be dealt with. Parents may also be proxies for observation and reporting, which may affect dependability or ac- curacy of reporting.

Home quarantine will have different psychological effects than being isolated in a hospital. On the positive side, children will feel more secure in familiar environments rather than in an austere, clinical environment. On the other hand, the sense of being restricted and cut off from their outside life can also be as traumatic as isolation. Also, the fact that their parents have to monitor and enforce the situation, rather than some external party may also be traumatizing.

In high profile incidents, a large amount of law enforcement will be needed to secure a school if children are being quarantined in place. This has repercussions for logistical issues such as providing medication, food, and other special needs for children.

It is currently unclear how the psychological and public safety risk/benefit analysis would be measured in order to allow parents into a quarantine situation. While there may be legal and safety reasons to quarantine children in place away from parents, in practice, keeping parents away from their children may create a tense situation, and psychologically both parent and child may have less anxiety if kept together. (Source: Powell, M, Terrorism Research Center. Project Pediatric Preparedness Final Report Unique Requirements, Goals, Capabilities and Gaps in Pediatric Emergency Preparation and Response. Prepared for the Emergency Medical Ser- vices Authority. Funded by FEMA. pages 62-63)

Behavioral health services for children, parents, and caregivers during the quarantine include: • Conduct a needs assessment to determine the range of services required to support people quarantined and their family members, as well as, health workers, law enforcement, and others supporting the quarantine • Provide behavioral health interventions to individuals quarantined, family members, health workers, law enforcement, others supporting the quarantine and the general population • Distribute psychoeducation information on quarantine, assessing the health risk and taking appropriate actions, reactions to a traumatic event, coping strategies, self-care and other topics • Assist officials overseeing the quarantine to develop public messages that generate trust and are accessible to everyone in the community

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Mass Fatality The Commonwealth of Virginia, the State of Maryland, and the District of Columbia developed plans to establish National Capitol Region Family/Assistance Reunification Centers (FACs) in response to terrorist attack or significant emergencies. FACs require the coordination, cooperation, and participation of local, state, and federal agencies. A public health emergency with mass fatalities would require FACs or other similar operational capabilities to manage the needs of families. Areas of the Commonwealth of Virginia outside of the National Capitol Region would likely open FACs or similar facilities.

The role of behavioral health at FACs include: • Grief counseling • Crisis intervention • Referral/assessment

CSBs would be asked to deploy staff to the FAC(s). Behavioral health workers in the FAC would coordinate with Public Health, Spiritual Care, Disaster Mortuary Opera- tional Teams (DMORTs), Volunteer Agencies, Public Information and many other functional areas.

KEY PRINCIPLES FOR BEHAVIORAL HEALTH The United States has been providing behavioral health services following natural disasters for over 30 years. There are overarching behavioral health principles, which provide the foundation of the interventions offered today. There have been a number of versions of the “key principles” published over the years. The version developed by the Arlington County Community Resilience Project and included in the Helping to Heal: A Training on Mental Health Response to Terrorism (Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services, 2004) has been adapted for public health emergencies:

• Do no harm – First and foremost behavioral health workers must assess an individual’s needs with great sensitivity. Accepting and validating a person’s reactions in the moment is critical to avoid disruption of the natural healing process. When in doubt about the level of intervention, err on the side of caution. • Assume resilience – Human beings are very resilient. The goal of behavioral intervention is to support and empower people as they access the strengths and coping mechanisms that have given them strength and comfort in the past. For example, helping individuals connect with family or other existing support networks can help them cope with the effects of the trauma. • Everyone who experiences a public health emergency is affected by it. A public health emergency, such as pandemic influenza, will inevitably spread throughout the world. A public health emergency has far reaching implications. Outbreaks can be expected to occur simultaneously throughout much of the U.S., overwhelming both human and material resources. People may be di-

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rectly affected by the health risk or by losing a loved one. They may also be indi- rectly affected by media exposure, hearing someone’s story, reactivation of past trauma, or factors such as economic or social impact that are part of the ripple effect after a public health emergency. • Simple human presence is powerful and reassuring. Providing emotional safety by being quietly present can be valuable following exposure to trauma. Behavioral health services following a public health emergency are aimed at acknowledging and normalizing individual responses versus actively seeking out pathological reactions. Simply being present with people may initially seem insufficient or less important than traditional behavioral health therapy, yet this service can do much to minimize long-term traumatization. • Be culturally competent. Having knowledge and awareness of the diversity that exists within the community intended to be served is crucial. As a behavioral health worker it is important to educate oneself regarding each individual’s cultural history, norms, values, belief systems, language, traditions, and view of the trauma/grieving processes in order to provide competent services. In addition, behavioral health workers need to explore and understand their own background, biases, and value system. This is important to ensure that behavioral health workers are comfortable with different points of view and are able to provide nonjudgmental services. (Source: Helping to Heal: A Training on Mental Health Response to Terror- ism, 2004, pages 43-44)

Public health emergencies affect both individuals and communities. In some cases the effect can be positive and empowering as community members realize through awareness of health, hygiene and other measures they can effectively cope with the risk. However, public health emergencies can cause social disruption, which in turn can interfere with individual recovery. The acute phase of the emergency can be relatively prolonged (weeks to months) in comparison to other disasters. Healthcare workers and first responders may be at higher risk of exposure and illness than the general population, further straining the infrastructure. Widespread illness in the community could increase the likelihood of sudden and potentially significant worker absenteeism in organizations providing essential services, such as transportation, utili- ties, education, and critical public safety services.

• Facilitating the recovery of the community as a whole impacts the individual’s ability to heal. The public’s perception of risk will impact the demands on medical resources, compliance with quarantine, participation of the workforce, including health care workers and the stability of the infrastructure. Fear of exposure or caring for family members can result in reluctance to go to work, school, or other events. The individual’s anxiety will be reduced by the community taking actions to address the health risk and meet the challenges created by the emergency. • Respect individual differences in moving through traumatic reactions. Every individual has their own process of recovery that may be appropriate for them. Some people may not exhibit traumatic reactions initially while others may remain in a state of immobility or denial for a longer period of time.

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Accepting and respecting a person’s pace of progress is crucial. It is to be expected that at any point some people may reject services as a healthy response to their individual needs. In some cases, behavioral health reactions may not arise for months or years after an event. • Services are enhanced by a flexible approach, which includes ongoing assessment, evaluation, and revision. Each community has unique requirements, which can be discovered only through accurate assessment. In addition, as community recovery progresses, needs for services change. Creativ- ity, responsiveness, and flexibility are key elements to effective service delivery. • Developing a team approach is vital to effective functioning. People who make up the disaster behavioral health team bring a variety of perspectives and points of view that, as a whole, reflect the community they serve. This allows the team to better assess needs as the community moves through the process of recovery. In addition, people bring different talents to the response and recovery of the emergency. Members of a team can be mutually supportive in maintaining optimal functioning, motivation, and direction as well as addressing issues of vicarious trauma. • Behavioral health services must coordinate as part of a larger response and recovery team, which may include fire, police, rescue, and recovery agencies. Behavioral health has an important role to support the first responders and provide immediate services to victims when appropriate. The coordination of behavioral health response with other agencies in an emergency situation is essential. Efforts to organize these services need to be addressed in most communities. Coordinating behavioral health services with agencies involved in these processes is important to helping survivors cope. (Source: Ibid)

INTERVENTIONS AND SERVICES Immediate Goals of Services Even a brief contact with a behavioral health worker or reading information on how to protect oneself from the health risk and the normal reactions to a crisis can help the public to regain a sense of control and an acceptance of the impact of the public health event. A large scale incident, such as pandemic influenza, may create a demand for services far beyond the resources of the CSB. Training others and using paraprofessionals can make it possible to extend services throughout the community. The overarching goals for immediate response by behavioral health workers include: • Alleviate distress through supportive listening, providing comfort, and empathy • Facilitate effective problem-solving of immediate concerns • Recognize and address pre-existing psychiatric or other health conditions in the context of the demands of the current stressor • Provide psychological information regarding reactions and coping strategies • Assist other agencies and leaders to develop public health messages that consider the psychosocial aspects of the emergency. • Plan for a long response (more than one year) to certain types of public health emergencies (i.e. pandemic influenza). • Provide services to workers in the field and their families.

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• Conduct trainings on behavioral health, resilience, stress management issues, and coping skills for State and local agencies deploying staff to the field. (Adaptation of Ibid, page 45)

Long-Term Goals of Services Over time, the behavioral health workers will become integrated into community activities as part of the disaster recovery, and will work with individuals and groups in their homes, businesses, community, and other settings. The long-term goals of services: • Assist people to understand their current situation and reactions, and to help them review their options • Provide emotional support to individuals and the community throughout the recovery process • Outreach to the community with public education, and resource and referral information • Link individuals and groups with other individuals, groups, and support networks that may provide assistance • Encourage disaster and community organizations to integrate behavioral health strategies into their disaster services and plans • Refer people in need of longer term behavioral heath services to the appropriate agency or professional (Source: Ibid)

RANGE OF INTERVENTIONS/SERVICES A list of intervention approaches is provided in this module to help behavioral health providers understand the range of services that may be appropriate following a public health emergency (these are adapted from those used after a natural disaster). Decid- ing which approach is used will depend upon the timeframe, setting, and individual and group needs. The range of interventions and services include: • Psychological first aid • Crisis intervention • Informational briefings • Psychoeducation • Community outreach • Brief counseling interventions • Support groups • Behavioral health consultation • Support role during death notification

(The following guidance describes the appropriate range of services for use with adults, older adolescents, and older adults who have adequate cognitive abilities.)

Psychological First Aid Rapid assessment is conducted to identify the people who are most acutely distressed and in need of medical attention. Initially, triage decisions are based on ob-

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servable and apparent data. Those experiencing reactions like shaking, screaming, or complete disorientation may need to receive emergency medical attention. Medi- cal assessment and assistance is necessary for older adult survivors who are vulnerable because of health conditions and physical or cognitive limitations. Those who appear profoundly shut down, numb, dissociated, and disconnected may also require medical attention.

Psychological first aid involves three basic concepts: protect, direct, and connect. • Survivors and family members need to be protected from viewing additional traumatic stimuli of the public health event. In addition, they need to be protected from curious onlookers and the media. • When disoriented or in shock, survivors need to be directed to a safe and protected environment. A brief human connection with a disaster behavioral health worker can help to orient and calm. • Disaster behavioral health workers assist survivors by connecting them with loved ones and needed information and sources.

Psychological support involves: • Addressing immediate physical necessities • Comforting and consoling the survivor • Providing concrete information about what will happen next to increase a sense of control • Listening to and validating feelings • Linking the survivor to support systems • Normalizing stress reactions to trauma and sudden loss • Reinforcing positive coping strengths • Facilitating some telling of the “trauma story” as appropriate for the survivor • Supporting reality-based, practical tasks (Source: Ibid, page 45-46)

Crisis Intervention While sharing elements of psychological first aid, crisis intervention aims to empower survivors so that they may effectively address immediate challenges. Crisis intervention typically involves five components: 1. Promote safety and security 2. Invite the person to share their experience 3. Identify current priority needs, problems, and possible solutions 4. Assess functioning and coping 5. Provide reassurance, normalization, psychoeducation, and practical assistance

1. Promote safety and security. Survivors need to feel protected from threat and danger. When given simple choices, many come to feel empowered as they exercise some control over their situations – which is critical for engaging initial coping and internal organization. May I get you something to drink? Are you feeling comfortable/safe here?

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2. Invite the person to share their experience. For some disaster survivors, it is therapeutic to verbalize emotions, reactions, and experiences as an important step toward coping with the situation. If you want to talk about what happened, I would like to listen. How have you been reacting and feeling?

For those who are highly distressed, however, talking in much detail about their experience and expressing related emotions might be retraumatizing. People may not be ready to express their emotional reactions. Just being with someone can be a great comfort.

If the person is able, provide reassurance and comfort to them and move on with problem-solving. There are often practical matters that need to be addressed. For example, someone may need to notify relatives and friends of the loss of a loved one, fill out insurance forms, notify his or her employer that he or she will need to be on leave of absence for a period of time, or pay bills. Behavioral health workers can help the survivor begin to prioritize and problem-solve the many practical decisions that need to be made.

3. Identify current priority needs and problems and possible solutions. Selecting one solvable problem as most immediate and addressing it successfully can help to bring back a sense of control and capability. Identifying potential sources of support among friends, family, faith organizations, health care providers, or in the community may be helpful. Describe the problems/challenges that you are facing now. Who might be able to help you with this problem? What has helped you in the past work through a serious problem?

4. Assess functioning and coping. Through observation, asking questions, and an understanding of the survivor’s past and current problems/losses, develop an impression of the survivor’s ability to address challenges. Based on this assessment, consider making referrals, pointing out coping strengths, and encouraging the survivor to seek support. How are you doing? How do you feel about how you are coping with this? How have you coped with stressful life events in the past?

5. Provide reassurance, normalization, psychoeducation, and practical assistance. Reassurance and normalization of feelings and reactions occur throughout the intervention. It is extremely important that the survivor feel that the response they receive is personal. Pay close attention to his/her experience and style, and do not offer “canned” responses. Psychoeducation should address the particular reactions mentioned by the survivor, and provide additional information through a pamphlet or individualized information. The way you’re feeling is normal (Source: Ibid, pages 46-48)

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Informational Briefings Survivors will seek information about the location and well-being of their loved ones, levels of threat and danger, procedural information. Behavioral workers do not provide informational briefings but they may consult officials about the need to do so and offer to be present to provide support as needed. They may also encourage officials to make sure that cultural and ethnic groups have access to these briefings. And they may offer suggestions to officials about: • Appropriate language/terminology • Level of detail for sensitive information • Approaches for addressing intense emotional reactions • Language to use in conveying messages of compassion and condolence (Source: Ibid, page 48)

Psychoeducation Psychoeducation for survivors, health care providers, and providers of community services is a core component of behavioral health response. Information that is typically provided includes information about: • Post-trauma reactions, including “normal reactions to abnormal situations” • Grief and bereavement • Effective coping strategies • When to seek professional help

Material should be specifically oriented to the actual event and locale, and adapted for each group or population so that it’s age- and culturally-appropriate.

Educational presentations for parents and teachers to help them recognize reactions of children in various age groups and provide them with strategies to help the children cope may be offered through schools, faith organizations, and other community events. If schools are closed, mass media may be a better alternative for disseminating information. (Source: Ibid, pages 49-50)

Community Outreach Community outreach is an essential component of a comprehensive behavioral health response to public health emergencies. Most survivors do not see themselves as needing behavioral health services and will not seek out help. Outreach is used to locate individuals in need of assistance and provide services at events, activities, organizations, and locations where people naturally congregate. Outreach is by far one of the most challenging and rewarding services offered by behavioral health. It is an essential element of crisis counseling services that impacts the overall success of a project. The mobility of people following a public health emergency where the public is evacuated may make it difficult to track down current addresses and phone numbers of the community members. Outreach may be very different during a public health emergency if events are cancelled, schools and businesses are closed. People may not venture out to community events due to fear of contagion. Commu- nity outreach will need to adapt to the situation and develop techniques not used

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for other types of major incidents. Community outreach involves: • Initiating supportive and helpful contact at sites where people gather • Reaching out and making information available to the public through the media, the Intenet, and a 24-hour hotline • Participating in or conducting meetings for preexisting groups through faith communities, schools, employers, community centers, and other organizations. • Providing psychoeducational, resource, and referral information to health care and human service providers, police and fire personnel, and other local community workers (Source: Ibid, page 50)

It takes a special person to work as an outreach worker. He or she must be able to travel around impacted communities and reach out with emotional support and information to people under distress. The outreach worker not only seeks out the individuals in need of support, but also reaches out to the community as a whole. Out- reach is a greater challenge than it may initially appear to be. Community outreach requires: • Ability to initiate conversations with those who have not requested services • Good interpersonal skills • Ability to quickly establish rapport, trust, and credibility • Thinking on your feet • A sense of diplomacy • Knowledge and respect of values and practices of cultural groups impacted by the event (Source: Ibid, page 51)

Depending on the magnitude of the public health emergency, type of health risk, and the size of the geographic area to be served, making personal contact through door-to-door canvassing of impacted communities can be one of the most effective methods of reaching disaster victims as long as the health risk is not due to infectious disease. There are many challenges to conducting door-to- door outreach visits. If the outreach worker is not familiar with the neighborhood it can be difficult to locate a particular destination. If the public health emergency is the result of a natural disas- Richmond, VA September 6, 2004 -- Business owners and residents alike visit the Disaster Recovery Center to get assistance ter street signs and landmarks may have been de- with FEMA teleregistration, disaster unemployment, SBA loans, stroyed; roads may be closed or blocked; and ris- and many other services. FEMA Photo/Liz Roll ing waters, aftershocks, or other hazards may pose a continuing threat. Once the outreach worker reaches his or her destination, not everyone may be open to the support and services offered.

The longer the emergency lasts, the more new challenges may the outreach worker faces, such as, identifying the primary and secondary victims, where they are currently located, and developing strategies for reaching them. People may be quarantined or

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leave the area on their own temporarily or permanently. At times the outreach worker may feel like they are playing a game of “hide and seek.”

Behavioral health outreach workers are encouraged to initiate strategies that make it easy and comfortable for community members to tell their stories, as this can be an intervention itself or may open the door for the person to seek additional services. Pre- senting the public with the opportunity to tell their stories may be accomplished in the following ways: • Being present at workshops for people who are seeking information demonstrates an active interest in the reality of their situation. Individuals are more likely to accept this kind of help before they will talk about their personal feelings. When offering this level of help, the behavioral health worker will quickly discover that people readily begin talking about their experience. • If the public health risk involves a contagion, alternatives to public workshops include: • A project website that provides an opportunity for people to share their story anonymously and read others. • Telephone hotlines that provides an opportunity for people unable to leave their homes or uncomfortable with a face to face intervention to share their stories with a behavioral health worker.

Community outreach relies on innovation to identify and reach people in need of assistance. The challenges of outreach during a public health emergency may be very different than those faced after a natural disaster or act of terrorism. Innovation is critical, particularly if events are canceled, schools are closed, and places where people normally congregate are closed, or if people are afraid to have any contact with outsiders because they don’t want to get sick. Outreach workers have been able to reach survivors by targeting community gatekeepers, specific groups, peer listening networks, and community agencies and organizations.

Community partnerships can be established with organizations that have an inroad to target populations, such as older adults, people with disabilities, children, and many others. Special activities and events, such as fairs, displays at events, books chronicling the stories of survivors, surveys of small businesses, and family activity nights, can be used by outreach workers to reach the public. Depending on the type of public health emergency, safety may determine timing of community events. They may be used during recovery when the public is over the fear of exposure.

Community outreach efforts may include: Community memorial and commemorative events – A behavioral health worker may help with the planning of community memorial and commemorative events. It is critical that the role is that of a consultant rather than a director. Survivor and community ownership of the event enhances its meaning and significance. A behavioral health worker may: • Suggest strategies for including children or other special survivor groups • Alert planners to the potential for misunderstanding or alienating individuals or groups through the use of particular language or symbols

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• Attend these events and be available to provide psychological support as needed and requested

Usual community gatherings –Reinstating usual gatherings or events, such as community parades, school plays, or church fairs as soon as possible promotes hope and the sense that the community can overcome harm and recover. Decisions to cancel or postpone these events must be made carefully and based on safety, as they provide valuable opportunities for social support and healing. A behavioral health worker may: • Assist community leaders in determining whether to hold an event • Offer suggestions for ways to adapt the event so that it appropriately acknowledges the community tragedy • Symbolic gestures – Symbols can have profound significance for people who wish to communicate gratitude and good will, or who are searching to find meaning, courage, and hope. Simple gestures can become powerful conveyors of compassion and condolence. A behavioral health worker may: • Assist affected groups to develop symbols • Provide assistance with the logistics to carry out idea

Materials and activities targeted toward different populations – Members of different populations, including different age and racial/ethnic groups, exhibit unique reactions to tragic events. To tailor a behavioral health response to their backgrounds and needs, a behavioral health worker may: • Form a multi-cultural outreach team to distribute information in the community and make presentations • Develop brochures in multiple languages and distribute them in locations fre- quented by different groups, such as neighborhood gas stations, grocery stores, strip malls, libraries, schools, and other public areas • Conduct life skills workshops with topics on stress management and how to cope with reactivated fears from experiences in survivors’ native countries • Conduct cross-cultural dialogues that provide people from different backgrounds to share their disaster experiences • Provide life skills training for youth at recreation centers, family resource centers, and juvenile detention/post-detention facilities • Work with youth to write and produce plays or other creative activities based on their experiences and feelings (Source: Ibid, pages 51-52)

Behavioral health workers need to consider the type of the public health emergency and the magnitude of the impact in order to develop a flexible plan for community outreach. For example, public health emergencies that result in mass evacuation may require outreach to shelters and neighboring communities where disaster survivors have relocated.

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Brief Counseling Interventions The therapeutic goals of brief counseling interventions involve the following: • Stabilizing emotions and regulating distress • Confronting and working with the realities associated with the event • Expressing emotions during and since the event, including anger, anxiety, and fear • Understanding and managing post-trauma symptoms and grief reactions • Developing a sense of meaning regarding the trauma • Coming to acceptance that the event and resulting losses are part of one’s life story

The most therapeutic approaches recognize that the survivor’s capacity to confront painful realities and intense emotions develops gradually, therefore, the treatment process must move at a rate that is comfortable to the survivor.

Counseling may use a particular treatment approach or be multi-modal and incorporate a combination of different approaches. Treatments commonly used for post- traumatic stress and traumatic bereavement include: • Cognitive-behavioral therapy • Phase-oriented treatment • Bereavement counseling • Eye movement desensitization and reprocessing • Brief therapies • Psychopharmacology (medication is not an eligible cost under the CCP) (Source: Ibid, pages 54-55)

Support Groups Support groups are especially appropriate, because of the opportunity for social support through the validation and normalization of thoughts, emotions, and post- trauma symptoms. Telling one’s “trauma story” in the supportive presence of others can be powerfully helpful. In addition, group reinforcement for using stress management and problem-solving techniques may promote courage and creativity. Sharing information about service and financial resources and other types of assistance is another important function of support groups.

Groups may be offered for parents, children, members of a particular neighborhood or particularly affected occupational group, and for survivors who suffered a particular trauma or loss (e.g., bereaved parents).

Grief counseling is an important component of group services. Some victims may not be ready to participate in grief groups early on. It is recommended that groups be facilitated by an experienced behavioral health professional, ideally with a co- facilitator, and be time-limited with expectations defined at the outset.

Service delivery for groups is not limited to formal support and therapy group sessions. Innovative alternatives such as impromptu group sessions, talk groups, in-

Module 7 158 formational groups, and drop-in groups may be appropriate interventions. A common crisis counseling strategy is to use groups to serve populations within the community with similar public health emergency-related experiences, such as schools, farmers, older adults, migrant workers, immigrants/refugees, business owners, ethnic groups, persons with mental illnesses, those who are homeless, veterans, university students and staff, squatter communities, unemployed disaster victims, families involved in buyouts, and people with disabilities. (Source: Ibid 55-56)

Behavioral Health Consultation Behavioral health professionals may be brought into decision-making and planning teams to advise public officials and community leaders about behavioral health issues. Public officials may seek behavioral health consultation on a variety of issues, such as behavioral health support, leave for rescue and recovery workers, and rituals or memorials for honoring the dead. To function effectively in this consulting role, behavioral health workers must be well-versed in emergency and criminal response protocols and the responding agencies’ roles and priorities. (Source: Ibid, page 56)

Death Notification Behavioral health professionals may have an immediate support role with bereaved families and loved ones during and after a formal death notification. Behavioral health professionals typically do not deliver the death notification but rather ac- company the persons responsible for the notification. Behavioral health profession- also may: • Provide support and behavioral health consultation to the family receiving the news • Provide support and behavioral health consultation to those conducting the notifications, when requested • Provide information to those responsible for the notification on specific cultural or ethnic customs regarding the expression of grief and rituals surrounding death and burial. (Source: Ibid, page 57)

DEATH NOTIFICATION PROCEDURE Mothers Against Drunk Driving (MADD) developed a curriculum on compassionate death notification for professional counselors and victim advocates. The curriculum was funded by the Office for Victims of Crime of the U.S. Department of Jus- tice. The following description of the MADD death notification curriculum was described in the CMHS Mental Health Response to Mass Violence and Terrorism:

• Obtain critical information before notification. It is important to be able to provide information about how, when, and where the person died, how the identification was made, and where the body is. If possible, learn about the persons to be notified, any medical conditions, and who is included in their support system;

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• Notify the family member of the decreased simply, directly, and in-person. After the persons responsible for notification have identified themselves and are seated, clarify the family members’ relationship to the deceased. Using the victim’s name, state clearly and without euphemisms that he or she has died. Use warmth and compassion and say, “I’m sorry.” Do not take the deceased’s personal items to the notification; • Expect intense emotional and physical reactions (flight, fight, and freeze). A member of the team should have CPR training and be able to treat shock reactions. Respond non-judgmentally and supportively to all reactions and questions. Avoid leaving the bereaved person alone, but do allow privacy for grief reactions; • Provide practical assistance. The bereaved person may need assistance making arrangements to be transported to identify or view the body. They nay need help making phone calls to arrange for transportation, child care, or to contact relatives or their employer, and; • Help the family decide about viewing the body or photographs. Ensure that the bereaved person is informed and prepared regarding what they will see and the condition of the body. Fro many, it is very important to see the remains of their loved one. A lesson learned from the Oklahoma City bombing is that many families ended up regretting not viewing their loved one’s remains. They had been discouraged from doing so because of the degree of mutilation (Office for Victims of Crime, 2000, Jordan 1999). For others viewing the body may be seen as inappropriate for cultural or religious reasons. Family members should be supported in making informal choices and encouraged to have accompaniment and support. (Source: Lord J. H. (1996) . Trauma Death and Death Notification: A Seminar for Professional Counselors and Victim Advocates. Irving TX: Mothers Against Drunk Driving (MADD) and the U.S. Department of Justice, Office for Victims of Crime in U.S. Deaprtment of Health and Human Services. Mental Health Response to Mass Violence and Terrorism: A Training Man- ual. DHHS Publ. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse Services Administration, 2004, pages 55-56. Office for Victims of Crime, 2000, Respond- ing to Terrorism Victims: Oklahoma City and Beyond. Washington, DC: U.S. Department of Justice. Jordan, F.B. (1999). The role of the medical examiner in mass casualty situations with special reference to the Alfred P. Murrah Building bombing. Journal of the Oklahoma State Medical Association, 92(4) 159-163.)

These interventions have varying levels of scientific evidence supporting their effi- cacy. It is recommended behavioral health professionals attempt to match the counseling approach with its perceived acceptability and helpfulness to the disaster survivor.

ADDRESSING THE UNIQUE NEEDS OF DIFFERENT POPULATIONS The behavioral health response to a public health emergency should be accessible to the entire community impacted by the heath risk. In order to develop an all-inclusive outreach program, behavioral health workers need to understand the demographic and cultural makeup of the community and behavioral health implications of these factors.

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Certain cultural or ethnic groups may be affected uniquely by a public health emergency. Services need to be both accessible and appropriate for everyone in the community.

Identifying unique needs of different populations is a strategy for assuring behavioral health services are sensitive to the diversity within the community and a technique for targeting groups of people that may have similar needs following a public health emergency. For example, the older adult population often have developed effective coping skills over the years based on their life experiences and in that regard are better prepared for the trauma related to a public health emergency than younger members of the community. But physical ailments, isolation, and loss of a support system may leave the older adult more vulnerable to the public health emergency. In contrast, children may have an extensive support system, but usually do not have the life experiences or coping skills that would assist them in responding to the dramatic changes in their lives caused by a public health emergency. Older adults and children may also be more susceptible to the transmission of certain disease outbreaks.

Defining unique populations also serves as a strategy for overcoming barriers to crisis counseling services. Language, cultural differences, physical and mental illnesses, and many other factors may become barriers if the behavioral health worker does not take steps to ensure services are accessible and appropriate for all community members.

The following section includes principles for developing cultural competence in behavioral health projects, guidance on working with community gatekeepers, and strategies for working with different populations. The following nine principles of developing cultural competence in behavioral health projects has been taken directly from the CMHS guidance Developing Cultural Competence in Disaster Mental Health Pro- grams, though written for natural disasters the information is useful for other types of events including public health emergencies.

PRINCIPLE 1: RECOGNIZE THE IMPORTANCE OF CULTURE AND RESPECT DIVERSITY Culture is one medium through which people develop the resilience that is needed to overcome adversity. Following a disaster, culture provides validation and influences rehabilitation. However, when daily rituals, physical and social environments, and relationships are disrupted, life becomes unpredictable for survivors. Disaster mental health workers can help reestablish customs, rituals, and social relationships and thereby help survivors cope with the impact of a disaster. When doing so, these workers need to recognize that diversity exists within as well as across cultures (Cross et al.,1989). In disasters, individuals within a given cultural group may respond in very different ways; some will be receptive to disaster relief efforts, while others will not. Older adults and young people within a particular culture may react to losses or seek help in different ways, depending on their degree of acculturation. Mental health workers also must be aware of and sensitive to issues stemming from biculturalism; these issues include conflict and ambivalence related to identity and the need to function in cross-cultural environments (Hernandez and Isaacs, 1998).

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Recognizing the importance of culture and respecting diversity require an institution-wide commitment. To meet this commitment, mental health workers must understand their own cultures and world views; examine their own attitudes, values, and beliefs about culture; acknowledge cultural differences; and work to understand how cultural differences affect the values, attitudes, and beliefs of others. Ta- ble 2-2 examines important considerations mental health workers should keep in mind when dealing with people from other cultures.

Important Considerations When Interacting with People of Other Cultures Giger and Davidhizar’s “transcultural assessment and intervention model” was developed to assist in the provision of transcultural nursing care. It is currently used by several other health and human services professions. The model identifies five issues that can affect the interactions of providers and service recipients. These issues, adapted below to apply to disaster crisis counseling, illustrate the importance of acknowledging culture and of respecting diversity. A complete description of the model can be found in Transcultural Nursing: Assessment and Intervention (Giger and Davidhizar, 1999).

Communication: Both verbal and nonverbal communication can be barriers to providing effective disaster crisis counseling when survivors and workers are from different cultures. Culture influences how people express their feelings as well as what feelings are appropriate to express in a given situation. The inability to communicate can make both parties feel alienated and helpless.

Personal Space: “Personal space” is the area that immediately surrounds a person, including the objects within that space. Although spatial requirements may vary from person to person, they tend to be similar among people in a given cultural group (Watson, 1980). A person from one subculture might touch or move closer to another as a friendly gesture, whereas someone from a different culture might consider such behavior invasive. Disaster crisis counselors must look for clues to a survivor’s need for space. Such clues may include, for example, moving the chair back or stepping closer.

Social Organization: Beliefs, values, and attitudes are learned and reinforced through social organizations, such as family, kinships, tribes, and political, economic, and religious groups. Understanding these influences will enable the disaster crisis counselor to more accurately assess a survivor’s reaction to disaster. A survivor’s answers to seemingly trivial questions about hobbies and social activities can lead to insight into his or her life before the disaster.

Time: An understanding of how people from different cultures view time can help avoid misunderstandings and miscommunication. In addition to having different interpretations of the overall concept of time, members of different cultures view “clock time”—that is, intervals and specific durations—differently. Social time may be measured in terms of “dinner time,” “worship time,” and “harvest time.” Time perceptions may be altered during a disaster. Crisis counselors acting with a sense

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Environmental Control: A belief that events occur because of some external factor—luck, chance, fate, will of God, or the control of others—may affect the way in which a survivor responds to disaster and the types of assistance needed. Survivors who feel that events and recovery are out of their control may be pessimistic regarding counseling efforts. In contrast, individuals who perceive that their own behavior can affect events may be more willing to act (Rotter, 1966). Disaster crisis counselors need to understand beliefs related to environmental control because such beliefs will affect survivors' behavior.

PRINCIPLE 2: MAINTAIN A CURRENT PROFILE OF THE CULTURAL COMPOSITION OF THE COMMUNITY No one knows when or where disaster will strike. For this reason, a predisaster assessment of a community’s composition and familiarity with cultural traditions and customs during times of loss, trauma, and grief can provide invaluable knowledge in the event of a disaster. The range of cultural diversity—ethnic, religious, racial, and language differences among subgroups—should be assessed and described in a comprehensive profile of the community. A comprehensive community profile describes the community’s composition in terms of: • Race and ethnicity; • Age; • Gender; • Religion; • Refugee and immigrant status; • Housing status (i.e., number of single-parent households, type of housing, rental versus ownership, number of persons per household); • Income and poverty levels; • Percentage of residents living in rural versus urban areas; • Unemployment rate; • Languages and dialects spoken; • Literacy level; • Number of schools; and • Number and types of businesses.

Information about the values, beliefs, social and family norms, traditions, practices, and politics of local cultural groups, as well as the history of racial relations or ethnic issues in the community, should be included in the community profile, because these cultural characteristics may take on additional significance in times of stress (DeVries, 1996). This information should be gathered with the assistance of and in consultation with community cultural leaders (“key informants”) who represent and understand local cultural groups.

Other sources of data incorporated in the community profile include the city hall or the county commissioner’s office, as well as the resources listed in Appendix C. Fi- nally, information included in the community profile should be updated frequently, because such data can change rapidly.

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PRINCIPLE 3: RECRUIT DISASTER WORKERS WHO ARE REPRESENTATIVE OF THE COMMUNITY OR SERVICE AREA Mental health programs are most effective when individuals from the community and its various cultural groups are involved in service delivery as well as in program planning, policy, and administration and management. Recruiting staff whose cultural, racial, and ethnic backgrounds are similar to those of the survivors helps ensure a better understanding of both the survivors and the community and increases the likelihood that survivors will be willing to accept assistance. For example, if American Indian or Alaska Native populations have experienced a disaster, tribal leaders, elders, medicine persons, or holy persons might be recruited to serve as counselors or in some other capacity. The community profile can be reviewed when recruiting disaster crisis counseling workers to ensure that they are representative of the community or service area.

If indigenous workers are not immediately available, coordinators can attempt to recruit staff with the required racial or ethnic background and language skills from other community agencies or jurisdictions (DHHS, Rev. ed. in press). Recruitment based solely on race, ethnicity, or language, however, may not be sufficient to ensure an effective response. People who are racially and ethnically representative of the community are not necessarily culturally or linguistically competent. The ability to speak a particular language is not necessarily associated with cultural competence. For example, a well-educated, Spanish-speaking Hispanic professional may not understand the problems and cultural nuances of an immigrant community whose members are living in poverty (DHHS, 2000d). Table 2-3 highlights the attributes, knowledge, and skills essential to development of cultural competence that should be considered when recruiting mental health staff.

Staff Attributes, Knowledge, and Skills Essential to Development of Cultural Competence

Personal Attributes • Genuineness, empathy, and a capacity to respond flexibly to a range of possible solutions • Acceptance and awareness of cultural differences and cross-cultural dynamics • Willingness to work with survivors of different cultures • Ability to articulate one's own values, stereotypes, and biases and to identify how they may accommodate or conflict with the needs of culturally diverse disaster survivors • Openness to learning about the cultures of diverse groups

Knowledge • History, tradition, values, artistic expressions of culturally diverse disaster survivors • Help-seeking behaviors, informal helping supports, and natural healing practices of survivors of various cultures • Role of language, speech patterns, and communication styles in culturally distinct communities

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• Psychosocial stressors relevant to diverse groups (e.g., migration, acculturation stress, legal and illegal discriminatory patterns, racism, and socioeconomic status) • Community resources (agencies, informal helping networks) and their availability for special populations

Skills • Ability to discuss cultural issues and to respond to culturally-based cues • Ability to assess the meaning of culture for the disaster survivor • Ability to interview and assess survivors on the basis of their personal, psychological, social, cultural, political, or spiritual models (Adapted from: Benedetto, 1998; DHHS, 1998)

PRINCIPLE 4: PROVIDE ONGOING CULTURAL COMPETENCE TRAINING TO DISASTER MENTAL HEALTH STAFF Cultural competence is an essential component of disaster mental health training programs. Training should be provided to help mental health workers acquire the values, knowledge, skills, and attributes needed to communicate and work in a sensitive, nonjudgmental, and respectful way in cross-cultural situations. Such training should be provided to direct services staff, administrative and management staff, language and sign-language interpreters, and temporary staff.

Cultural competence training programs work particularly well when they are provided in collaboration with community-based groups that offer expertise or technical assistance in cultural competence or in the needs of a particular culture. Involv- ing such groups not only enables program staff to gain firsthand knowledge of various cultures, but also opens the door for long-term partnerships (Hernandez and Isaacs, 1998).

Training should cover basic cultural competence principles, concepts, terminology, and frameworks. For example, training should include discussion of: • Cultural values and traditions; • Family values; • Linguistics and literacy; • Immigration experiences and status; • Help-seeking behaviors; • Cross-cultural outreach techniques and strategies; and • Avoidance of stereotypes and labels (DHHS, 2000e).

Even if the initial training period is of limited duration, participants should have an opportunity to examine and assess values, attitudes, and beliefs about their own and other cultures. Self-assessment helps identify areas where skills need to be developed (DHHS, 1998). Training should stress that people of a given cultural group may react quite differently to disaster, depending on their level of acculturation.

Cultural competence training is a developmental process. Ongoing education— through in-service training and regularly scheduled meetings with project staff to discuss cultural competence issues—is essential (Hernandez and Isaacs, 1998).

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PRINCIPLE 5: ENSURE THAT SERVICES ARE ACCESSIBLE, APPROPRIATE, AND EQUITABLE Survivors are not always receptive to offers of support. For example, some members of cultural groups may be reluctant to take advantage of services because of negative past experiences. Undocumented immigrants may not seek services because they fear deportation. Such individuals may be reluctant or refuse to move to temporary shelters, to accept State or Federal assistance, or to discuss information that they think could be used against them.

Inequitable treatment following disasters may reinforce mistrust of the public services and disaster assistance systems. Following the 1989 Loma Prieta earthquake in California, shelter services in the more affluent neighborhoods had more community volunteers than survivors. The mayor visited the disaster site in these areas. Less affluent neighborhoods had fewer volunteers, and some volunteers made remarks that the survivors felt were offensive. The mayor did not visit these areas (Dhesi, 1991). Moreover, food and meal preparation in shelters was not culturally appropriate following the earthquake, and many Latinos reported that they became sick from eating the food prepared by the Anglo relief workers (Phillips, 1993).

In studies of Hurricane Andrew’s aftermath, racial and ethnic minority group survivors were less likely to have insurance than were white survivors because of practices that exclude certain communities from insurance coverage at affordable rates. Survivors from minority groups were also more likely to receive insufficient settle- ment amounts (Peacock and Girard, 1997). Concerns related to gender also were investigated after Hurricane Andrew. Many non-English-speaking women of color, especially single women, were subjected to dishonest practices of construction con- tractors (Enarson and Morrow, 1997).

The delivery of appropriate services is a frequent problem. Racial and ethnic dis- crimination, language barriers, and stigma associated with counseling services have a negative effect on many individuals’ access to and utilization of health and mental health services (Denboba et al.,1998). Families who participated in focus groups reported problems with cultural and ethnic biases and stereotypes, offensive communication and interactions based on such biases and stereotypes, lack of cross- cultural knowledge, and lack of understanding of the values of various cultural groups (Malach et al., 1996).

Disaster mental health programs must take special care to exercise culturally competent practices. They should make efforts to ensure that staff members speak the language and understand the values of the community. Providing food that has cultural significance can be important. Involving cultural group representatives in disaster recovery committees and program decision making (for example, as members of planning boards or other policy-setting bodies) can help ensure that disaster services are accessible, appropriate, and equitable. Culturally sensitive outreach techniques also can help ensure that services are accessible and appropriate to all survivors. For example, outreach workers should: • Allow time for and devote energy to gaining acceptance, take advantage of •

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associations with trusted organizations, and be wary of aligning their efforts with those of agencies and organizations that are mistrusted by cultural groups; • Determine the most appropriate ways to introduce themselves; • Recognize cultural variations in expression of emotion, manifestation and description of psychological symptoms, and views about counseling; and • Assist in eliminating barriers by carefully interpreting facts, policies, and procedures.

The following table addresses special considerations that should be taken into account when counseling refugees.

Special Considerations When Working with Refugees Refugees may differ from each other and from native populations on several dimen- sions, including:

Language: Refugees frequently do not speak English well, if at all. This presents communication challenges throughout all phases of a disaster.

Culture: Refugees have their own cultures. Because they are new to the United States, they usually are less well-versed in Western culture than are immigrants, who have had more time to understand it.

Economic marginalization and differences: When they arrive in the United States, many refugees can barely manage economically. Many are supporting relatives left at home. On the other hand, some refugees—especially those with education and highly sought skills—find well-paying jobs quickly. Thus, although poverty is common among refugees, not all refugees are poor.

Fractured social relations: The communities of origin of many refugees have failed to provide needed security. In addition, many refugees have experienced personal attacks by representatives of their community or the larger society. Some become so disillusioned by this experience that they are reluctant to form new community bonds. In addition, refugees often face within-group schisms. Preexisting ethnic, religious, and political divisions of the society of origin are frequently rein- stituted in refugee communities formed in the new country.

Some refugees solve the problem by restricting new relationships to the safest ones, for example, by forming or joining small groups of people who emigrated from the same geographic area. When a disaster forces relocation, it can break up this small community and make recovery more problematic (Athey and Ahearn, 1991).

The negative experiences of many refugees also make them suspicious of government. They may be reluctant to seek out or accept assistance following disaster. Un- documented migrants may fear deportation, but even refugees who have achieved legal status may fear that accepting of assistance following a disaster will put them at risk of deportation. Thus, refugees often are the last group to obtain assistance following disaster.

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Experience of traumatic stressors and of loss: Refugees often have experienced horrific events that cause symptoms of Post-Traumatic Stress Disorder. They may have lost family members, their homes, and their possessions, and some have been deprived of sufficient food or water, lacked medical care, or lived in inadequate housing for long periods of time. A disaster can lead to the emotional re- experiencing of these events (Van der Veer, 1995). On the other hand, some refugees may have gained strength and resilience from their previous experiences and bring that strength to the new disaster.

Family dynamics and role changes: Another challenge for many refugee families is that of new family dynamics upon resettlement. Children may have seen their parents fearful, helpless, and stressed during the flight and—upon resettlement— anxious, powerless, and exhausted. Children may come to believe that adults are not to be trusted because they have not seen adults playing a protective and nurturing role.

Intergenerational conflict resulting from differing rates of acculturation presents another family problem. Finally, parents may feel deprived of their role as family heads when they find they must depend on children as language translators or navi- gators within the new culture (de Monchy,1991).

De Monchy (1991) identifies three principles for effective service delivery with refugees: • Trauma experiences need to be acknowledged. • Refugees need to be recognized as successful survivors, and their wisdom and strengths affirmed. • Empowerment and the recovery of control need to be encouraged, especially for refugees who are reestablishing parental roles with their children.

PRINCIPLE 6: RECOGNIZE THE ROLE OF HELP-SEEKING BEHAVIORS, CUS- TOMS AND TRADITIONS, AND NATURAL SUPPORT NETWORKS Culturally competent disaster mental health services proactively respond to the culturally defined needs of the community. Disruption of many aspects of life and the need to adapt to difficult circumstances cause stress and anxiety in many survivors. In some cases, these problems can be as difficult as the disaster itself. Effective response requires familiarity with help-seeking behaviors; customs and traditions related to healing, trauma, and loss; and use of natural support networks of various cultural groups.

Help-Seeking Behaviors Different cultures exhibit different help-seeking behaviors. In many cultures, people turn to family members, friends, or cultural community leaders for help before reaching out to government and private-sector service systems. They may prefer to receive assistance from familiar cultural community leaders or groups rather than unfamiliar service systems. In most communities, churches and other places of worship play a role similar to that of an extended family, and survivors turn to them first for assistance.

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Many survivors may be reluctant to seek help or may reject disaster assistance of all types. Some people feel shame in accepting assistance from others, including the government, and equate government assistance with “welfare.” Members of racial and ethnic minority groups, including refugees and immigrants, also may be reluctant or afraid to seek help and information from service systems because of historical mistrust of the health, mental health, and human services systems or because of fear of deportation (Aponte, Rivers, and Wohl, 1995). Other groups may prefer to suffer or even perish rather than seek help from people they mistrust. Therefore, building trusting relationships and rapport with disaster survivors is essential to effective crisis counseling.

Those who do seek help may find relief procedures confusing. Feelings of anger and helplessness and loss of self-esteem can result from survivors’ encounters with relief agencies. These feelings result from the survivors’ lack of understanding of the disaster relief system as well as government and private agencies’ often bureau- cratic procedures.

Customs and Traditions in Trauma and Loss Religious and cultural beliefs are important to survivors as they try to sort through their emotions in the aftermath of traumatic events. Beliefs may influence their perceptions of the causes of traumatic experiences. For example, in many cultures, people believe that traumatic events have spiritual causes. These beliefs can affect their receptivity to assistance and influence the type of assistance that they will find most effective. Different populations may elaborate on the cultural meaning of suffering in different ways, but suffering itself is a defining characteristic of the human condition in all societies. In most major religions, including Christianity, Judaism, Islam, Hinduism, and Buddhism, the experience of human misery—resulting from sickness, natural disasters, accidents, violent death, and atrocity—also is a defining feature of the human condition.

Different cultural groups also handle grief in different ways. Family customs, beliefs, and degree of acculturation affect expressions of grief. Disaster mental health workers must recognize that grief rituals, although diverse in nature, can help people return to a reasonable level of functioning. For example, Western tradition holds that grief should be “worked through.” This process includes acceptance of the loss; extinction of behaviors that are no longer adaptive; acquisition of new ways of dealing with others; and resolution of guilt, anger, and other disruptive emotions.

If a community remains intact after a disaster, cultural norms, traditions, and values determine the strategies that the survivors use to deal with the effects. When the entire community is affected, however, cultural mechanisms may be overwhelmed and unable to fulfill their customary functions of regulating emotions and providing identity, support, and resources (DeVries, 1996). Disaster mental health workers can support the healing process by helping rebuild the community’s cultural support system. Workers will be most effective when they recognize and understand the importance of culture in the lives of disaster survivors and the beliefs, rituals, and level of acculturation of the community in which they work.

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Customs and Traditions for Healing Many cultural groups hold beliefs about illness and healing that differ sharply from those held by Western society. People in every culture share beliefs about the causes of illness and ideas about how suffering can be mitigated. For example, members of some cultures believe that physical and emotional problems result from spiritual wrongdoings in this life or a previous one. They believe that healing requires for- giveness from ancestors or higher spirits. Some people believe that suffering cannot be ameliorated (DeVries, 1996). Others demonstrate stress and emotional conflict through complaints about their physical health.

Traditional healers, such as local herbalists, faith healers, and acupuncturists, play important roles in recovery of mental and physical health within some cultures. In general, the work of healers is based on the principle that the body cannot be isolated from the mind, and the mind cannot be removed from its social context. Dis- aster mental health workers who interact with cultures in which healers play a key role in health must understand the concepts of integration of body, mind, and spirit when they provide disaster crisis counseling services to diverse populations. They must be able to integrate traditional methods of healing into service delivery (de Monchy, 1991). Although the crisis counselor may not subscribe to certain cultural healing beliefs, he or she must acknowledge their existence and recognize their importance to some disaster survivors. At the same time, the worker must be alert for any use of dangerous healing practices, such as ingestion of harmful mixtures con- taining lead or other toxic substances, and take corrective measures. Reestablishing rituals in appropriate locations is another way to help survivors in the recovery process. Symbolic gathering places, such as churches, mosques, trees, and safe places for meeting after sundown are important in some cultures and are required for certain rituals. After a disaster, survivors may lose access to symbolic places, and this loss may limit their ability to mobilize healing resources. Identifying new locations for rituals can foster social support and facilitate coping mechanisms following disaster (DeVries, 1996).

Disaster mental health workers also may help organize culturally appropriate anniversary activities and commemorations as a way to help survivors mark a milestone in the healing process. Cultural and religious traditions, including special ways of both celebrating and mourning, can be incorporated into such events and may en- rich their symbolic meaning and healing potential. Any attempts to facilitate activities involving customs and traditions must be undertaken carefully and only after consultation with members of the involved cultural groups.

Natural Support Networks In many cultures, the family or kin group is chiefly responsible for its members, and support from kin may be essential in helping individuals overcome grief and trauma. However, when disaster strikes, all members of the extended family may be affected, leaving many people without this customary support network.

Traditions concerning the role of the family, who is included in the family, and who makes decisions vary across cultures (DHHS, 2000e). Elders and extended family

Module 7 170 play a significant role in some cultures, whereas in other cultures, isolated nuclear families are the decision makers (DHHS, 2000e). Households in racial and ethnic communities are, on average, larger than white households (O’Hare, 1992); they also are more likely to be multigenerational. Asians, for example, are more than twice as likely as whites to live in extended families (O’Hare and Felt, 1991).

Disaster mental health workers must recognize that family support may not be available when entire kin groups are affected. Helping families and friends reunite is one way to ensure mutual support. Likewise, formal support groups can help assure those with limited access to relatives and acquaintances that they are not alone. Individuals who do not relate to support groups because of cultural and linguistic Did You Know … differences may need more individualized According to 1990 census data, nearly services. 14 percent of the Nation’s population— 32 million people—speak a language Disaster mental health workers also must other than English in their homes. More recognize that in many cultures, the individ- than 300 languages are spoken in the ual cannot be separated from the family and United States (Goode et al., 2001). community (Reichenberg and Friedman, 1996). In such cultures, unlike those of Western society, the individual does not exist apart from the group; outreach efforts focused on individuals are, therefore, neither comprehensible nor effective. For example, among some Asian American and Pacific Islander populations, intervention strategies that diffuse the power of family relationships are especially inappropriate. Mental health workers can assess who is significant in a survivor’s family structure by asking the survivor to describe his or her home, family, and community (Managua, 1998).

PRINCIPLE 7: INVOLVE AS “CULTURAL BROKERS” COMMUNITY LEADERS AND ORGANIZATIONS REPRESENTING DIVERSE CULTURAL GROUPS Involving “cultural brokers”—community leaders and groups that represent diverse groups—is vital to the success of disaster mental health efforts. Collaborating with organizations and leaders who are knowledgeable about the community is the most effective way of gaining information about the community. Collaboration can assist in assessing needs, creating community profiles, making contact with and gaining the trust of survivors, establishing program credibility, integrating cultural competence in training, and ensuring that strategies and services are culturally competent (DHHS, 1998).

In most communities, and in diverse communities in particular, some of the most influential individuals are cultural group leaders who possess “insider” knowledge of the community and are willing and able to articulate that knowledge (Hernandez and Isaacs, 1998). These individuals, who may not be immediately visible, can include spiritual leaders, members of the clergy, teachers, civic leaders, local officials, or long-term residents who have the respect and confidence of their neighbors. They often can provide outsiders with the best insights into a local culture’s values, norms, customs, conventions, traditions, and expectations (Hernandez and Isaacs, 1998).

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Organizations representing various cultural groups and other special interest groups in the community should be invited to participate in disaster mental health programs. These organizations can provide valuable insight during the planning process, serve as a point of entry to the survivor community, and enhance cultural relevance of service delivery. Including individuals from various cultures on planning task forces and committees will help ensure that they concur with the selected strategies.

Should a disaster occur, community-based organizations can provide an important communication link with the cultural groups they represent. For example, churches do much more than serve the spiritual needs of the African American community. They are also the center of political, social, educational, and cultural activities. Therefore, African American ministers may play an important part in mental health outreach and recovery efforts.

Informal, culture-specific groups such as sewing circles and youth sports teams can also be sources of support to disaster survivors. The crisis counseling program staff should identify the most effective ways to work with such groups. Community- based organizations that should be involved include: • Civic associations; • Social clubs; • Neighborhood groups; • Faith-based organizations; • Interfaith groups; • Mutual aid societies; • Voluntary organizations; • Health care and social service providers; and • Nonprofit advocacy organizations (Hernandez and Isaacs, 1998).

To ensure effective use of resources, crisis counselors should coordinate their work with that of other public and private agencies responding to the disaster. The coordinating agency should recognize unique jurisdictional situations that may arise when working with various American Indian and Alaska Native cultures. American Indian and Alaska Native tribes are federally recognized sovereign nations. Disaster mental health agencies should acknowledge the need for a partnership that includes various agencies within tribes, different levels of government, and many tribes working together to improve access to disaster assistance. Although under the Staf- ford Act, a State government must request a Presidential disaster declaration on behalf of a tribe, agencies subsequently can work directly with the tribe and with existing authorities and resources to tailor disaster plans to the tribe’s unique needs and jurisdictional requirements.

PRINCIPLE 8: ENSURE THAT SERVICES AND INFORMATION ARE CULTURALLY AND LINGUISTICALLY COMPETENT Language can be a major barrier to service delivery. Survivors who are monolin- gual, limited in their English, or deaf or hard of hearing may be at a particular dis- advantage. Emergency response programs generally have few or no staff trained to

Module 7 172 work with bilingual populations (Phillips and Ephraim,1992). For example, most of the information provided immediately after Hurricane Andrew in Florida was available only in English (Yelvington, 1997). As a result, many Latinos and Haitians did not receive needed food, medical supplies, and disaster mental health assistance information.

“Linguistic competence” ensures accurate communication of information in languages other than English. This capability enables an organization and its personnel to communicate effectively with persons of limited English proficiency, those who are illiterate or have low literacy skills, and individuals who are deaf or hard of hearing (Goode et al., 2001). Elements of linguistic competence include the availability of trained bilingual and bicultural staff, translations of educational materials and documents, and sign-language and language interpretation services. Although linguistic competence and cultural competence involve distinct skills, they are in- trinsically connected (DHHS, 1999).

Availability of Trained Bilingual and Bicultural Staff Ideally, disaster mental health workers should be bilingual, bicultural, and from the affected community. However, in many circumstances, workers who are bilingual but not from the affected culture and community must be hired. In such situations, communication challenges may arise, even though the disaster worker or interpreter speaks the same language as the survivors. Examples or related issues follow. • Disaster mental health workers may be responsible for assisting survivors who have a language pattern that is different from their own. Dialects, in addition to colloquialisms and accents, can be difficult to understand and communication barriers can result. • Words may have different meanings even among people who share a language. Rogers (1992) noted difficulty in communicating disaster information between members of the United States Army and people in a native Polynesian culture because, although they both spoke English, the two groups did not assign a common meaning to certain words and phrases. The language differences led to frustration and a breakdown of credibility.

Bilingual disaster survivors who primarily speak Spanish may be more withdrawn when interviewed in English rather than in Spanish. An individual’s speech pattern may be halting or disrupted and expression of affect may be reduced when the person is required to speak in a language other than his or her primary language. In such situations, the disaster worker’s assessment of the survivor’s issues and needs can be distorted. Ideally, the preferred or primary language of bilingual disaster survivors should be used in delivering outreach and other services (Aponte et al., 1995).

Program managers must be cautious in selecting bilingual staff members and interpreters. Those who are bilingual also must understand nonverbal and cultural patterns to communicate effectively. Bilingual staff members should demonstrate bilingual proficiency and undergo cultural competence training (DHHS, 2000a).

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Dissemination of Educational Information Written information should be translated³ into multiple languages, as appropriate for the community to be served. The literacy level of the target population must be considered when developing written materials. Any written materials should be supplemented with other forms of information (DHHS, 2000a). For example, messages may be conveyed by radio or through announcements at churches and other community centers. Most localities now have television stations that broadcast in the languages of various cultural groups. Although these communications media should be used, it is important to note that some people do not have access to television and may depend on radio broadcasts for information.

Crisis support programs should establish relationships with multicultural television stations, radio stations, and newspapers before a disaster occurs. In addition, program staff should invite television and radio station personnel to participate in the development of a disaster communications plan.

The information needs of people who are deaf or hard of hearing also must be considered. Closed-captioned television, for example, is a critical communication tool for this population. The Federal Communications Commission requires that all emergency information presented on television be accessible to persons who are deaf or hard of hearing.

³ Interpretation is the oral restating in one language of what has been said in another language. Translation typically refers to the conversion of written materials from one language to another (Goode et al., 2001).

Language and Sign-Language Interpretation Language interpretation may be used when the language barrier is so great that communication between mental health workers and survivors is not possible or when no bilingual staff can be hired. Sign-language interpretation also must be considered when developing communication strategies.

Although language interpreters may be the only viable option in some situations, hiring bilingual staff members remains the preferred solution. Van der Veer (1995) notes that an interpreter’s behavior may evoke certain feelings in the disaster survivor. Factors such as the interpreter’s gender, age, or level of acculturation may affect the survivor’s willingness to speak openly. Disaster survivors may be ashamed of mental health problems that are considered a sign of madness or a cause for con- tempt in their cultures. They also may distrust interpreters who are from the same country and speak the same language, but who have different political or religious backgrounds (Van der Veer, 1995).

Interpreters should be trained to accurately convey the tone, level, and meaning of the information presented in the original language. Without adequate training, interpreters may interpret information inaccurately or incompletely. The most common problems include changing open-ended questions into leading questions, altering the content of questions, and adding comments. Problems in interpreting an-

Module 7 174 swers include leaving out part of the answer, adding something to the answer, and making mistakes because of limited understanding of English (Van der Veer, 1995).

When working with refugees, mental health workers should be aware that interpreters might have experienced traumatic events similar to those experienced by the refugees. In such situations, the interpreter may want to avoid reliving unhappy or traumatic memories. Thus, the interpreter may present information inaccurately, evade certain topics, change the subject, or tell the mental health worker that the interview is too stressful for the disaster survivor (Westermeyer, 1989). The following table provides useful guidelines for using interpreters.

TABLE 2 - 5 Guidelines for Using Interpreters The following guidelines should be considered when using language interpreters (Bamford, 1991; Gaw, 1993; Paniagua, 1998; Westermeyer, 1989): • Before hiring interpreters, attempt to identify mental health workers who speak the language spoken by survivors and who identify with the survivors’ culture. • Hire certified, qualified interpreters who share the survivor’s racial and ethnic background. • Determine the survivor’s dialect before asking for an interpreter. • Compare the level of acculturation of the interpreter with that of the survivor. If it is not similar, effective communication may not be possible because Western values may be reflected in the interpreter’s comments. • Introduce the interpreter to the disaster survivor, and allow time for them to build trust through informal conversation. • Take time for translation. Use a sequential mode of interpretation—that is, the disaster survivor speaks, the interpreter interprets what has been said into Eng- lish, the disaster mental health worker speaks, and the interpreter speaks again.

Do not use survivors’ friends and relatives, including their children, as interpreters. The survivor may not feel comfortable expressing concerns of a personal nature to relatives and friends. Using children can reverse the hierarchical role of parents and place burdens on children. Moreover, such responsibility may require skills beyond the child’s current stage of development and be too stressful for the child (DHHS, 2000c).

PRINCIPLE 9: ASSESS AND EVALUATE THE PROGRAM’S LEVEL OF CULTURAL COMPETENCE Self-assessment and process evaluation are keys to ensuring that disaster mental health services are as effective as possible and to making maximum use of resources. Self-assessment helps programs identify organizational problems that may impede the delivery of culturally competent services. The self-assessment tool presented in Table 2-6 may be used in conjunction with the Cultural Competence Checklist for Disaster Crisis Counseling Programs, presented in Appendix F. The Cultural Competence Continuum (Figure 1-1) is another useful tool for assessing a program’s level of cultural competence.

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TABLE 2 - 6 A Cultural Competence Self-Assessment for Disaster Crisis Counseling Programs Six elements are needed to ensure cultural competence of mental health agencies (Bernard, 1998). Programs can use these elements to assess their level of cultural competence as well.

Leadership • Are the leaders of the program committed to cultural competence? • Does the project manager hold staff accountable for knowledge of the provision of appropriate services to all disaster survivors?

Understanding of cultural competence • Has the program staff developed a common understanding of cultural competence and do they clearly and frequently communicate that understanding to others?

Organizational culture • Does the crisis counseling program promote and encourage cultural competence? • Is the program administered by an organization with a strong commitment to and history of working toward cultural competence? • Are policies, procedures, and systems in place for delivering interpretation, bilingual, or translation services?

Training • Have all crisis counseling staff members been trained in cultural competence, and are they familiar with the diverse cultural and ethnic groups in the community? • Are training programs ongoing? • Are regular meetings convened and educational opportunities offered for staff members to discuss cultural competence issues and concerns, build cross- cultural skills, and develop strategies?

Cultural competence plan • Has the program identified goals designed to address the mental health needs of the community in a culturally competent manner? • Has the program explored various methods of working with disaster survivors in a way that respects and is sensitive to the needs of all groups in the community? • Has the program established partnerships with community-based agencies that serve cultural and ethnic groups for input on needs assessment, program planning, and evaluation? • Has the program developed a mechanism to acquire knowledge about the customs, values, and beliefs of special populations?

Managing the plan • Has a person or group been identified to evaluate the success of the program in

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addressing cultural competency issues? • Have methods been instituted to recognize innovations in serving culturally distinct groups and implement those innovations project-wide?

Process evaluation helps ensure that the disaster mental health program stays on course. It also can identify problems or gaps in providing culturally competent services. Involving representatives from as many cultural groups as possible in process evaluation ensures that diverse cultural groups or group perspectives are heard and understood.

The program can use a variety of techniques for collecting information for process evaluations. For example, staff might create an evaluation task force or advisory group or a discussion or focus group that includes representatives of different cultural groups. A group that includes a disaster survivor perspective, as well as representatives of partner agencies, can provide qualitative information and innovative ideas that can help the crisis counseling program more effectively address the community’s cultural needs. Evaluation methods should be consistent with the cultural norms of the groups being served. Evaluators should be sensitive to the culture and familiar with the culture whenever possible and practical (DHHS, 2001).

Program staff should regularly communicate process evaluation findings to key informants and cultural groups engaged in the project and in the evaluation in order to ensure their ongoing support.

Developing a culturally competent disaster crisis counseling program requires commitment and diligence. The rewards of such dedication are at the heart of the program—effective and appropriate services to help disaster survivors recover and heal.

(Source: Aponte, J., Rivers, R., and Wohl, J. (1995). Psychological Interventions and Cultural Di- versity. Boston, Massachusetts: Allyn and Bacon; Athey, J. L., and Ahearn, F. L. (1991). The mental health of refugee children: An overview. In F. L. Ahearn and J. L. Athey (Eds.), Refugee Children: Theory, Research and Services (pp. 3-19). Baltimore, MD: The Johns Hopkins University Press; Bamford, J. (1991). Pre-school hearing, speech, language and vision screening. Effective Health Care 4(2). York: NHS Centre for Reviews and Dissemination; Benedetto, R. (1998, June). Introduc- tion to special populations and migrant/farm workers. Training conducted at the Annual FEMA/ CMHS Crisis Counseling Assistance and Training Workshop, Emmittsburg, Maryland; Bernard, J. A. (1998). Cultural competence plans: A strategy for the creation of a culturally competent system of care. In M. Hernandez and M. Isaacs (Eds.), Promoting Cultural Competence in Children’s Men- tal Health Services. Baltimore, MD: Brookes Publishing Company; Cross, T. L. (1989). Towards a Culturally Competent System of Care. Vol. I: A Monograph of Effective Services for Children who are Severely Emotionally Disturbed. Washington, DC: Georgetown University Child Development Center; De Monchy, J. L. (1991). Recovery and rebuilding: The challenge for refugee children and service providers. In F. L. Ahearn and J. L. Athey (Eds.), Refugee Children: Theory, Research and Services (pp. 163-180). Baltimore, MD: The Johns Hopkins University Press; Denboba, D., Brag- don, J., Epstein, L., Garthright, K., and Goldman, T. (1998). Reducing health disparities through cultural competence. Journal of Health Education, 29(5, Suppl.), 47-53; DeVries, M. (1996). Trauma in cultural perspective. In B. Van der Kolk, A. D. McFarlane and L. Weisaeth (Eds.), Trau- matic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press; Dhesi, N. (1991). The Social Impacts of the 1906 and 1989 Earthquakes. Unpub-

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lished manuscript, University of Colorado, Boulder; Enarson, E., and Morrow, B. H. (1997). A gen- dered perspective: The voices of women. In W. G. Peacock, B. H. Morrow and H. Gladwin (Eds.), Hurricane Andrew: Ethnicity, Gender, and the Sociology of Disasters. Routledge, New York ; Gaw, A. (1993). Culture, Ethnicity, and Mental Illness. Washington, DC: American Psychiatric Press; Giger, J., and Davidhizar, R. (1999). Transcultural Nursing: Assessment and Intervention (3rd ed.). St. Louis: Mosby Year Book; Goode, T., Sockalingam, S., Brown, M., and Jones, W. (2001). Policy Brief 2: Linguistic Competence in Primary Health Care Delivery Systems: Implications for Policy Makers. Washington, DC: National Center for Cultural Competence; Hernandez, M., and Isaacs, M. (1998). Promoting Cultural Competence in Children’s Mental Health Services. Balti- more, MD: Paul H. Brookes Publishing; Malach, R., Nelkin, V. S., and Jones, D. A. (1996). Family Perspectives: Cultural/Ethnic Issues Affecting CSHCN-Educational Fact Packets. Bernalillo, NM: Southwest Communications Resources; O’Hare, W. (1992). America’s minorities—The demographics of diversity. Population Bulletin, 46(4). Washington, DC: Population Reference Bureau; O’Hare, W., and Felt, J. (1991). Asian Americans: America’s fastest growing minority group (Population Trends and Public Policy, No. 19). Washington, DC: Population Reference Bureau; Paniagua, F. (1998). Assessing and Treating Culturally Diverse Clients. Thousand Oaks, CA: Sage Publications; Peacock, W. P., and Girard, C. (1997). Ethnic and racial inequalities in hurricane damage and insurance settlements. In W. G. Peacock, B. H. Morrow and H. Gladwin (Eds.), Hurri- cane Andrew: Ethnicity, Gender, and the Sociology of Disasters. New York: Routledge; Phillips, B. D. (1993). Cultural diversity in disasters: Sheltering, housing, and long-term recovery. Interna- tional Journal of Mass Emergencies and Disasters, 11(1), 99-110; Phillips, B. D., and Ephraim, M. (1992). Living in the aftermath: Blaming processes in the Loma Prieta earthquake (Working Paper No. 80.). Boulder: IBS, Natural Hazards Research and Applications Information Center, Univer- sity of Colorado; Reichenberg, D., and Friedman, S. (1996). Traumatized children: Healing the invisible wounds of war: A rights approach. In Y. Daniel, N. S. Rodley and L. Weisaeth (Eds.), In- ternational Response to Trauma Stress. Amityville, NY: Baywood; Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80 (1), 1-28; U.S. Department of Health and Human Services (1999). Cultural Competence: A Journey. Rockville, MD: U.S. Department of Health and Human Services (no publication number). Bureau of Primary Health Care, Health Resources and Services Administration. U.S. Department of Health and Human Services (1998). Cultural Competence Monograph Series. Cultural competence for health care professionals working with African-American communities: Theory and practice (Pub. No. 98-3238). Bureau of Primary Health Care, Health Resources and Services Administra- tion; Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Admini- stration; and the Office of Minority Health; U.S. Department of Health and Human Services (1999). Disaster Mental Health: Crisis Counseling Programs for the Rural Community (Pub. No. SMA 99-3378). Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; U.S. Department of Health and Human Services (1998). Family-based or Cultural Competence Systems of Health Care. U.S. Department of Health and Human Services (no publication number). Bureau of Pri- mary Health Care, Health Resources and Services Administration; U.S. Department of Health and Human Services (2001). Guidelines to Help Assess Cultural Competence in Program Design, Appli- cation, and Management. U.S. Department of Health and Human Services (no publication number). Bureau of Primary Health Care, Health Resources and Services Administration; U.S. Depart- ment of Health and Human Services (2001). Mental Health: Culture, Race, and Ethnicity—A Sup- plement to Mental Health: A Report of the Surgeon General (Pub. No. SG-CRE-EXEC). Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Ser- vices Administration, Center for Mental Health Services; U.S. Department of Health and Human Services (2000c). Psychosocial Issues for Children and Adolescents in Disasters (2nd ed.) (Pub. No. ADM 86-1070R). Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; U.S. Department of Health and Human Services (2000d). Quality Health Services for Hispanics: The Cultural Com- petency Component (Pub. No. 99-21). Rockville, MD: U.S. Department of Health and Human Ser- vices. Health Resources and Services Administration, Office of Minority Health, and Substance Abuse and Mental Health Services Administration; U.S. Department of Health and Human Ser- vices. Disaster Response and Recovery: A Strategic Guide (Pub. No. SMA 94-3010R). Rockville,

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MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Ser- vices Administration, Center for Mental Health Services. (Rev. ed. in press.); U.S. Department of Health and Human Services (2000e). Training Manual for Mental Health and Human Service Workers in Major Disasters (2nd ed.) (Pub. No. ADM 90-538). Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; Van der Veer, G. (1995). Psychotherapeutic work with refugees. In R. J. Kleber, C. R. Figley, and B. P. R. Gersons (Eds.), Beyond Trauma: Cultural and Societal Dynam- ics (pp. 151-169). New York: Plenum Press; Watson, O. M. (1980). Proxemic Behavior: A Cross- cultural Study. The Hague, The Netherlands: Mouton; Yelvington, K. A. (1997). Coping in a temporary way: The tent cities. In W. G. Peacock, B. H. Morrow and H. Gladwin (Eds.), Hurricane An- drew: Ethnicity, Gender, and the Sociology of Disasters. New York: Routledge In Center for Men- tal Health Se rvices, Developing Cultural Competence in Disaster Mental Health Programs, Wash- ington D.C.: U.S. DHHS; Publication No. SMA 3828 Printed 2003)

WORKING WITH UNIQUE POPULATIONS Cultural/Ethnic Groups Other cultural issues include the person’s perception of time and fate. Some groups and individuals may consider being on time extremely important, while others may be more flexible with schedules. Be aware of such attitudes, and respect these differences by not imposing rigid timetables or by being late to appointments. Some cultures are more concerned with here and now than the past and will be reluctant to talk about past experiences.

People who believe their recovery is in the hands of an external force—luck, fate or di- vine intervention—might not understand initially how a behavioral health worker can help them. On the other hand, those who believe they have the power to heal themselves may be more receptive to crisis counseling services. (Source: Virginia, 2004)

Recent Immigrants The most recent U.S. Census, estimated that approximately 140,000 people would migrate to Virginia from another country between April 1, 2000 and July 1, 2005 (http://www.census.gov/popest/states/NST-comp-chg.html). Immigrating to another country can be stressful. Not only may immigrants need to adapt to a new language, but they must also assimilate to a new culture, which leaves them more vulnerable during a crisis. This vulnerability may be intensified by the following: • Leaving behind social support systems (e.g., family, friends) and trying to establish new ones • Securing employment and financial stability • Changing family member roles (e.g., adults could develop an unfamiliar dependency on children who learn English quickly) • Adapting to a new culture and environment (Source: Ibid, page 70)

Refugee Community Fleeing their native countries because of social or political disorder, many refugees have suffered loss of loved ones and possessions. A public health emergency may remind them of past losses and lead to retraumatization—or a show of resilience

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that comes from already having experience with difficult situations. It is important to acknowledge the trauma in their history and validate the insight and strength of refugees. Some refugees feel betrayed by their native country and are wary of building friendships in their new homeland, except with a select few. This distrust— especially in refugees who suffered from political oppression—extends to police officers, the military, social service workers, and government employees, making some hesitant to seek out and accept help.

Some points to consider when working with refugees: • Respect their views about assistance agencies and staff members • Team with appropriate community gatekeepers • Approach refugees lightly, displaying courtesy and cultural competence • Take time to earn the confidence of refugees (Source: Ibid, page 70)

Children Children process information, and experience and express emotions differently than adults. According to the Center for Mental Health Services’ Mental Health Response to Mass Violence and Terrorism (a publication in press, written by Dr. Deborah De- Wolfe), disasters, violence victimization, and sudden deaths of loved ones are experienced within the context of a child’s psychological development, life and family situation, and critical caretaking relationships. Terrifying events can cause overwhelming and unfamiliar physical reactions and emotions that can be traumatizing to children.

Children have a difficult time deciding what is fact and what is fantasy, which leads to fear and confusion. In trying to make sense of what has happened, children often blame themselves for causing or worsening the incident, which can lead to feelings of guilt and shame.

Very young children depend on a stable environment and reliable people to take care of them. As children become older, they may try to understand why the event happened and what will happen next. Family, significant adults, pets, playmates, school, and neighborhoods are important features in a child’s world. Children need to be reassured their world is secure. (Source: Ibid, pages 71-72)

The unique challenges of urgent and long-term behavioral health care for children following an emergency is summarized in the Project Pediatric Preparedness Final Re- port developed by the Terrorism Research Center:

Mental Health Care (Urgent) Definition: The ability to prevent, recognize, mitigate, and treat specific to their different age groups the immediate symptoms of psychological/emotional distress in children involved in a traumatic incident, as well as treat immediate symptoms in parents and responders dealing with child victims.

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Unique Requirements and Challenges There is enough difference between short-term and long-term mental health needs to necessitate each to be broken out separately; there are different systems in place to deal with each.

Children, parents/families, and responders may have different mental health needs. What may be upsetting for a family member or parent is not necessarily upsetting for a child. Conversely, children may not have the mental wherewithal to process and deal with a traumatic event the way an adult may be able to and therefore may suffer more.

The type of mental health intervention needed depends on time and length of exposure (direct or indirect), type of incident, and child’s history. It should be remem- bered that children do not always have to witness something directly to be traumatized; recurrent images on television, for example, can be upsetting.

Children’s cognitive and developmental levels, age, cultural and religious background can all impact on their socio-emotional responses.

It is not always possible to honor parents’ wishes in a traumatic situation. Sometimes parents do not want information passed on to very young children, but that can put teachers and other caregivers in a bind. There needs to be an understanding of the expectations of parents when something happens.

Parents want to be with their children and this can impact mental health well-being. During a major incident, while it may be unavoidable in some cases that children are separated from adults, especially if there is some sort of contamination, most children, especially younger children, feel more secure emotionally when their parents are with them. If they are not, then they may be more susceptible to mental health trauma.

While first responders need to focus their training and real-life efforts on the task at hand,there needs to be some sort of balance between practicality and dealing with children and their emotions. A first responder does not have time for psychology with children. However,they can be trained to provide information in a different way to a child that might be less alarming to their mental state. First responders have been asking for this type of training.

Mental Health Care (Long-Term) Definition: The ability to prevent, recognize, mitigate, and treat specific to their different age groups the delayed symptoms of psychological/emotional distress in children involved in a traumatic incident.

Unique Requirements and Challenges Language, culture, costs and availability can be barriers to effective long-term mental health needs of children and families in the community.

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Stigma about seeking mental health care can prevent the parent/ guardian from allowing the child to get help. Public education about the value of seeking psychiatric treatment needs to be improved.

Under normal circumstances, there is already a treatment shortage, only 20 % of children gain access to the mental health care they need. There is also a very severe shortage of child psychologists. Moreover, the costs of long-term care can also prohibit access.

There is not enough understanding of how to handle mass mental health needs. There is not enough coping skills curriculum, and it is an area in which the community needs to be involved.

Parents, teachers and pediatricians need to be able to recognize the signs of what constitutes a delayed mental health reaction. (Source: Powell M, Tulsa, Project Preparedness Final Report, Unique Require- ments, Goals, Capabilities and Gaps in Pediatric Emergency Preparation and Re- sponse. OK: Terrorism Research Center Prepared for the Emergency Medical Ser- vices Authority, Funded by FEMA, pages 72-73 and 75-76)

FEMA provides the guidance below on reassuring children following a natural disaster that will also be helpful during public health emergencies.

Reassuring Children After a Disaster Suggestions to help reassure children include the following: • Personal contact is reassuring. Hug and touch your children. • Calmly provide factual information about the recent disaster and current plans for insuring their safety along with recovery plans. • Encourage your children to talk about their feelings. • Spend extra time with your children such as at bedtime. • Re-establish your daily routine for work, school, play, meals, and rest. • Involve your children by giving them specific chores to help them feel they are helping to restore family and community life. • Praise and recognize responsible behavior. • Understand that your children will have a range of reactions to disasters. • Encourage your children to help update your a family disaster plan.

If you have tried to create a reassuring environment by following the steps above, but your child continues to exhibit stress, if the reactions worsen over time, or if they cause interference with daily behavior at school, at home, or with other relationships, it may be appropriate to talk to a professional. You can get professional help from the child’s primary care physician, a behavioral health provider specializ- ing in children’s needs, or a member of the clergy.

Behavioral health staff assessing the needs of children should consider the child’s exposure to the natural disaster, as well as the home environment. Keep in mind that children who have witnessed the disaster only via the media can also experience stress reactions. Key considerations include:

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• Direct threat to life and physical safety • Seeing graphic acts of death and injury • Hearing cries for help • Randomness and length of the event • Separation from family members, friends, and caregivers • Family atmosphere • Parental resilience • Exposure to media coverage • Economic hardship

The first step to assisting children is to help them regain a sense of safety and resume normal daily activities. To help them cope: • Answer questions about what happened or what could happen honestly and at a level the child will understand, without dwell- ing on scary details • Openly admit to children that you cannot answer all of their questions • Encourage children to express emotions by talking, drawing, or painting • Encourage children to express their feelings to adults, including teachers and parents • Allow silences • Encourage children to participate in recreational activities • Help children understand that there are no “bad” emotions

Parents, caretakers, and teachers play the most important role in how a child will respond to a disaster. Advise parents, caretakers, and teachers to: • Stay calm and take care of themselves • Not allow the natural disaster to dominate family or classroom time indefinitely • Put together disaster plans and include children in the process • Give children lots of love and extra attention • Validate children’s fears and reassure them verbally, telling them the adults will do everything possible to protect them • Do not allow children to watch news coverage without an adult, who can answer questions and give support • Limit children’s viewing of news coverage as it can further traumatize children and/or enhance their fears/nightmares; consider the age and maturity of the child when deciding how much to limit • Maintain routines and discipline

One-on-one support from a behavioral health worker and extensive intervention might be needed for children who show instant signs of trauma or more problematic reactions. Such children may appear disoriented, display atypical behavior, or be in shock. Appropriate immediate responses might be: • Physical comforting, including snacks and blankets • Rest • Repeated assurance of safety • Honest and age-appropriate answers to questions • Creative materials so they can draw and play

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• Opportunities to talk about their feelings (Source: http://www.fema.gov/rebuild/recover/cope_child.shtm#2)

Older Adults Older adults may in some ways be uniquely resilient to the grief and trauma of public health emergencies. The wisdom and experience accrued over a lifetime can provide them with the tools to help cope with loss, changes, and painful emotions. As older adults become more physically frail or have significant health problems, however, they may be more vulnerable to health risks. When an older person is already feeling vulnerable due to changes in health, mobility, and cognitive abilities, the feelings of powerlessness and vulnerability associated with the public health emergency can be overwhelming. Being quarantined can be disorienting and confusing. Sensory impairment may cause older adults to be unresponsive to offers of help. Some could reject behavioral health help because of the fear of being institutional- ized. Other ways that older adults could be affected include: • Overwhelming grief after losing grandchildren • Fear after losing children who were their primary caretakers • Distresses over having to step in to care for a child whose parents have died, which can be intensified as they worry about changing their lifestyle and making sure there is enough money to care for an extra person in their household • Memories of combat that could be stirred up in war veterans who have witnessed mass casualties

Services for older adults need to be coordinated with senior groups, caretakers, and health care providers. When assessing the needs of older adults, consider the following: • Trauma and loss • Psychological and physical stress • Medical and health status, including their senses, memory, and mobility • Cultural background, including past trauma and loss • Availability and proximity of support systems • Living situation, including assistive features of their homes, such as shower rails and emergency phone numbers on speed-dial • Priority of concerns and needs (Source: Virginia, 2004, pages 77-78)

Rural Communities The U.S. Census Bureau defines rural areas as open country and settlements with fewer than 2,500 residents. The U.S. rural population was 59 million (21 percent) in 2000 (http://www.ers.usda.gov/Briefing/Rurality/WhatIsRural/). The Virginia rural population was approximately 2 million (27 percent) in 2000 (http://www.nemw.org/ poprural.htm).

There is heightened awareness of public health threats in rural areas where the economy is based on agriculture. Today’s farmer has become a biosecurity specialist securing animals and plants from public health threats such as food borne pathogens and

Module 7 184 infectious diseases. September 11, 2001, has brought new attention and efforts to secure our food supply from intentional threats. Public health emergencies may not only threaten health and safety, but have the potential to economically damage agricultural industries and rural communities.

The rural culture differs from urban areas in the seasonal effect of the work, accessibility, and free time available. Besides the normal phases people experience after a disaster, there are other timing considerations. In a farming area, times of seeding, ground preparation, and harvest typically offer reduced accessibility of outreach workers to the affected population. Consideration should also be given to the differing roles and corresponding stressors that apply to men, women, and children in the area….Even if a rural area appears to be homogeneous, ethnic and cultural differences can exist. Differences might exist in educational background, religious beliefs, country versus town dwellers, farmers versus ranchers, people who live by the river versus those who do not, etc. Some small communities are as divided by income, education, and religion as are the most diverse inner-city neighborhoods.

A sense of independence and self- determination is a hallmark of the residents in rural areas. Many rural residents tend to view themselves and their communities as possess- ing a higher quality of life and a more realistic, down-to-earth lifestyle than their urban coun- terparts. Family, close friendships, and a highly developed sense of community com- bine to create a sense of self-sufficiency that persists even in the most difficult circumstances.

Frequently, in times of disaster, these values Zuni, VA, September 24, 1999 -- Residents try to cope with are demonstrated as family, friends, and com- cleanup after Hurricane Floyd flooded their homes. Photo by Liz Roll/ FEMA News Photo munity members provide mutual support, shelter, and care to one another. Rural people may not actively seek help. Residents of rural areas often are not aware of services available or how to access them. They may think the process is too cumbersome or intrusive. It is also common for a farmer or small business owner not to apply for assistance due to pride, an underestimation of loss, or a belief that others are more in need of help. If the decision is made to apply for assistance, the process may be particularly difficult for someone unaccustomed to admitting need and seeking assistance. Asking for help is very difficult when the cultural expectation is competence and self-reliance.

Receiving any form of behavioral health services may be seen as a negative reflection on a person’s character or family life. This pervasive attitude is even more prevalent in rural communities. The rural resident may have a negative impression of behavioral health services and thus would be offended if made to believe they needed such support. Having fewer behavioral health resources in a community and

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a self-reliant cultural bias, people in rural communities may lack an understanding of the need and use of behavioral health services. Therefore, it is recommended that programming and project identity avoid the use of mental health jargon and frame services in terms of everyone deserving counseling services.

In rural America, traditional organized religion is often a powerful presence. The religious traditions of individuals, families, and communities have become the primary expression of their sense of right and wrong, moral and immoral, good and bad. These traditions provide the structure and language by which the rural population evaluates the world and makes decisions. Such a personal belief system can aid greatly in the recovery process. Collectively, the community faith-based centers represent a cross-section of the local social structure with respect to income, education, vocations, and community involvement.

When providing services to rural community members, consider the following: • Respect their reluctance to discuss behavioral health issues • Team with appropriate community gatekeepers; these are often individuals from families that are respected in the community • Approach them from a wellness perspective • Use messages of resilience and encourage them to stay positive • Take time to earn their trust (Source: Ibid, pages 79-80)

First Responders Emergency workers—police, rescue squads, firefighters—are often the first ones on the scene and the last ones out. Long hours, harsh working conditions, and a close- up view of death and destruction leave them vulnerable to intense trauma reactions. They may have more exposure to the health risk than the general population. (Ibid, pages 80-81)

Specifically, first responders are affected by: • Scale of an event • Randomness of an event • Failure to save people immediately or at all • Exposure to carnage • Identifying with survivors • Direct threat to life or of harm • Erratic work schedules and environments • Fatigue • How clearly they understand their role • How much training, experience, and equipment they have to do their job • Authority issues within their organizations • Jurisdiction issues with other agencies

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• Cultural clashes with communities or other workers • How they are perceived by a community (Source: Adapted from Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., & Gusman, F.D. Disaster mental health services: A guidebook for clinicians and administrators. Menlo Park, CA: Department of Veterans Affairs, The National Cen- ter for Post-Traumatic Stress Disorder. Available from http://www.ncptsd.org/ publications/disaster/index.html in Virginia, 2004, Helping to Heal: A Training Manual on Mental Health Response to Terrorism, pages 81-83)

The most severe reactions arise when first responders: • Are overexposed to the dead and dying • Deal with corpse removal, especially of children • Experience extreme fatigue and physical exhaustion • Are exposed to toxic agents like chemical or radioactive material or other public health risks

Personal situations, such as problems at home or fantasies Working with Firefighters and Paramedics about being heroes, also shape first re- I have worked with several of the firefighters and paramedics who sponders’ experience responded to the Pentagon on September 11 and were part of the with the public recovery efforts. In the first stages, I did ride-alongs at four stations health emergency. to gain trust, educate them about the program, etc. I went on the In particular, lacking “Fireline” show for the department in November 2001, and again in social support could November 2002, to discuss the Community Resilience Program and leave some first how persons would recognize symptoms of stress. responders vulner- By December 2001, I had spoken with many of those who re- able. Police officers, sponded, and even had some “dinner-time firehouse discussions.” for example, often Others would seek me out individually, just to express difficulties work solo or with sleeping or images coming into their minds. The wife of a para- one partner. The medic who was part of the recovery met with me several times dur- solitary nature of ing the first 6 months because she was having nightmares and was their business gives crying when the news came on. Her husband also stayed on my them few chances to “watch” because, although he is a “tough guy,” he was having a build supportive re- stress reaction of increased irritability, and some family problems lationships—the had come up that made it more challenging. closest bond they have might be with I have continued occasional ride-alongs and events so that they re- their partner. main familiar with me. Often different fire or paramedic supervisors Should something will contact me saying they have a concern and asking me to come happen to their out to the station. partner, it could be Virginia, 2004, page 81 devastating.

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Firefighters treat each other more like family. They share meals together and sometimes even live in the same house. Having more people to talk to, however, does not mean they will share their feelings. Like law enforcement workers, many firefighters worry about being labeled “unfit for duty” if they open up about being scared or anxious.

When do first responders need the help of behavioral health workers? Watch for these stress reactions: • Shock • Impaired concentration • Irritability and anger • Confusion and disbelief • Distorted perception of situations • Terror and despair • Intrusive thoughts • Guilt • Decreased self-esteem • Feeling powerless and helpless • Grief • Disassociation with individuals and activities

Arlington, VA, September 20, 2001 -- FEMA Urban Search and Res- While these reactions are common, cue workers from New Mexico Task Force-1 continue work at the in the long term they could lead to Pentagon. Photo by Jocelyn Augustino/FEMA News Photo depression, chronic anxiety, or retraumatization. They could also cause or worsen existing problems at work, with families, or with substance abuse. Stress prevention and management needs to be incorporated into training by employers. If first responders are reluctant to open up in job-sponsored forums, however, they may consider getting help from outside their working world. This could include a community program or behavioral health services provided by phone or online. They may respond more positively in an environment that recognizes their contributions and respects their silences. It is important that intervention should be individual, voluntary, and at a pace with which first responders are comfortable. (Source: Ibid, pages 82-83)

The following table offers immediate and longer-term suggestions you can give first responders to help manage their workload, maintain a balanced lifestyle, reduce stress, and conduct a self-assessment for trauma reactions.

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Approaches for Stress Prevention and Management for First Responders

Dimension Immediate Response Longer Term Response Management of Workload Clarifying with immediate on-site Planning, time management, and supervisor regarding task priority avoidance of work overload (e.g. levels and work plan "work smarter, not harder') Recognizing that "not having Conducting periodic review of pro- enough to do" or "waiting" is an gram goals and activities to meet expected part of crisis mental stated goals health response Delegating existing "regular" work- Conducting periodic review to de- load so that workers are not at- termine feasibility of program tempting disaster response and scope with the human resources their usual job available Dimension Immediate Response Longer Term Response Balanced Lifestyle Ensuring nutritional eating and Maintaining family and social con- hydration; avoiding excessive junk nections away from program food, caffeine, alcohol, or tobacco

Getting adequate sleep and rest, Maintaining (or beginning) exer- especially on longer assignments cise, recreational activities, hobbies, or spiritual pursuits Engaging in physical exercise and Pursuing healthy nutritional habits gentle muscle stretching when possible Maintaining contact and connec- Discouraging overinvestment in tion with primary social support work

Dimension Immediate Response Longer Term Response Stress Reduction Strategies Reducing physical tension by using Using cognitive strategies (e.g., familiar personal strategies (e.g. constructive self-talk, restructuring taking deep breaths, washing face distortions) and hands, meditation, relaxation techniques)

Using time off to "decompress" and Exploring relaxation techniques "recharge batteries" (e.g. getting a (e.g. yoga, meditation, guided im- good meal, watching TV, shooting agery) pool, reading a novel, listening to music, taking a bath, talking to family) Talking about emotions and reac- Pacing self between low- and high- tions with coworkers during appro- stress activities, and between propriate times viding services alone and with support Talking with coworkers, friends, family, pastor, or counselor about emotions and reactions

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Dimension Immediate Response Longer Term Response Self-Awareness Recognizing and heeding early Exploring motivations for helping warning signs for stress reactions (e.g., personal gratification, feeling needed, personal history with victimization or trauma)

Accepting that one may not be able Understanding when "helping" is to self-assess problematic stress not being helpful reactions Over-identifying with or feeling Understanding differences between overwhelmed by survivors' and professional helping relationships families' grief and trauma may re- and friendships sult in avoiding discussing painful subjects Traumatic overload and prolonged Examining personal prejudices and empathic engagement may result in cultural stereotypes vicarious traumatization or compassion fatigue

Recognizing discomfort with despair, hopelessness, rage, blame, guilt, and excessive anxiety, which interferes with the capacity to "be" with clients Recognizing over-identification with survivors' frustration, anger, anguish, and hopelessness resulting in loss of perspective and role

Recognizing when own disaster experience or personal history interferes with effectiveness Being involved in opportunities for self-exploration, and addressing emotions evoked by disaster work

(Source: Adapted from the Center for Mental Health Services, In Press, Mental Health Response to Mass Violence and Terrorism, Rockville, MD: CMHS, SAMHSA, DHHS)

Other Considerations Public health emergencies may potentially impact many different groups in different ways. It is important that the behavioral health workers assess which groups have been impacted and how they have been impacted. This section provides Virginia’s experience with other groups and illustrates how behavioral health workers can identify and provide appropriate services to each of these groups.

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PEOPLE WITH PHYSICAL Reaching People Who are Deaf or Hard of Hearing DISABILITIES People with physical disabilities may The CRP helped members of the deaf and hard of hear- feel extremely helpless if separated ing community recover by providing group and individ- from caretakers or special equip- ual crisis counseling with deaf and hard of hearing ment or assistance, such as wheel- counselors. Ultimately, the goal was to connect service chairs, hearing aids, walking sticks, providers together and train the trainers to provide psy- or seeing-eye dogs. As much as is chological preparedness education to the deaf and hard possible, the specific physical needs of hearing community. The deaf and hard of hearing of people with different sight, hear- counselors also presented a workshop on psychological ing, and mobility limitations need to preparedness at the National Deaf and Hard of Hearing be met. Outreach materials, for ex- in the Government conference held at the National Insti- ample, can be produced with close tutes of Health. The presentation was standing room captioning or written in Braille. only and demonstrated the desire for such information Also, interpreters can be used to help in the deaf and hard of hearing community. communicate in sign language. Virginia, 2004, page 86 PEOPLE WITH SERIOUS MENTAL ILLNESS People with serious mental illnesses can feel terrified and confused by a public health emergency. Not fully understanding what happened can lead to additional trauma, which may require extra medication or hospitalization. When providing services, consider the following: • Recognize they may be resilient and “rise to the occasion” • Others may need additional behavioral health support, medication or hospitalization. • Offer the range of interventions designed for the general population to people with mental illnesses • Watch closely for trauma reactions that are similar to symptoms of mental illness • Monitor people with PTSD who could react to triggers such as sirens and feelings of powerless that may remind them of past trauma (Source: CMHS, 2000, Field Manual for Mental Health and Human Service Work- ers in Major Disasters. Rockville, MD: Substance Abuse and Mental Health Ser- vices Administration, U.S. Department of Health and Human Services)

ECONOMICALLY DISADVANTAGED COMMUNITIES Economically disadvantaged communities generally have fewer behavioral health services available to residents. Residents may be mistrusting of government- sponsored programs and hesitant to take advantage of services. People living in such communities may be unemployed, underemployed, facing the stress of losing a job, or unable to find one due to a disaster. Financial worries could heighten their anxiety after a disaster. Economically advantaged communities, on the other hand, may resist services because residents might have a difficult time accepting their lack of control over the situation and their need for help. Assistance could be seen as handouts or governmental intrusion they are unaccustomed to accepting.

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In order to provide behavioral health services to different groups, behavioral health workers are encouraged to assess their level of cultural awareness and seek to increase it by gaining an understanding of the community makeup that influences reactions to tragic events. Community gatekeepers and leaders are an invaluable resource during this process, as they provide information about vulnerabilities, access, communication, and other issues.

Understanding and appreciating different populations is not only about what is in a community profile or what gatekeepers have to say—it requires a continual assessment of the salient population groups that require assistance as a result of disasters, looking at how they and their situations change. Be patient, be flexible—and be watchful. There will always be new groups to help and new ways to help them. (Source: Virginia, 2004, page 87)

THE ROLE OF BEHAVIORAL HEALTH STAFF CMHS recommends using crisis counselor and outreach worker synonymously. The following description of roles has been adapted from CMHS guidance Staff Roles and Services within Crisis Counseling Programs:

Both should be providing crisis counseling services to survivors in a variety of locations through an outreach method of service delivery. It may be more acceptable to some communities for "outreach workers" to provide crisis counseling services; other communities may be quite comfortable with "crisis counselors" providing these services. Either reference, outreach worker or crisis counselor, is acceptable in describing the individuals who will be providing services. Throughout this guidance, "outreach workers" and "crisis counselors" will be used interchangeably.

Crisis counselors provide: • active and supportive listening • validation of the appropriateness of an individual's feelings and reactions affir- mation that such feelings and reactions are normal • education to survivors about ways to manage their distress and take care of themselves as they pursue recovery • assistance to survivors in determining their priorities and developing plans for meeting those priorities • information and referral on disaster assistance and human service resources

Crisis counselors do not: • engage in case-finding activities • provide case management services • create or implement emergency preparedness activities • advocate in an adversarial manner • engage in fundraising for disaster survivors • provide childcare or transportation for disaster survivors

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Typically, a team of outreach workers is composed of behavioral health professionals and para-professionals indigenous to the community. All are trained in the basics of disaster behavioral health. Their cre- dentials and roles are explained below:

Professionals: Professionals are individuals who have a master's level or higher degree in psychology, social work, counseling, psychiatric nursing, or who are psychologists, psychiatrists, or related professionals. They usually are licensed by the State, have experience in the behavioral health or counseling field and the expertise to provide clinical supervision and training to crisis counselors. Typically, a professional coordinates and supervises the Houston, TX., 9/3/2005 -- Counselors and volunteers help stressed local outreach team and may offer consulta- and grief stricken evacuees deal with the trauma of Hurricane tion and support to crisis counselors who are Katrina in the Astrodome. FEMA photo/Andrea Booher working with individuals' with complex or difficult situations. They may also assess survivors to determine if their needs exceed the scope of the behavioral health services or they may work directly with individuals, families, and groups whose problems are unusually challenging or complex. Professionals often need training in how behavioral health services during a public health emergency differs from traditional behavioral health or counseling practice. Essential skills include in-depth understanding about the normal human response to disaster and techniques for helping survivors integrate those experiences to ensure their return to pre-disaster levels of functioning.

Para-professional: The term para-professional refers to individuals who work as crisis counselors, have a bachelor's degree or less, or who are not human service professionals. They have strong intuitive skills about people or relate well to others. They possess good judgment, common sense, are good listeners, and most often are indigenous to the community. Para-professionals will engage in outreach, crisis counseling, and provide education, information and referral services for individuals, families and groups. Successful Crisis Counseling Programs train paraprofessionals regarding the human response to disaster and methods for working with people who are experiencing the psychological consequences of disasters. Training should include the scope and limits of the program, the role of the crisis counselor, cultural considerations, ethical conduct, techniques for introducing oneself and the program, helping individuals understand their disaster experience, record keeping, functional assessment skills, basic group process skills, and methods for guiding individuals in problem solving and setting priorities.

Indigenous Worker: Indigenous workers are crisis counselors who come from within the local community and are often part of the cultural or ethnic group receiving services. They are familiar to and recognized by community members. They may be community leaders or have a nurturing role in their communities. They may be behavioral health professionals already working in the community. Other examples

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of indigenous workers include retired persons, students and active community volunteers. Indigenous workers may have formal training in counseling or related professions. They may be para-professionals or professionals in other fields, as well. (Source: CMHS, Staff Roles and Services within Crisis Counseling Programs, http://mentalhealth.samhsa.gov/cmhs/EmergencyServices/ccp_pg03.asp)

SUMMARY Responding to the behavioral health needs of individuals and a community following a public health emergency requires that the CSB coordinate with many other organizations and agencies at the Federal, State and local level. Public health emergencies pose a greater risk to larger numbers across the country. Service resources could become quickly overwhelmed. Service initiatives such as psychoeducation and training on behavioral health that can be used to reach out to large numbers may play an elevated role in a public health emergencies. There is no clear guidance on how many people will need to be referred to longer term services. There is indication the numbers could far surpass what has been experienced for natural disasters and terrorism due to mass fatality and the magnitude of the public health event.

RESOURCES

American Red Cross Publications and guidance on disasters and behavioral health response to disasters http://www.redcross.org/services/disaster/0,1082,0_319_,00.html

Centers for Disease Control and Prevention Publications and guidance on public health emergencies http://www.bt.cdc.gov/mentalhealth/

SARS control and psychological effects of quarantine Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, and Styra R. , Toronto, Canada. Emerg Infect Dis [serial on the Internet]. 2004 Jul [date cited]. http://www.cdc.gov/ncidod/EID/vol10no7/03-0703.htm

Center for the Advancement of Collaborative Strategies in Health Redefining Readiness: Terrorism Planning Through the Eyes of the Public Lasker RD. New York, NY: The New York Academy of Medicine, 2004 http://www.cacsh.org/pdf/RedefiningReadinessStudy.pdf

Center for Mental Health Services http://www.mentalhealth.org/cmhs/

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Design and Implementation of Disaster Mental Health Services: A Handbook for Mental Health Professionals (unpublished) Center for Mental Health Ser- vices, Substance Abuse and Mental Health Services Administration, U.S. De- partment of Health and Human Services http://nmhicstore.samhsa.gov/cmhs/EmergencyServices/pubs.aspx

Disaster mental health: Crisis counseling programs for the rural community. DHHS Publication No. SMA 99-3378 Washington, DC

Mental health response to mass violence and terrorism: A training manual DeWolfe, D.J. (Ed.). (In press). Rockville, MD: Center for Mental Health Ser- vices, Substance Abuse and Mental Health Services Administration Program Guidance http://mentalhealth.samhsa.gov/cmhs/EmergencyServices/progguide.asp

Department of Veterans Affairs www.ncptsd.org/publications/disaster/index.html

Federation for American Immigration Reform Immigration Reform Web site: http://www.fairus.org/html/042vasoc.htm

National Association for Rural Mental Health http://www.narmh.org

National Center for PTSD Research, publications and fact sheets on trauma related topics http://www.ncptsd.va.gov/

Disaster mental health services: A guidebook for clinicians and administrators Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., & Gusman, F.D. (1998). Menlo Park, CA: National Center for Post-Traumatic Stress Disorder, U.S.

National Organization on Disability http://www.nod.org/

New York Academy of Medicine http://www.nyam.org

Northeast Midwest Institute Research organization focusing on economic vitality, environmental quality, and regional equity for Northeast and Midwest states

SAMHSA Disaster Technical Assistance Center http://mentalhealth.samhsa.gov/dtac/default.asp

State statistics on rural population http://www.nemw.org/poprural.htm

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Terrorism Research Center Project Pediatric Preparedness Final Report Unique Requirements, Goals, Ca- pabilities and Gaps in Pediatric Emergency Preparation and Response Powell, M, Terrorism Research Center. Prepared for the Emergency Medical Services Authority, FEMA funded, pages 62-63.

U.S. Census Bureau www.census.gov/population/www/index.html

American Fact Finder http://factfinder.census.gov/servlet/BasicFactsServlet

U.S. Department of Agriculture http://www.ers.usda.gov/Briefing/Rurality/WhatIsRural/

U.S. Department of Health and Human Services

HHS Pandemic Influenza Plan and other guidance http://www.dhhs.gov

Office of Minority Health Resource Center www.omhrc.gov

Virginia Department of Health http://www.vdh.virginia.gov

Virginia Pandemic Flu Plan http://www.vdh.virginia.gov/PandemicFlu/pdf/ DRAFT_Virginia_Pandemic_Influenza_Plan.pdf

Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services http://www.dmhmrsas.virginia.gov

Helping to Heal: A Training Manual on Mental Health Response to Terrorism http://www.dmhmrsas.virginia.gov/CWD-default.htm

Virginia: Social policy issues. Accessed 2003 at the Federation of Ameri- can.

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This historical image depicts two American Red Cross employees handing out medical supplies to a woman from a mobile unit. CDC

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INTRODUCTION Promoting behavioral health during a public health emergency requires close coordination with other government offices and organizations that will be responding. Behav- ioral health workers will not only be providing information to the public about potential reactions and coping strategies, but may also be helping officials understand what the public is going through to help the officials communicate more effectively.

A public health emergency, such as pandemic influenza, may present a variety of unique communication challenges. For instance, during a severe pandemic, sources of outreach behavioral health workers usually use may not be available: schools may be closed, community events may be canceled, stores and offices may be closed. Communicating will likely require strategies that will reach people in their homes, such as the internet, mailings, television, newspapers, and radios, as well as telephone hot lines. There may also be places where people still go during a public health emergency, such as vaccination sites, doctor’s offices, pharmacies, and hospitals. Additionally, the duration of a public health emergency may be much longer than other disasters. For example, pandemic influenza is anticipated to occur in waves, lasting 6 to 8 weeks in an impacted commu- Hampton Roads Media Briefing nity, with the actual duration of the pandemic lasting for up to 18 months in the United States (VDH Draft Pandemic Influ- enza Plan, 2006, Executive Summary). Other issues may surface in a public health emergency that may not be present in other disasters, such as stigmatization. It is critical that behavioral health workers are aware of these potential issues and barriers so they will be better prepared to address them before, during, and after a public health emergency.

It is important to note that coping in a public health emergency may include taking steps to protect against and reduce illness, such as washing hands, covering coughs, and preparing emergency supply kits. Encouraging people to take action will help them cope more effectively with the stress reactions they may have as a result of the emergency (See the article Encouraging and Active Rather than Passive Public in Module 3). Behavioral health and public health are closely linked in helping people get through a public health emergency.

This module provides information about communicating effectively before, during, and after a public health emergency, with specific information about pandemic influenza, as it is one of the greatest threats we are now facing.

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CRISIS AND EMERGENCY RISK COMMUNICATION Seven Risk Communication Concepts The Department of Health and Human Services Pandemic Influenza Plan provides guidance to help State and local governments prepare for pandemic influenza. One of the 11 supplements to the plan is Public Health Communications. Within this section are seven key risk communication concepts, listed below, to help prepare communications for pandemic influenza. 1. When health risks are uncertain, as likely will be the case during an influenza pandemic, people need information about what is known and unknown, as well as interim guidance to formulate decisions to help protect their health and the health of others. 2. Coordination of message development and release of information among federal, state, and local health officials is critical to help avoid confusion that can undermine public trust, raise fear and anxiety, and impede response measures. 3. Guidance to community members about how to protect themselves and their family members and colleagues is an essential component of crisis management. 4. Information provided to the public should be technically correct and succinct without seeming patronizing. 5. Information presented during an influenza pandemic should minimize speculation and avoid over-interpretation of data, overly confident assessments of in- vestigations and control measures. 6. An influenza pandemic will generate immediate, intense, and sustained demand for information from the public, healthcare providers, policy makers, and news media. Healthcare workers and public health staff are likely to be involved in media relations and public health communications. 7. Timely and transparent dissemination of accurate, science-based information about pandemic influenza and the progress of the response can build public trust and confidence. (Source: HHS Pandemic Influenza Plan, 2005, Supplement 10, http:// www.hhs.gov/pandemicflu/plan/sup10.html)

Principles of Emergency Risk Communication EMERGENCY RISK COMMUNICATION Regardless of the kind of risk, threat, or disaster, there are basic rules for emergency risk communication. These apply when talking to anyone: the media, the public, officials, and stakeholders. The Basics of Emergency Risk Communica- tion, adapted from the Centers for Dis- Activity in the Virginia Emergency Operations Center after Hurri- ease Control and Prevention are provided cane Isabel. Michaele White, Governor's Office

Module 8 200 below to help guide the CSB’s communication efforts. Though during a public health emergency, other officials may be providing information to the media, but the CSB will still have an important role in ERC.

The Basics of Emergency Risk Communication (ERC) Emergency Risk Communication is the art of providing information during a crisis that: • Responds as quickly, accurately, and fully as possible • Educates individuals on the best possible choices they can make for their well-being • Communicates risks without creating panic • Acknowledges when facts are limited or unavailable • Enables and models resilience and recovery

How to do it: • Realize that your goal is not to dictate what the public should do. • Instead, give people information to keep them involved, interested, thoughtful, solution-oriented, and collaborative. • Listen to the audience. • Find out what they know, what they are thinking, and how they are feeling. • Provide information that addresses their concerns and uncertainties. • Earn trust and credibility—do not expect it. • If you do not know or are unsure about something, say so. • If you make a mistake, correct it. • Be honest and open. • Coordinate with other sources. • Take the time to build relationships and collaborate with other credible organizations. • Work with the media. • Respect their formats and deadlines. • Be open and accessible to them. • Share background information and positive messages with them. • Leave “office-speak” at the office. • Information that is shared with empathy and uses real-life stories captures an audience more than any jargon can. • Plan, deliver, and assess. • Develop and communicate messages that meet the needs of the audience. • Evaluate their impact and revise as appropriate.

What counts most in Emergency Risk Communications: • Simplicity • Credibility • Verifiability • Consistency • Speed (Source: CDC, 2003, Emergency Risk Communication (ERC) CDCynergy, Office of Communications, HHS)

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COMMUNICATION PLAN AND GOALS Before an emergency or disaster strikes, it is important to develop a communication plan that will guide communication efforts. This plan should identify the chain of command within the emergency response; the spokesperson for the CSB or local government office; individuals and groups who you need to coordinate with to communicate; your goals, strategies, and messages; and your target audiences. Knowing this information before an emergency or disaster will help you communicate and promote your CSB’s behavioral health services more effectively during a public health emergency. Be- low is a list of the type of information to include in your communication plan.

Behavioral Health Response History • Identify disasters and emergencies that have impacted your area in the past to understand what people in your community may have already experienced, how they reacted, and what you may expect in the future. • Identify how the CSB’s behavioral health communication is incorporated into the overall emergency response. • If there has been an emergency or disaster in your area before, determine what public information and education efforts about behavioral health were conducted. • If there has been an emergency or disaster in your area before, determine the messages that were used, what was effective and what was not.

Coordination and Planning • Include the name and contact information of person or persons who generated and approved the communication plan with the date of origination and updates. • Identify the chain of command in your county for planning for responding to emergencies and disasters. • Identify the spokesperson for your CSB or for your county government, and others who may be responding such as the public health office and emergency management. • Identify the individual or office that coordinates verification and release of information to the public, media, stakeholders, and others. • Meet with officials and public information staff (and the spokesperson if it will be someone other than yourself) who will be responding after a public health emergency to share contact information, prepare coordination and communication roles and procedures, and explain how behavioral health fits with overall planning, response, and recovery. • Request that behavioral health information be integrated into overall public health emergency planning and response messages and communication. • Coordinate messages among your outreach workers and other public health, emergency management, and response organizations to ensure that the information is consistent before you talk to the media or the public. • Identify groups and organizations—governmental, public, private, and nonprofit— that will respond to a public health emergency. Make a list with names and contact information for each. • Identify stakeholder groups and organizations your CSB works with regularly that

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may require information and coordination from you after a public health emergency. Make a list with names and contact information. • Identify and make a list of potential partner organizations, associations, and other groups to which the specific audiences in your area may belong. Reaching out through these organizations may help you build credibility and establish trust. To make this list, consider going to an online directory, such as www.superpages.com, and searching on churches, associations, community and civic organizations, community centers, and others, by zip code. • Make sure to include the following information for your lists: • Name of organization • Description of organization (i.e. local government, military, businesses, religious, etc.) • Types of communication they conduct that you could use (newsletters, web sites, meetings, etc.) • Contact name • Title • Telephone • Cell phone • Email • Fax • Pager • Be familiar with State and local emergency response plans (See Module 3).

The HHS Pandemic Influenza Plan provides the following guidance about providing coordinated communications leadership across jurisdictional tiers: • Work with state and local officials to involve communications professionals on senior leadership teams, including roles as liaisons to national communications teams at CDC and other agencies as necessary. • Maintain strong working relationships with colleagues in other jurisdictions and regions, even when an outbreak may not yet have affected your area directly or may have subsided locally. The following colleagues are especially important to consider: • Public affairs directors and information officers from other local and state health departments • City and state government public affairs officers • Communications staff at congressional and other government offices • Communications staff at local and regional police, fire, and emergency management offices • Regional health and emergency preparedness colleagues • State and local mental health agencies • Hospital public relations/affairs departments • State and local Emergency Operations Center coordinators • Federal Emergency Operations Centers • Promote public acceptance and support for national response measures and contingency plans. (Source: HHS Pandemic Influenza Plan, 2005, Public Health Communications, Supplement 10, http://www.hhs.gov/pandemicflu/plan/sup10.html#apdx1)

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Below is guidance for State and local officials from the HHS Pandemic Influenza Plan (HHS Pandemic Influenza Plan, Public Health Communications, Supplement 10, http://www.hhs.gov/pandemicflu/plan/sup10.html#apdx1) about collaborative planning. This information will be helpful for behavioral health workers as they coordinate with other offices to prepare a comprehensive communications plan. • Collaborative planning should begin as early as possible. Communications professionals in the public and private sectors need to ensure strong and well- integrated working relationships that will help sustain communications resources as a pandemic evolves. Federal interaction with WHO and other international partners is vital to surveillance and other essential information ex- change and to building collaborative and consistent messaging strategy. The following recommendations are critical elements of a comprehensive domestic response: • When appropriate, coordinate training and other preparedness activities that include options for backing up key communications personnel in the event of their personal illness or emergency. • Coordinate with partner agencies to prepare for appropriate public, healthcare provider, policy, and media responses to outbreaks of pandemic influenza. Be prepared to address the following topics as a pandemic alert draws near: • Basic health protection information the public and other target audiences will need • Responsiveness, capabilities, and limitations of the public health system • Roles and responsibilities of diverse pandemic response stakeholders • Resources to help people cope with escalating fear, anxiety, grief, and other emotions. • How public health procedures and actions may change during different pandemic phases and why unusual steps may be needed to protect public health. • Consider when and how to use federal assistance when available. For instance, background information and frequent updates for communications and other healthcare professionals will be available on the www.pandemicflu.gov website and through other official mechanisms. • Identify and engage credible local resources as partners. For example, local chapters of nonprofit health organizations may assist with urgent communications to community groups. • Affirm mechanisms with news media representatives to optimize effective working relationships during pandemic phases. • Ensure that communications professionals have opportunities to participate with other public health and emergency staff in tabletop exercises and drills to help identify and resolve potential problems in the Interpandemic and Pan- demic Alert periods. (Source: Ibid)

Communication Goals and Messages Identify what your goals may be in communicating behavioral health information before, during, and after a public health emergency, such as:

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• Informing the public about the behavioral health impact, such as common reactions. • Informing the public about effective coping strategies. • Educating the public. • Demonstrating the behaviors and actions that are encouraged. • Providing information about actions people can take to help protect and prepare themselves, and help reduce the spread of disease, while explaining that these actions are positive coping steps and will help them prepare mentally as well as physically. • Providing information about the types of reactions people may have during different stages of a public health emergency. • Encouraging peo- Know your community and the various “Community Leaders” who have ple to call or visit a website for in- access to the community. Respect and value the diversity of every formation and community that you plan to do outreach in. Different populations re- help. spond very differently to stress and frustration. It is essential that this is recognized and the CCP being developed reflects the differences. If Your goals may be your CSB is in a disaster prone area, you should be pro-active rather broadly determined than reactive. START PLANNING NOW! Being planning how you will before a public health provide coverage of the Disaster Recovery Centers when asked to. We emergency; during a are already meeting with the City Emergency Management Staff to plan specific public health for our response to hurricane season. emergency, these Hampton-Newport News CSB goals should be tailored to that event, and updated throughout the course of the public health emergency to meet the information needs of the individuals and communities impacted. Develop messages that will help you meet your goals. The section on message mapping in this module will explain how to accomplish that.

Remember that your goals and messages will change during the course of the public health emergency. What you communicate will also depend on the type of emergency, who was impacted, changing community needs, changing and updated information, and how you are communicating (i.e. brochure or checklist or ad). Also note that you may find that some messages and methods of communicating work better than others. Be prepared to revise your materials and how you communicate to focus on what works.

Target Audiences • Identify specific audiences or groups in your area. • Determine the best ways to reach these different audiences. • Understand your audiences—their perceptions, beliefs, customs, fears, etc.—before you start to communicate with them so your efforts will better address their specific concerns before, during, and after a public health emergency. • Identify potential obstacles your CSB has faced in reaching various groups. • Identify organizations that may be helpful in reaching these various groups.

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Strategies • Identify and prepare information about behavioral health to have on hand, which may be prepared with blanks for information you will update at different phases of a public health emergency. • Identify ways in which your CSB or the local government agency responsible for communicating to the media before, during, and after a public health emergency, will provide information, and work to ensure that behavioral health information about reactions and coping strategies to the emergency are incorporated into this communication. • Determine if your CSB already has a website or a section on its website about behavioral health related to emergencies and disasters; include information specific to public health emergencies here. • Determine if your CSB has a toll free number people may call for more information before, during, and after a disaster, as well as a TDD or TDY number. • Identify and make a list of the media that reach people in the general areas served by your CSB as well as the specific groups served. Remember that the media that reach people and specific audiences in the impacted area may not always be physically located in the same area. Include the information below on your list: • Type of media (newspaper, radio, television, newsletter, etc.) • Name of media • Audience (general, military, farmers, etc.) • Circulation or reach (number of people reached and where they are located) • Frequency of the media (daily, weekly, monthly, quarterly) • Contact name • Title • Telephone • Fax • Cell phone • Email

Make sure that all media inquiries are directed to the designated spokesperson, and that any communication with the media has been approved beforehand. UDED IN A MEDIA COMMUNICATION Below is information from the World Health Organization about what should be included in a media communications plan. This information was developed to respond to public health emergencies. Though some of the recommendations may be more applicable to officials who are responsible for the overall response, but these are important for behavioral health workers to understand and include in the CSB’s plan.

A media communications plan should: • describe and designate staff roles and responsibilities for different emergency scenarios; • designate who is accountable for leading the response; • designate who is responsible for implementing various actions; • designate who needs to be consulted during the process; • designate who needs to be informed about what is taking place;

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• designate who will be the lead spokesperson and backup for different scenarios; • include procedures for information verification, clearance and approval; • include procedures for coordinating with important stakeholders and partners (for example, with other health agencies, and law enforcement and elected officials); • include procedures to secure the required human, financial, logistical and physical support and • resources (such as people, space, equipment and food) for media communication operations during a short, medium and prolonged public health event (24 hours a day 7 days a week if needed); • include agreements on releasing information and on ownership (who releases what, when and how); • include polices and procedures regarding employee contacts from the media; • outline well thought out contingency plans for various scenarios; • include regularly checked and updated media contact lists (including after- hours news desks); • include regularly checked and updated partner contact lists (day and night); • outline exercises and drills for testing the media communication plan as part of larger preparedness and response training; • identify subject-matter experts (for example, university professors) willing to collaborate during an emergency, and develop and test contact lists (day and night); know their perspectives in advance; • identify target audiences; • identify preferred communication channels (for example, telephone hotlines, radio announcements, news conferences, web site updates and faxes) to communicate with the public, key stakeholders and partners; • contain holding statements (messages prepared in advance), core messages and message templates; • contain fact sheets, question-and-answer sheets, talking points and other sup- plementary materials for potential scenarios; • contain a signed endorsement of the media communication plan from the agency’s director; • contain procedures for posting/updating information on a web site; • contain task checklists for the first 2, 4, 8, 12,16, 24 and 48 hours; and • contain procedures for evaluating, revising and updating the media communication plan on a regular basis. (Source: Effective Media Communication during Public Health Emergencies, World Health Organization, July 2005, page 14)

MESSAGES What you say is critically important in helping you meet your communication goals. To determine your messages, consider using message maps. Message maps are risk communication tools that will help you organize complex information and present that information more clearly so people impacted by a public health emergency are more likely to hear and process your messages accurately. To prepare message maps, begin with a key message, then develop three short supporting facts for that key message.

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According to the HHS, the messages should be written at a 6th grade reading level and presented in three short sentences that convey three key messages in 27 words. This is based on surveys indicating that lead or front-page media and broadcast stories usually convey only three key messages usually in less than 9 seconds for broadcast media or 27 words for print.

It is important to remember that people process information differently during a crisis, so it is important to keep your messages clear and concise. What follows is information about mental noise and message maps from Communication in Risk Situations: Re- sponding to the Communication Challenges Posed by Bioterrorism and Emerging In- fection Diseases, published by the Association of State and Territorial Health Officials in April 2002.

Mental Noise Theory When people are upset they have difficulty hearing, understanding, and remember- ing. • Send a limited number of clear messages: 3 key messages • Keep messages brief: 10 seconds or 30 words • Repeat messages: Tell them what you are going to tell them. Tell them. Tell them what you told them. • Use visual aids: graphics, slides • Be aware that it takes three positive messages to balance one negative statement • Avoid unnecessary use of the words: No, Not, Never, Nothing, None

Body Language • Body Language often overrides verbal communication. It provides up to 75% of message content. It is noticed intensely and is easily negatively interpreted. • Poor eye contact can leave an audience feeling that you are dishonest, unconcerned or nervous • Sitting back in your chair can make you look uninterested or unconcerned • Crossing your arms across your chest can convey that you are defiant, defensive, or uninterested • Frequent hand to face contact can make you look dishonest or nervous • Drumming or tapping with hands or feet conveys nervousness, hostility, or im- patience • Resting your head in your hand can make you look bored or tired • A raised voice can send the message that you are hostile, nervous, or deceitful

Message Maps Your responses to an individual's questions and concerns will affect your success. Prepare and practice. Consider how to answer questions in general and how to respond to specific inquiries.

Guidelines • Be prepared. If you know your subject and know your audience, most questions can be anticipated. Develop and practice responses. • Track Your Key Messages. Use your responses as opportunity to reemphasize your key messages.

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• Keep Your Answers Short and Focused. Your answer should be less than 2 min- utes long. • Practice Self-Management. Listen. Be confident and factual. Control your emotions. • Speak and Act with Integrity. Tell the truth. If you don't know, say so. Follow up as promised. If you are unsure of a question, repeat or paraphrase it to be certain of the meaning. • Whenever possible develop message maps

Message maps are risk communication tools that are used to help address mental noise. They help organize complex information and make it easier to express current knowledge. • Limit to 3 key messages • Maximum of 3 supporting statements for each key message

Draft Sample Message Maps You can use these examples to develop your own message maps for potential crisis situations. Limit your message to three key points. Back up those points with up to three supporting facts.

These sample maps (not all of the message maps within the document are included here) are drafts only and are part of a federal government sponsored project being conducted with the assistance of the Center for Risk Communication and the Oak Ridge Institute for Science and Education.

How contagious is smallpox? Key Message Fact 1 Key Message Fact 2 Key Message Fact 3 Smallpox spreads slowly This allows time for us to Vaccination within 3 to 4 compared to measles or the trace contacts and vaccinate days of contact will generally flu those people who have come prevent the disease in contact. Supporting Fact 1-1 Supporting Fact 2-1 Supporting Fact 3-1 People are only infectious when The incubation period for the People who have never been vac- the rash appears and they are ill disease is 10-14 days cinated are the most important ones to vaccinate Supporting Fact 1-2 Supporting Fact 2-2 Supporting Fact 3-2 It requires hours of face-to-face Resources for finding people are Adults who were vaccinated as contact available. children may still have some immunity to smallpox Supporting Fact 1-3 Supporting Fact 2-3 Supporting Fact 3-3 There are no asymptomatic carri- Finding people who have been Adequate vaccine is on-hand and ers exposed and vaccinating them is the supply is increasing the successful approach

(Source: Association of State and Territorial Health Officials, 2002, Communication in Risk Situations: Responding to the Communication Challenges Posed by Bioterror- ism and Emerging Infection Diseases, pages 7-13)

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The United States Department of Health & Human Services developed several message maps, specifically for avian influenza and pandemic influenza. Those that follow are from the Mental Health Series, and are presented first with a question, then the main point, and three supporting points.

701. What can people do if thinking about pandemic influenza makes them anxious? • People can prepare as they would for any emergency such as an earthquake, hurricane, or blizzard. • People should keep their own supply of canned and other non-perishable foods. • People should keep their own supply of drinking water. • People should keep their own supply of essential medicines and household goods.

• People can take good care of their physical needs to help their feelings. • People can remember that good physical health helps produce good mental health. • Avoiding increased use of drugs, alcohol, and tobacco can help reduce anxiety. • Eating a balanced diet, practicing good sleep habits, maintaining normal routines, and getting regular exercise can help reduce anxiety.

• People can address their emotional and spiritual needs to help them be calmer. • Recognize and reduce other sources of stress as much as possible. • Identify and plan for healthy ways to take care of themselves. • Call on sources of social and spiritual support, such as friends and houses of worship.

702. Are there things people can do to help manage worries about pandemic influenza? • Helping others can reduce our own anxiety. • Know your neighbors, especially those who live alone or have health problems. • Help others get supplies when you are doing your own shopping. • Help others make plans for getting aid during an influenza pandemic.

• People can stay informed. • People should be aware there is no pandemic influenza in the United States or the world at present. • People can stay informed through the government pandemic influenza web site (http://www.pandemicflu.gov) • People can stay informed through local and national media and other sources.

• People can prepare as they would for any emergency such as an earthquake, hurricane, or blizzard.

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• People should keep their own supply of canned and other non-perishable foods. • People should keep their own supply of drinking water. • People should keep their own supply of essential medicines and household goods.

703. If vaccine and antiviral medicines are both likely to be in short supply, what hopes can people have? • There are things people can do to protect themselves and others during an influenza pandemic. • Health officials would describe the signs and symptoms of the specific Basic human needs for self-protection and disease. protection of loved ones can have both • People should practice good health positive and negative impacts on public habits, including eating a balanced health efforts. Stress, worry, and fear will diet and getting enough rest. be present to varying degrees throughout a • People should discuss their own pandemic. Communications professionals health concerns with their doctor, should work ahead of time with others— health department, or other trusted including mental health experts—to assess sources. the effect of message content on public anxiety, anticipate other possible stressful • The United States and other countries situations, and plan appropriate are preparing to respond to an influenza countermeasures. pandemic. HHS Pandemic Influenza Plan, • The U.S. Department of Health and Public Health Communications Human Services and others are in- (Supplement 10) creasing supplies of vaccines and medicines. • The United States has been working with the World Health Organization and other countries to strengthen detection and response to outbreaks. • Preparedness efforts are on-going at the national, state, and local level.

• People can take common-sense steps to keep from spreading germs. • People should cover their coughs and sneezes, and wash their hands frequently. • People should stay away from sick people as much as possible. • If you are sick, you should stay away from others as much as possible. (Source: HHS Pandemic Influenza Pre-Event Message Maps from the Mental Health Series http://pandemicflu.gov/news/rcommunication.html)

In addition to the message maps provided above, here are more sample message maps for behavioral health for before, during, and after a public health emergency, specifically pandemic influenza.

KEY MESSAGE: Pandemic influenza is not the same as seasonal influenza. • Pandemics rarely happen, and when they do, even healthy people may be at risk for serious complications.

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• Pandemics can have a serious impact on society with travel limitations, school and business closings, and quarantines. • There may not be a vaccination in the beginning stages of a pandemic and healthcare systems could be overwhelmed.

KEY MESSAGE: Many of us are concerned about the threat of pandemic influenza and are experiencing a variety of stress reactions. • It is normal to feel afraid or anxious. • Sometimes, stress can bring on physical reactions such as headaches, backaches, or fatigue • You can take steps now to prepare for pandemic, such as making an emergency supply kit and getting more information so you will have a better idea of what to expect.

KEY MESSAGE: You have an important role in helping prepare for and protect against pandemic influenza • Follow the advice of public health officials. • Put together an emergency supply kit in case you and your family need to stay home during a wave of pandemic influenza. • Prepare mentally by knowing the signs of stress, such as anxiety, grief, and even anger, and determine how you will cope with that stress.

KEY MESSAGE: Coping with the pandemic influenza can involve following the recommendations of public health officials to reduce the chances of getting sick. • Wash your hands frequently. • Cover your mouth when you cough. • Stay home if you are sick.

KEY MESSAGE: It can be difficult to cope with a quarantine, isolation or social distancing measures. • Your cooperation helps protect you, your family, and your community. • Your cooperation may help reduce the spread of disease. • Prepare mentally by knowing the signs of stress, such as anxiety, grief, and even anger, and determine how you will cope with that stress.

KEY MESSAGE: Prepare mentally to cope with pandemic influenza. • Learn about normal reactions to a crisis, such as anxiety, anger, and grief. • Focus on effective coping strategies that work for you, such as reading, listening to music, or spending time with friends. • Take care of yourself by eating right, getting enough sleep, and exercising.

KEY MESSAGE: Remember that stress can cause physical symptoms. • Some people may develop headaches or backaches. • Others may have trouble falling or staying asleep. • Some may experience changes in their appetites.

KEY MESSAGE: Children may also have stress reactions during a public health emergency.

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• Some children may become nervous or afraid. • Some may act more clingy or regress to younger behavior • Others may be reluctant to go to school or attend events.

KEY MESSAGE: Children need your help and reassurance during a public health emergency. • Continue normal routines, such as reading at bedtime. • Reassure your children by talking to them about the public health threat • Give them things they can do, such as making sure they wash their hands and cover their mouths when they sneeze or cough.

Addressing Stigmatization

In some instances, victims may be stigmatized by their communities and refused services or public access. Fear and isolation of a group perceived to be contaminated or risky to as- sociate with will hamper community recovery and affect evacuation and relocation efforts. In a disease outbreak, a community is more likely to separate from those perceived to be infected. During the SARS outbreak, which was believed to have originated in China, cities reported that the public avoided visiting their Chinatown sections of the cities. In fact, the governor of Hawaii publicly had dinner in the Chinatown section of Honolulu at the time to help counter the stigmatization that was occurring.

Leaders must be sensitive to the possibility that although unintentional and unwarranted segments of their community could be shunned because they become “identified” with the problem. This could have both economic and psychological impact on the well-being of members of the community and should be challenged immediately. This stigmatization can occur absent any scientific basis and could come not only from individuals but entire nations. During the first avian influenza outbreak in Hong Kong in 1997-98 and during the first West Nile virus outbreak in New York City in 1999, policies of other nations banned the movement of people or animals, absent clear science calling for those measures.

Crisis and Emergency Risk Communications: By Leaders for Leaders (CDC), page 17-18

Remember to always include ways people may get more information or help (toll free number, web address, physical address) by including a statement such as the one below in all your communication: For free information about how you and your loved ones can cope with these reactions, call NUMBER or visit WEB.

As with any communication, you will face obstacles in reaching your goals. Identify those obstacles, which may include: • Lack of understanding about disaster mental health • Perception or stigma of mental health in the community or within specific groups • Resistance to seeking help or assistance of any kind • Perception of government programs

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The CDC provides a list of psychological barriers people have during a crisis or disaster which can impact what information people hear, which include denial, fear, anxiety, confusion, dread, hopelessness or helplessness, but seldom panic. To combat these barriers, the CDC offers the following recommendations: • Public must feel empowered – reduce fear and victimization • Mental preparation reduces anxiety • Taking action reduces anxiety • Uncertainty must be addressed (Source: CDC, 2006, Participants Manual, Crisis and Emergency Risk Communi- cation, By Leaders for Leaders, Power Point Presentation)

Background Information for Developing Communications Messages about Pandemic Influenza The language, timing, and detail of key messages will depend on a number of factors, including demographics and group psychological profiles of intended audiences, available or preferred media, and urgency. However, the following points may help communications professionals adapt appropriate health messages related to an influenza pandemic: • By definition, pandemic influenza will result from a new influenza A subtype against which humans have limited or no natural immunity. Pandemic influenza virus infection therefore is likely to cause serious, possibly life-threatening disease in greater numbers, even among previously healthy persons, than occurs during seasonal interpandemic influenza outbreaks. • Global influenza pandemics are unpredictable events, presenting challenges for communication.. • Global and domestic surveillance, coupled with laboratory testing, are vital to identifying new influenza A subtypes virus strains with pandemic potential. • The threat of a pandemic may be heightened when a highly pathogenic avian influenza A virus spreads widely among birds and infects other animals, including humans. The strains can mutate or adapt and give rise to a strain that spreads easily from person to person in a sustained manner, causing a pandemic. • Illness and death may be much higher during a pandemic than during annual seasonal community influenza outbreaks; pandemics can also occur in waves over several months. • It could take many months to develop an effective pandemic influenza vaccine and immunize substantial numbers of people. Antiviral medications for treatment or prevention of pandemic influenza could have an important interim role, but may also be in short supply. Consequently, practical and common sense measures, such as frequent handwashing, covering your mouth and nose while sneezing or coughing, and staying home from work or school if you are ill with influenza-like illness, may be important to help prevent the spread of pandemic influenza. • Although travel restrictions and isolation and quarantine procedures may limit or slow the spread of pandemic influenza in its earliest stages, these measures are likely to be much less effective once the pandemic is widespread. Alternative population containment measures (e.g., cancellation of public events) may be necessary.

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• The United States is preparing for pandemic influenza by: • Developing a coordinated national strategy to prepare for and respond to an influenza pandemic • Educating healthcare workers about pandemic influenza diagnosis, case management, and infection control practices • Refining global and domestic pandemic influenza surveillance systems • Developing guidelines for minimizing transmission opportunities in different settings • Expanding supplies of antiviral medications in the Strategic National Stockpile and establishing guidelines for their use • Developing candidate vaccines and establishing plans for the rapid development, testing, production, and distribution of vaccines that may target specific pandemic influenza strains • Developing materials that states and localities can adapt as guidance for use during an influenza pandemic. (Source: HHS Pandemic Influenza Plan, Public Health Communications (Supplement 10) http://www.hhs.gov/pandemicflu/plan/sup10.html#apdx1)

When preparing and delivering messages, use the information below. This guidance may be helpful for behavioral health workers in developing messages, and assisting other officials in developing their communication about a public health emergency.

Points to Remember When Preparing and Delivering Messages When preparing messages: • prepare three key points that communicate your core messages; • prepare supporting message points; • develop supporting material such as visuals, examples, quotes, personal stories, • analogies, and endorsements by credible third parties; • keep messages simple and short; and • practice delivery.

To communicate voluntariness – prepare messages that: • make the risk more voluntary by providing options and choices; • encourage public dialogue and debate; • ask permission; and • ask for informed consent.

To communicate controllability – prepare messages that: • identify things for people to do (for example, precautions and preventive actions); • indicate a willingness to cooperate and share authority and responsibility with others; • provide important roles and responsibilities for others; • tell people how to recognize problems or symptoms; and • tell people how and where to go to get further information.

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To communicate familiarity – prepare messages that: • use analogies to make the unfamiliar familiar; • encourage experiential learning; • have high visual content; and • describe means for exploring issues in greater depth.

To communicate fairness – prepare messages that: • acknowledge possible inequities; • address inequities; and • discuss options and trade-offs.

To communicate trust – prepare messages that: • cite credible third parties; • cite credible sources for further information; • acknowledge that there are other points of view; • indicate a willingness to be held accountable; • describe achievements; • indicate conformity with the highest professional, scientific and ethical standards; • cite scientific research; • identify the partners working with you; and • indicate a willingness to share the risk.

When delivering messages during an emergency • recognize and acknowledge anger, frustration, fear, outrage or concern; • provide three or more positive points to counter negative information or bad news; • accept and involve the public and the media as legitimate partners; • indicate through actions, words and gestures that you share their concerns; • listen carefully to what people are concerned about; • convey compassion, conviction and optimism through actions, gestures and words; • speak clearly, simply and calmly – avoid technical terms and long words or phrases; and • gain trust by admitting that there are things you do not know.

When conducting a news conference or other formal media event: • make your formal statement as brief as possible; • include all pertinent information in your statement and allow time for questions; • limit the number of speakers to no more than three and limit each to 3–5 min- utes; • remember that it is primarily held to allow the media to ask questions, not to attend a lecture; and start on time – journalists have deadlines and need enough time to file your story.

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When addressing affected populations: • identify the information they most need to protect themselves; • use very clear means and formats to communicate the information to them; and • use diverse formal and informal channels, such as community meetings, open houses, stand-up presentations where people congregate, radio broadcasts and posters.

When communicating through the media during an emergency: • brief the media promptly following an incident; • fill information vacuums; • state, if appropriate, that the information is preliminary; • state that the media will be updated as additional information becomes available; • state what is factual and known – avoid speculating on the unknown; • hold regular briefings (for example, every 2 hours) even if nothing Each crisis will carry its own psychological has changed; baggage. A leader must anticipate what mental • state when you expect new infor- stresses the population will be experiences and mation to become available; apply appropriate communication strategies to • provide dedicated hotlines and attempt to manage these stresses in the telephone information services for population. all important Crisis and Emergency Risk Communication: By • stakeholders; Leaders for Leaders, Introduction • provide a media communications Centers for Disease Control and Prevention center that is staffed 24 hours a day; • plan how often information updates will be provided, who will do it, and how; and • use news conferences, briefings and one-on-one interviews. (Source: World Health Organization, 2005, Effective Media Communication during Public Health Emergencies: A WHO Handbook. Hyer RN and Covello VT. Geneva, Wall Chart, http://www.who.int/csr/resources/publications/ WHO%20MEDIA%20HANDBOOK%20WALL%20CHART.pdf)

Include yourself in your messages by using words such as “We” and “Us.” It helps people join with you and join together to recover...even if some are not having reactions. Here is an example: Some of us feel the situation is hopeless, and may have a greater risk of experiencing reactions such as anger, fear, headaches, or sleeping problems. Others feel they are coping pretty well. Yet, all of us can take steps to cope with reactions to this disaster for our loved ones, our communities, and ourselves.

Throughout this manual are several references to the importance of the public in preparing for and responding to a public health emergency. It is important to read the article within Module 3, Disaster Planning, called Crisis Communication: Encouraging an Active Rather than Passive Public. In Module 6, the article called Pandemic Influenza Risk Communication: The Teachable Moment, also by Peter Sandman, includes important information. Below is more information from Peter Sandman, included on a

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CD-ROM/DVD produced by The American Industrial Hygiene Association, May 2004, about addressing emotion in emergency communication. Visit www.psandman.com for additional information about crisis and risk communication. The information below will be helpful for behavioral health workers in developing messages for the public, as well as in helping guide communication efforts for other officials.

Beyond Panic Prevention: Addressing Emotion in Emergency Communication Copyright © 2002 by Peter M. Sandman. All Rights Reserved. (Based on work done for the Centers for Disease Control and Prevention) http://www.psandman.com/handouts/AIHA/page28.pdf

1. Fear, Panic, and Denial • Panic is relatively rare. People usually don't panic in emergencies. • Denial is much more common. To reduce denial, provide action opportunities, and accept fear as natural and appropriate. • Over-reassurance is the wrong response to all levels of fear. Be candid --but gen- tly candid for those in denial.

2. Vigilance, Hypervigilance, and Paranoia • Hypervigilance is a normal response to emergencies. Harness it by telling people what "warning signs" to look for. • To disentangle hypervigilance from paranoia, validate the hypervigilance.

3. Empathy, Misery, and Depression • Empathy for victims causes sadness; extreme or prolonged sadness turns into misery or even depression. • Treat the misery as legitimate. Expect people to bear it, and help them bear it by offering them ways to aid victims.

4. Anger, Hurt, and Guilt • Validate anger and provide socially acceptable ways to express it. • Injured self-esteem (hurt) is a natural response to intentional attacks. Validate it and help people bear it. • People often feel guilty in an emergency -- guilty that they survived, that they can't adequately protect their families, that they are still worried about routine hassles. Once again, help them bear it.

5. Resilience. Expect people to recover from emergencies, though perhaps not immediately or easily. "Post-traumatic growth" is real.

6. You Too. Emergency responders have all these responses also. Take care of yourself and your people. (Source: Beyond Panic Prevention: Addressing Emotion in Emergency Communication, Copyright © 2002 by Peter M. Sandman. All Rights Reserved, www.psandman.com)

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The importance of behavioral health messages before, during, and after a public health emergency is very clear, and it is critical that behavioral health information is incorporated into the overall emergency preparedness and response communication.

AUDIENCES Anyone within an area impacted by a public health emergency will be the audience. However, that does not mean that everyone will need or process information the same way. Behavioral health workers will need to identify the different groups of people in the area and make sure that information is tailored to them and provided in ways that will reach them most effectively. The first step is to identify the groups, which may include the following: • Age (e.g., children, teens, older adults) • Cultural • Family (e.g., single-parent, blended- family, or multiple-family households) • Gender • Languages and dialects • Psychiatric disability status • Military and/or government • Physical disability status • Professions and unemployment rate • Race/ethnicity • Refugee and immigrant status Governor Kaine Views the Damage in Franklin, October 2006 Photos by • Religion Marc LaFountain, VDEM • Rescue workers/disaster workers

Additional factors to consider include: • Education and literacy levels • Income levels • Lifestyles and customs

Determine how each of these specific groups may need information provided differently, whether it is a translation, specific cultural concerns, or other, and remember that the type of information may be appropriate for one group may not be appropriate for another. It is critical that you have a good understanding of your audiences— their perceptions, beliefs, customs, fears, etc.—before you start to communicate with them so your efforts will better address their specific concerns after a disaster. Part- nering with organizations and groups who represent specific audiences can be valuable in helping you do that. The HHS Pandemic Influenza Plan (page S10-7) states the following about understanding audiences: “Communications efforts should also take into account knowledge, attitudes, and beliefs (KABs) that suggest how audiences understand and react to certain messages. Concerns will vary by group or subgroup but will likely include personal safety, family and pet safety, and interruption of routine life activities. State and local communications professionals should identify methods to assess the unique KABs of target audiences in their populations and communities. Such

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activities can help identify potential barriers to compliance with response measures, and inform message development to build support and trust.”

Behavioral health messages may need to reach a variety of groups, and that communication may need to be tailored to more effectively reach certain groups. Consider the following: • Does information need to be translated into other languages? • Does information need to be presented to children, teens, or older adults? • Does information need to be altered to effectively reach specific groups, such as military, or based on culture or religion?

Identify organizations that may be helpful in reaching various groups. Often, communicating through an organization that already has the trust and credibility of a specific group will help your outreach workers make more progress within that impacted group.

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When a person is seeking information about something A danger, early in a crisis, especially they do not know, the first message they receive carries if you’re responsible for fixing the more weight. The tendency is for people to typically ac- problem, is to promise an outcome cept the information and then if they head a second outside your control. Never utter a message that conflicts with the first, they start to weigh promise, no matter how heartfelt, them against each other. This is especially dangerous if unless it’s in your absolute power to the first message is incorrect but it sounds logical. deliver. We can hope for certain Crisis and Emergency Risk Communication: outcomes, but most we can’t prom- By Leaders for Leaders, page 10, ise. Instead of offering a “knee jerk” Centers for Disease Control and Prevention promise, “we’re going to catch the SOBs who did this,” promise “we’re going to throw everything we have at catching the bad guys, or stopping the spread of disease, or preventing further flood damage.”

An influenza pandemic, according to the VDH draft Pandemic Influenza Plan, 2006, page 2, could occur in waves lasting 6 to 8 weeks in an affected community. Communi-

Module 8 222 cation in the first wave may be different in subsequent waves, however, behavioral health workers will be able to take advantage of what they learned earlier in the process. The public may already have a good understanding about the disease, but have different reactions to later waves. It will be important to assess the audience to understand their knowledge, beliefs, and perceptions throughout the entire period to ensure that information provided is meeting their needs.

STRATEGIES FOR PROMOTING BEHAVIORAL HEALTH DURING A PUBLIC HEALTH EMERGENCY There are several ways in which you may reach people impacted by a public health emergency to provide them with helpful information. It will be especially important that strategies used will reach people in their homes, and be accessible from their homes, as a public health emergency may significantly reduce the amount of time away from home or number of trips people take to the store, public gatherings, etc. Concern about the risk of infection may also reduce the likelihood that people will talk to someone they don’t know. Federal plans for pandemic influenza refer to state and local governments running public information campaigns. These campaigns may involve more public service and paid advertising on radio and television, in newspapers, and through direct mailings. All of these are described in more detail in this section. It is important to use a variety of methods and communicate on a regular and frequent schedule to help: • Establish recognition for the CSB and behavioral health (which helps you break through barriers in reaching people, as they may be more willing to hear from an organization they have heard of then one they have not). • Gain acceptance for the behavioral health messages and information you are providing. • Integrate behavioral health into other public health information provided to help normalize the concept of behavioral health. • Educate people about common reactions. • Provide information about effective coping strategies. • Encourage behaviors and actions that will promote overall well-being

Before a public health emergency occurs, there is information that you can prepare now, with blanks for information specific to the event that may be filled in during and after an emergency. Some items to prepare now include: • Fact sheets • Backgrounders • Checklists • Brochures • Draft press releases • Draft scripts and sound bites • Draft Public Service Announcements • Draft advertisements • Websites

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It is important that all your public information and education efforts are coordinated to reinforce the messages, and that you always include a statement about how people can get more information. To help you plan and coordinate your communication efforts to ensure regular and frequent communication, create, implement, and maintain a calendar with a schedule of all your public information and education efforts. Use a combination of efforts that are coordinated with special events, workshops, and other efforts in which the CSB is involved.

Media/Public Relations Media interest during a public health emergency will be high, giving the CSB and other officials a better chance of getting your message out. It is critical that you have information and messages prepared before a disaster strikes to ensure that the right information will be provided to disaster survivors as soon as possible. Trying to generate fact sheets and press releases, and prepare messages in the chaos of a public health emergency will be difficult. Prepare information about behavioral health and how it relates to a public health emergency to have on hand, which may be prepared with blanks for information you will update at the time of a disaster. Some items to prepare now include: • Fact sheets • Backgrounders • Checklists • Brochures • Draft releases • Draft scripts or speaking points • Website

Your CSB may already have materials on hand to distribute during a public health emergency. Work with public health officials and emergency officers to include behavioral health message within their information, including materials such as: • Press releases • Press conferences • Brochures • Fact Sheets • Backgrounders • Stuffers, rack cards, and mailings • Posters • Flyers • Public Service Announcements (radio, TV, newspaper) • Paid advertisements (radio, TV, newspaper) • Town hall meetings • Websites (County, community, disaster preparation/emergency, etc.) • Toll free numbers

Below is a list of media and public relations efforts you may consider to help promote behavioral health efforts. • Interviews, through which you are interviewed by media (usually one at a time), at

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their request or yours. • Press conferences, through which the spokesperson makes formal announcements, statements, or updates to several media at one time. • Press releases, which are written statements with Recognizing Opportunities to Speak Out news and/or updates that you send to the media with important information; • Submit letters to the editors of local newspapers. these are typically one page • Contact your local newspaper to find out how to submit and double spaced. an opinion article. • • Media advisories, which Call in to local talk radio programs when pertinent topics you send to announce a are being discussed. press conference or avail- • Contact local talk-radio producers to solicit an invitation ability for media inter- to appear on their programs. views. • Contact local civic groups to solicit speaking opportuni- • Fact sheets, which provide ties. information about a spe- • If you give a speech, contact local news outlets and ask cific topic, such as coping them to cover your presentation. strategies, common reac- • Contact local television news producers to explore ways tions, preventative meas- they can cover your issues. ures, behavioral health in- Communicating in a Crisis: Risk Communication Guidelines formation, CSB informa- for Public Officials, 2002, page 76, SAMSHA, HHS tion, etc. • Backgrounders, which provide background information about the CSB. • Bylined articles, editorials and opinion columns, which are printed with your name, and can be longer than a press release. • Talk shows, (television or radio) through which the spokesperson provides updates, information, and answers questions. • Town and community organization meetings, through which you present information to a group of people, who may or may not include the media, and are available to answer questions. • Public Service Announcements, which may be used for print, radio, or television, and are aired or printed at the discretion of the media.

Many of the tactics above should be handled by a spokesperson. Below is more information about the role of a spokesperson and guidance for those who may be required to speak on behalf of their organization to the media.

THE SPOKESPERSON The spokesperson provides information to the public, usually through the media, at meetings, and at other events. The spokesperson not only provides information, but represents the organization, and can help model the kind of behavior he or she is promoting. It is critical that this individual has accurate information, compassion, credibility, and composure, as well as the ability to provide information and respond to inquiries immediately. Much information already exists about the roles and responsibilities of a spokesperson. Some basics follow.

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HOW TO TALK TO THE MEDIA The following interview tips apply to any interview, but are especially useful in the event of a crisis:

BEFORE: Do: • Ask who will be conducting the interview. • Ask which subjects they want to cover. • If you are the not the correct contact person to do the interview, say who is and why. • Ask about the format and duration. • Ask who else will be interviewed. • Prepare and practice.

Don’t: • Tell the news organization which reporter you prefer. • Ask for specific questions in advance. • Insist they do not ask about certain subjects. • Demand your remarks not be edited. • Insist an adversary not be interviewed close-up • Assume it will be easy.

DURING: Do: • Be honest and accurate. • Stick to your key message/s. • State your conclusions first, then provide supporting data. • Be forthcoming to the extend you decide beforehand. • Offer to get information you don’t have. • Explain the subject and content. • Stress the facts. • Give a reason if you can’t discuss a subject. • Correct mistakes by stating you would like an opportunity to clarify.

Don’t: • Lie or try to cloud the truth. • Improvise or dwell on negative allegations. • Raise issues you don’t want to see in the story • Fail to think it through ahead of time. • Guess. • Use jargon or assume the facts speak for themselves. • Say “No comment.” • Demand an answer not be used.

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AFTER: Do: • Remember you are still on the record. • Be helpful. Volunteer to get information. Make yourself available. Respect deadlines. • Watch for and read the resulting report. • Call the reporter to politely point out inaccuracies, if any. If we can not give people what they need when they need it, Don’t: others will. And those “others” • Assume the interview is over if the equipment is off. may not have the best interest • Refuse to talk any further. of the public in mind when • Ask: “How did I do?” they’re offering advice. • Ask to review the story before publication or broad- Crisis and Emergency Risk cast. Communication: By Leaders for • Complain to the reporter’s boss first. Leaders, page 7, CDC (Source: Communication in Risk Situations: Respond- ing to the Communication Challenges Posed by Bioter- rorism and Emerging Infectious Diseases, 2002, page 18, Association of State and Territorial Health Officials)

Though a public health emergency such as pandemic influenza may have a longer period of media interest, it is difficult to sustain media and public relations, or to ensure that what is communicated to the public through the media is the message you want communicated. Remember that it is the news media that decide what is newsworthy and not. So, though this is a critical piece of your public information and education efforts, it is just one piece of a comprehensive communications plan.

Paid Advertising Paid advertising is an important component of an effective public information and education plan. Federal pandemic influenza plans include planning and running a public information and education campaign for risk communication. During a public health emergency, this may be one of the most effective ways in which to reach the public. Though it may seem difficult, time-consuming, and expensive, it doesn’t have to be. The benefits of paid advertising include: • Establishing regular and consistent communication, especially once media attention has waned and it is more difficult to communicate your behavioral health messages. • Controlling your message rather than relying on reporters or others to communicate on your behalf and risking the possibility of inaccurate, inappropriate, or even no, communication • Controlling where your message is communicated to effectively reach those impacted by the public health emergency • Controlling how often your message is communicated to help break through the clutter for people to actually hear the message often enough to take the recommended steps for behavioral health, including preventative steps promoted by public health officials

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• To get even more ads aired, as media are often more willing to provide free placements for a public health emergency response effort when a certain number of spots are paid.

Paid advertising may include: • Print (can be used for information that needs to be updated frequently) • Newspapers • Newsletters (community organizations, etc.) • Radio (can be used for information that will be updated frequently) • Scripts for 30- and/or 60-second spots, which may be pre-recorded or live-read by DJs on local radio stations, and updated, rotated, and changed frequently to keep information current. • Traffic and Weather sponsorships which are about 10-seconds, and also read by DJs who people are familiar with and trust; plus people are listening for traffic and weather, making it more likely that your behavioral health message will be heard. • Television (good for information that doesn’t need to be changed frequently) • 30- and/or 60-second spots • Direct Mail (good for information that doesn’t need to be changed frequently) • Letter • Stuffer • Brochure • Flyer • Post card or reply card • Outdoor Advertising (good for information that doesn’t need to be changed frequently) • Billboards • Transit (buses, trains, subways and in the associated stations)

Contact local media and request their help to produce ads and plan a local campaign that is within your budget. Most media, including cable companies, radio stations, and newspapers, have advertising staff that will help you write, design/produce ads, and plan an effective advertising schedule.

Elements to include in paid advertisements: • Headline or introduction • Message (no more than three main points, whether it is a list of reactions, or coping strategies) • Call to action (what you want the audience to do: Call or visit our web site for free information) • CSB name • Logo • Tag line • Telephone number (including TDD or TDY for hearing impaired) • Web address

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Suggestions for designing your paid advertisements: • Be concise; present information and facts quickly, and in language that is easy to understand and that your audience will relate to. • Make the design simple and uncluttered, and use only one font. • Try to use a photo or graphic in print ads that is a good representation of behavioral health or actions the CSB is encouraging. TIP: In headlines and titles, avoid • If you are using testimonials, quotes, photos, or graph- using questions that have a “yes” ics, make sure you have written permission. or “no” answer, such as: “Have • Repeat. Repeat. Repeat. One ad will not be effective in you been feeling anxious?” It will reaching people with information that may help them be too easy for your audience to understand their reactions, impact their coping strate- make the wrong choice and stop gies, or know where to get help. Run your ads on a reading or listening, which means regular basis to create frequency and consistency, and they will miss the important infor- to help individuals get your message. mation you are communicating. • Use the same font, logo, and basic design elements in all of your materials to help people recognize information from your CSB. • Measure your results by tracking the number of calls and hits to your web site.

Educational Materials Educational materials help you provide more detailed information. These may be specific to audience or subject matter. They are great tools to give to people to review when they are ready, and ways to help provide information in several places. In a public health emergency, these can be very helpful as people may take them home to read, and they can pick them up in places where they may already be, such as at vaccination sites, doctor’s offices, pharmacies, and hospitals. They may also be sent through a direct mailing, or sent when someone calls, writes, or emails for more information. Some types of educational materials include: • Brochures • Booklets • Stuffers or rack cards • Postcards • Flyers • Posters • Checklists

Elements to include in educational materials: • Title • Introduction • Information that reinforces other messages, but may go into more detail • Call to action (what you want the audience to do: Call or visit our web site for free information) • CSB name • CSB/description of services • Logo • Tag line • Telephone number (including TDD) • Web address

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Suggestions for designing your educational materials: • Use only one type of font, or consider one for headings and subheads, another for the copy. • Use photos or graphics. • If you are using testimonials, quotes, photos, or graphics, make sure you have written permission. • Use the same font, logo, and basic design elements in all of your materials to help people recognize information from your CSB.

Identify how to distribute your educational materials, considering areas where people (general and more specific audiences) may go, such as: • Vaccination sites • Pharmacies • Hospitals • Doctors’ offices • Grocery stores • Gas stations • Government offices • Post offices • Libraries and community centers • Restaurants • Stores • Inserts in other mailings, such as those by local utility, water, or cable companies

Promotional Materials and Events A great way to help gain recognition for your CSB and behavioral health is through promotional materials that have the CSB information printed on them. Consider the following, along with other items that may be more directly tied to a public health emergency and would be useful to those who receive them: • Stress balls • Thermometer • Bottles of hand sanitizer • Pens or pads of paper

Include your CSB name, logo, tag line, telephone number, and web address on your promotional materials to help establish and maintain recognition, and provide a way for people to reach your CSB when they are ready.

Another important public information and education effort is to participate in local events to distribute your information and conduct brief outreach. During a public health emergency, events may be canceled, however, there could be events before a pandemic to help prepare the community, and this is a great way to be the message out. This participation can go a long way to helping you reach your goals for behavioral health.

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Website During any crisis, having a website is an important way to give large numbers of people access to information to help them and their loved ones. During a public health emergency, this could be one of the best ways to ensure that people have access to immediate and accurate information that is the On a beautiful September day, Community Recovery set up a display most up-to-date. of photos depicting the flood in Bishop and Hurley, Virginia. Our booth Also, links to other had approximately 700 visitors throughout the day. Folks stopped by to local, state and Fed- chat with outreach workers and tell their personal stories about how the eral websites can flood had affected them or someone they knew. Many still told of floods help ensure that that had happened years ago in which they had lost their home or per- people in the ef- sonal items. Others who suffered no damage at all would stand quiet fected area have ac- for a while and look at the photos and talk among themselves about the cess to many sources devastation and how they were glad it had not happened to them. They of information. also spoke compassionately for those who had to endure the ravages A benefit of having a of nature and had no choice about their predicament. The tool we used website is that it to get them to talk to us personally was an oven stick with Community gives people access Recovery information printed on it. The stick had telephone numbers to to information when contact if an individual wanted to call for additional information or it is convenient for schedule a visit from an outreach worker. Most of the visitors did not them. Additionally, know what an oven stick was, so that opened the door for easy conver- getting information sation and made them feel more comfortable in talking to us in public through a website about their concerns. For any reader of this missive that may not know may seem more pri- what an oven stick is—it is a marked ruler with a notch on one side vate than calling and near the end of the stick that is designed to hook over the edge of a hot talking to someone oven rack and pull it out of the over; the main end of the rule has a who may ask ques- small notch designed to fit against the rack and push it back into the tions about behav- oven. This way, the user hopefully would not get burned. ioral health that an Community Recovery, Second Phase individual isn’t Report on Program Accomplishments ready or willing to answer. Some people may be reluctant to call for information, but will visit a website. See below for more recommendations. • Develop a CSB website, and include information specific to public health emergencies. • Include behavioral health information on local town, city, or county website/s in a special section. • Include behavioral health information with other public health and disaster preparedness and response websites. • Make sure to include the web address on all materials. • Issue a news release to announce the website so people know about it and what they will find there. • Link to other websites that have public health and/or disaster recovery information. • Request that local media, local government or CSB, other organizations, public health offices, and disaster response offices have a link on their website to yours.

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Additionally, make sure to track web hits so you can monitor how many people visit your site and what types of information they most frequently read. This information can be helpful when measuring the success of your communication efforts as well as understanding what information appears to be the most helpful.

Toll Free Number To make it easier for people to contact your CSB, and remember the telephone number to call, establish one toll free telephone number that people can call for free to get help, referrals, and other information. Include this number on all of the materials that reach the public: advertisements, press releases, brochures, flyers, posters, public service announcements, and websites. Try to maintain this number and have a staffing plan ready even so when a public health emergency or other disaster occurs, the number can be operational quickly, you can start publicizing it immediately, and most importantly, people can start using it right away. Have scripts or fact sheets and other resources ready for those who staff the toll free number so they give consistent, accurate, and current information to callers. Also, have a method for capturing information about the number of calls to the number, as well as dates and times of the calls to help you measure the success of your promotional efforts.

TIMING When you communicate is important, and understanding the normal lifecycle for emergency risk communications can help you determine what you will say during which period to make the most of efforts to communicate and promote your behavioral health services.

Emergency Risk Communication Lifecycle Below is a general overview of the Emergency Risk Communication (ERC) lifecycle from the CDC. Keep in mind, however, that every crisis is different, this cycle may not fit every event. Additionally, should another pandemic influenza wave, or other crisis, occur during any of the phases, this lifecycle, along with your communication goals and messages, will be impacted.

The ERC Pre-Crisis Phase This phase occurs before an emergency or disaster. Plan and prepare by: • Anticipating questions and answers. • Drafting fact sheets about your organization, normal reactions to a disaster and effective coping strategies, and other materials for the media, such as press releases, with blanks to fill in later. • Identifying spokespersons and communication response resources. • Refining and training on communication plans. • Building relationships with experts and other response organizations.

The ERC Initial Phase • Intense media interest and widespread confusion. • Show empathy and compassion.

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• Put your spokesperson out front to show that your organization is facing issues head-on in a reasonable, caring and timely manner. • Establish your organization as a credible resource and a place to go for help. • Inform the public about what they can do for their safety and well-being. Let the public know that you’re committed to keeping them informed.

The ERC Maintenance Phase • Stay on top of rumors, conflicting facts and misinformation that may be circulating. Address these and help the public more accurately understand the situation. • Share background information about the event as appropriate. • Promote your response efforts positively and enthusiastically to gain understanding and support for them. • Provide information about normal reactions and effective coping strategies. • Explain recommendations that are made to the public about their safety and well-being. • Enable decision-making by your explanations.

The ERC Resolution Phase • Decreased public/media interest. • Increased understanding about the event and where to go for help. • Reinforce public health messages. • Continue to promote your services. • Examine mishaps and learn from them. Continue to focus on what works.

The ERC Evaluation Phase • Evaluate your communication activities. Glean from lessons learned and adapt your approach accordingly. • Document what worked and what didn’t work, as well as specific ways to improve your communication plan. (Source: Centers for Disease Control and Prevention, Emergency Risk Communi- cation, CDCynergy, 2002, page 7, Office of Communications, U.S. Department of Health and Human Services)

SUMMARY Promoting behavioral health services before, during, and after a public health emergency is critical in helping people cope with their stress. It is important that behavioral health messages are incorporated into the overall emergency messages, and that behavioral health encourages actions to help people reduce their chances of getting sick.

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RESOURCES

Department of Health and Human Services HHS Pandemic Influenza Plan, Public Health Communications http://www.hhs.gov/pandemicflu/plan/sup10.html#apdx1

HHS Pandemic Influenza Pre-Event Message Maps, Mental Health Series http://pandemicflu.gov/news/rcommunication.html

Substance Abuse and Mental Health Services Administration Center for Mental Health Services, Emergency Mental Health and Trau- matic Stress http://www.mentalhealth.samhsa.gov/cmhs/EmergencyServices/

Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations http://www.mentalhealth.samhsa.gov/disasterrelief/publications/ allpubs/SMA03-3828/default.asp

Communicating in a Crisis: Risk Communication Guidelines for Public Officials http://www.riskcommunication.samhsa.gov/RiskComm.pdf

Centers for Disease Control and Prevention Emergency Risk Communication Emergency and Risk Communication Overview http://www.bt.cdc.gov/erc/

CDCynergy http://www.cdc.gov/healthmarketing/cdcynergy/index.htm

Crisis and Emergency Risk Communication, By Leaders for Lead- ers http://www.cdc.gov/communication/emergency/leaders.pdf

Virginia Department of Emergency Management http://www.vaemergency.com/

Virginia Department of Health http://www.vdh.virginia.gov/

Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services http://www.dmhmrsas.virginia.gov/Default.htm

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World Health Organization http://www.who.int

Effective Media Communication during Public Health Emergencies http://www.who.int/csr/resources/publications/WHO%20MEDIA% 20HANDBOOK.pdf

7 Steps to Effective Media Communications During Public Health Emer- gencies http://www.who.int/csr/resources/publications/WHO%20MEDIA% 20HANDBOOK%20WALL%20CHART.pdf

Other Association of State and Territorial Health Officials http://www.astho.org

Communication in Risk Situations http://www.astho.org/pubs/ASTHO%20Risk%20Communication%20e- Workbook.htm

Peter Sandman, Risk Communications Expert www.psandman.com

Beyond Panic Prevention: Addressing Emotion in Emergency Commu- nication http://www.psandman.com/handouts/AIHA/page28.pdf

Crisis Communication: Encouraging an Active Rather than Passive Public www.psandman.com/handouts/AIHA-DVD.htm

Pandemic Influenza Risk Communication: The Teachable Moment http://www.psandman.com/col/pandemic.htm

Adjustment Reactions: The Teachable Moment in Crisis Communication http://www.psandman.com/col/teachable.htm

Crisis Communication Section http://www.psandman.com/terror.htm

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INTRODUCTION Module 9 offers guidance on how to manage stress in the chaotic and changing environment before, during and after a public health emergency. Behavioral health workers supporting individuals and communities during a public health emergency may be at greater risk of exposure to the health risk than the general population. It is crucial they are trained on protective measures. Providing behavioral health services following any type of public health emergency or disaster is demanding and often stressful work. Worker safety and self-care needs to be a focus throughout the response. This module explains how management can plan and prepare to care for staff during a public health emergency and the importance of promoting self-care and personal safety to all behavioral health staff.

Strategies for Management BEFORE AND DURING THE CRISIS The HHS website includes a Faith-Based & Community Organizations Pandemic In- fluenza Preparedness Checklist that lists preparedness and response tasks for preparing your organization to work with the general population during a Pandemic outbreak. The checklist describes planning, communication, policy, resource and coordination tasks to be completed before and during the crisis:

1. Plan for the impact of a pandemic on your organization and its mission: • Assign key staff with the authority to develop, maintain and act upon an influenza pandemic preparedness and response plan. • Determine the potential impact of a pandemic on your organization’s usual activities and services. Plan for situations likely to require increasing, decreasing or altering the services your organization delivers. • Determine the potential impact of a pandemic on outside resources that your organization depends on to deliver its services (e.g., supplies, travel, etc.) • Outline what the organizational structure will be during an emergency and revise periodically. The outline should identify key contacts with multiple back- ups, role and responsibilities, and who is supposed to report to whom. • Identify and train essential staff (including full-time, part-time and unpaid or volunteer staff) needed to carry on your organization’s work during a pandemic. Include back up plans, cross-train staff in other jobs so that if staff are sick, others are ready to come in to carry on the work.

2. Communicate with and educate your staff, members, and persons in the communities that you serve: • Find up-to-date, reliable pandemic information and other public health advisories from state and local health departments, emergency management agencies, and CDC. Make this information available to your organization and others. • Distribute materials with basic information about pandemic influenza: signs and symptoms, how it is spread, ways to protect yourself and your family (e.g., respiratory hygiene and cough etiquette), family preparedness plans, and how to care for ill persons at home.

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• When appropriate, include basic information about pandemic influenza in public meetings (e.g. sermons, classes, trainings, small group meetings and announcements). • Share information about your pandemic preparedness and response plan with staff, members, and persons in the communities that you serve. • Develop tools to communicate information about pandemic status and your organization’s actions. This might include websites, flyers, local newspaper announcements, pre-recorded widely distributed phone messages, etc. • Consider your organization’s unique contribution to addressing rumors, misinformation, fear and anxiety. • Advise staff, members, and persons in the communities you serve to follow information provided by public health authorities--state and local health departments, emergency management agencies, and CDC. • Ensure that what you communicate is appropriate for the cultures, languages and reading levels of your staff, members, and persons in the communities that you serve.

3. Plan for the impact of a pandemic on your staff, members, and the communities that you serve: • Plan for staff absences during a pandemic due to personal and/or family illnesses, quarantines, and school, business, and public transportation closures. Staff may include full-time, part-time and volunteer personnel. • Work with local health authorities to encourage yearly influenza vaccination for staff, members, and persons in the communities that you serve. • Evaluate access to mental health and social services during a pandemic for your staff, members, and persons in the communities that you serve; improve access to these services as needed. • Identify persons with special needs (e.g. elderly, disabled, limited English speakers) and be sure to include their needs in your response and preparedness plan. Establish relationships with them in advance so they will expect and trust your presence during a crisis.

4. Set up policies to follow during a pandemic: • Set up policies for non-penalized staff leave for personal illness or care for sick family members during a pandemic. • Set up mandatory sick-leave policies for staff suspected to be ill, or who become ill at the worksite. Employees should remain at home until their symptoms resolve and they are physically ready to return to duty (Know how to check up-to- date CDC recommendations). • Set up policies for flexible work hours and working from home. • Evaluate your organization’s usual activities and services (including rites and religious practices if applicable) to identify those that may facilitate virus spread from person to person. Set up policies to modify these activities to prevent the spread of pandemic influenza (e.g. guidance for respiratory hygiene and cough etiquette, and instructions for persons with influenza symptoms to stay home rather than visit in person.) • Follow CDC travel recommendations during an influenza pandemic. Recom-

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mendations may include restricting travel to affected domestic and international sites, recalling non-essential staff working in or near an affected site when an outbreak begins, and distributing health information to persons who are returning from affected areas. • Set procedures for activating your organization’s response plan when an influenza pandemic is declared by public health authorities and altering your organization’s operations accordingly.

5. Allocate resources to protect your staff, members, and persons in the communities that you serve during a pandemic: • Determine the amount of supplies needed Houston, TX, October 12, 2005 -- Erica Lopez, a FEMA PIO, deals with media related questions in the DRC. FEMA hires and to promote respiratory hygiene and cough trains hundreds of local staff for disaster relief work. Photo by etiquette and how they will be Ed Edahl/FEMA obtained. • Consider focusing your organization’s efforts during a pandemic to providing services that are most needed during the emergency (e.g. mental/spiritual health or social services).

6. Coordinate with external organizations and help your community: • Understand the roles of federal, state, and local public health agencies and emergency responders and what to expect and what not to expect from each in the event of a pandemic. • Work with local and/or state public health agencies, emergency responders, local healthcare facilities and insurers to understand their plans and what they can provide, share about your preparedness and response plan and what your organization is able to contribute, and take part in their planning. Assign a point of contact to maximize communication between your organization and your state and local public health systems. • Coordinate with emergency responders and local healthcare facilities to improve availability of medical advice and timely/urgent healthcare services and treatment for your staff, members, and persons in the communities that you serve. • Share what you’ve learned from developing your preparedness and response plan with other Faith- Based and Community Organizations to improve community response efforts. • Work together with other Faith-Based and Community Organizations in your local area and through networks (e.g. denominations, associations, etc) to help your communities prepare for pandemic influenza (Source: Faith-Based & Community Organizations Pandemic Influenza Prepared- ness Checklist , http://www.pandemicflu.gov/plan/faithcomchecklist.html)

AFTER THE CRISIS The ending of the public health emergency, whether it involved immediate response or long-term recovery work, can be a period of mixed emotions for workers. While

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there may be some relief that the disaster operation is ending, there is often a sense of loss and "letdown," with some difficulty making the transition back into family life and the regular job. Following are some action steps that can help ease the dis- engagement and transition process for workers.

Minimizing Stress for Workers After the Crisis • Allow time off for workers who have experienced personal trauma or loss. • Transition these individuals back into the organization by initially assigning them to less demanding jobs (CMHS, 1994). • Develop protocols to provide workers with stigma-free counseling so that workers can address the emotional aspects of their experience (CMHS, 1994). • Institute exit interviews and/or seminars to help workers put their experiences in perspective (Bradford & John, 1991) and to validate what they have seen, done, thought, and felt. • Provide educational in-services or workshops around stress management and self-care. • Offer group self-care activities and acknowledgments. (Source: CMHS, 1994)

Staff Recruitment and Selection There are worker characteristics to look for—and some to watch Hire local people. One of the best things we did out for when staffing a behavioral was to identify people to hire who were in the health response to a public health local communities and who knew the commu- emergency. The chart below, nity very well. To find people who were well- adapted from the Helping to known in the communities, we went to local po- Heal: A Training on Mental lice and fire departments to ask for their recom- Health Response to Terrorism, mendations. Our team leaders were the pri- may help CSB managers assess mary points of contact within the four jurisdic- staff’s strengths and limitations tions served by the Project. Since the area be- prior to an event to identify those ing served was so large, it was easier and more who are both willing and able to effective to break it into smaller teams. provide services during the public health emergency. Having staff Ralph Worley, Colonial CSB, Project Rebound with characteristics that are more suited to crisis work will help reduce manager’s stress levels too.

Because of the intense chaos that is the very essence of an emergency, the “ideal” behavioral health should, at the very least, possess a calmness under pressure, community “connections,” and the ability to work with some degree of independency. The chart of attributes on the following page may be used to help guide decisions regarding how to staff an emergency management team, as well as to assist in making hiring decisions.

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Attribute Look for … Watch out for … Quick-thinking initiative • Natural curiosity. • Thrill seekers and • Learning gleaned from ex- “adrenaline junkies.” perience. • Extreme risk-takers and • Creative solutions to complex those who engage in dan- problems. gerous behaviors. • Flexibility. • People who depend on • Organization in the midst of routine and stability. chaos. Sociability with clear • Finding the silver lining – • Over-involvement with personal boundaries making the best of difficult survivors. situations and seeking the • Insincerity or artificiality. best in others. • Team player. • Approachability. • Friendliness. • Genuineness. • Tact. • Discretion. Clear professional • Familiarity with incident • Over-concern with turf boundaries command issues. issues. • Recognition and respect of • Instigators of organiza- operations at local, state and tional struggles. national levels. • Impartiality. Natural counseling skills • Empathy – ability to make • Inability to accurately survivors feel they’re under- summarize and reflect stood. others’ feelings. • Supportive and active listen- • Rigidity and formality. ing skills – asking the right • Disrespectful tone and questions, validating survi- body language. vors’ answers and feelings, • Tardiness. and helping ease confusion and worry. • Respect – positive and appropriate attention paid to survivors. (Source: Helping to Heal: A Training on Mental Health Response to Terrorism, 2004, page 119)

Generally, the majority of the staff hired for the behavioral health response to natural disasters are paraprofessionals. A large scale public health emergency may also rely on paraprofessionals in order to disseminate information and support to large numbers of people. Paraprofessionals are people within existing demographic, ethnic, cultural, or other groups or populations such as seniors, who receive special training in behavioral health after a public health emergency. Paraprofessionals provide outreach in areas impacted by the public health emergency to provide the public with information about stress and effective coping strategies. These people are often able to gain trust and access to specific groups quicker, so behavioral health assistance may be provided to these groups. Paraprofessionals may also be able to provide unique insights and under-

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standing of different groups that will help other behavioral health workers more effectively communicate.

The safety and well-being of the behavioral health staff are important, and this is highlighted even more after a crisis. Some issues that require special attention are identification, communication, and stress management.

Identification It is important for all behavioral health staff to have some consistent form of identification to present to other responders and to the public. Identification provides authority and credibility for the individual staff member, as well as to the organization, and will help give staff access to the impacted community. Identification may include strategies such as: • Wearing matching T-shirts • Carrying badges with photo identification and official insignia • Identifying themselves with vocational phrases such as “outreach workers” • Carrying letters of introduction on official letterhead (Source: Ibid)

Communication Managers and staff need to be able to reach each other to be notified of potential emergencies, be aware of their location, and be able to communicate throughout the day. Consider items such as Palm Pilots and other personal digital assistants, cell phones and text messages for workers in the field (Source: Ibid).

Stress Management The success of the behavioral health response to a public health emergency depends on the effectiveness of the behavioral health workers. Behavioral health workers have to manage their stress levels to be able to help others. Managers can have a tremendous impact on the stress of their staff by creating an environment that provides effective management and leadership, clear goals and defined roles, team support and stress management by following the recommendations below, extracted from Substance Abuse and Mental Health Services Administration’s Training Manual for Mental Health and Human Service Workers in Major Disasters.

Effective Management Structure and Leadership • Clear chain of command and reporting relationships • Available and accessible clinical supervisor • Disaster orientation provided for all workers • Shifts no longer than twelve hours with twelve hours off • Briefings provided at beginning of shifts as workers exit and enter the operation • Necessary supplies available (e.g., paper, forms, pens, educational materials) • Communication tools available (e.g., cell phones, radios) • Full-time disaster-trained supervisors and program director with demonstrated management and supervisory skills • Clear and functional organizational structure • Program direction and accomplishments reviewed and modified as needed

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Clear Purpose and Goals • Clearly defined intervention goals and strategies appropriate to assignment setting (e.g., crisis intervention, debriefing) • Community needs, focus and scope of program defined • Periodic assessment of organizational health and service targets and strategies • CMHS Program Guidance guidelines integrated into service priorities • Staff trained and supervised to define limits, make referrals • Feedback provided to staff on program accomplishments, numbers of contacts etc.

Functionally Defined Roles • Staff oriented and trained with written role descriptions for each assignment setting • When setting is under the jurisdiction of another agency (e.g., Red Cross, FEMA), staff informed of their role, contact people, and expectations • Job descriptions and expectations for all positions • Participating disaster recovery agencies' roles understood and working relationships with key agency contacts maintained

Team Support • Buddy system for support and monitoring stress reactions • Positive atmosphere of support and tolerance with "good job" said often • Team approach that avoids a program design with isolated workers from separate agencies • Informal case consultation, problem solving and resource sharing • Regular, effective meetings with productive agendas, personal sharing, and creative program development • Clinical consultation and supervision • In-service training appropriate to current recovery issues provided

Plan for Stress Management • Workers' functioning assessed regularly • Workers rotated between low, mid, and high stress tasks • Breaks and time away from assignment encouraged • Education about signs and symptoms of worker stress and coping strategies • Individual and group defusing and debriefing provided • Exit plan for workers leaving the operation: debriefing, reentry information, opportunity to critique, and formal recognition for service • Education about long-term stresses of disaster work and the importance of ongoing stress management • Program checklist including organizational and individual approaches and implementation plan • Plan for regular stress interventions at work and meetings (see next chart) • Extensive program phase down plan: timelines, debriefing, critique, formal recognition, celebration, and assistance with job searches

Management of Workload • Task priority levels set with a realistic work plan

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• Existing workload delegated so workers not attempting disaster response and usual job • Planning, time management, and avoidance of work overload (e.g., "work smarter, not harder") • Periodic review of program goals and activities to meet stated goals • Periodic review to determine feasibility of program scope with human resources (Source: SAMSHA, Training Manual for Mental Health and Human Service Workers in Major Disasters, 2000, page 33)

STRESS MANAGEMENT FOR MANAGERS Managers for behavioral health response teams are often so busy taking care of The best advice I could give is that self-care staff and the community, they forget to is critical, and that, as managers, we really take care of themselves. Therefore, it is have to take off that “we can be all tings to important for managers to watch for all people” mentality when serving in a dis- signs of stress and ways to manage stress aster. If you don’t take care of yourself, you referred to earlier in this module. will burn out. It’s almost a guarantee.

Ruby, E. Brown, Ph.D., Project Director, Strategies for Behavioral Arlington CSB, Arlington Community Health Workers Resilience Project (Source: Virginia, 2004) WORKER SELF-CARE Behavioral health workers help individuals and the community to recognize and cope with their stress. Behavioral health workers who aren’t coping well with their own stress won’t be a good model for the type of behavior they are trying to promote, which is effective stress management. Therefore, it is critical that these workers be able to recognize and effectively cope with their own stress. Behavioral health response work is both challenging and rewarding, and it can be hard to take a break or step back. But to help others, behavioral health workers must also take care of themselves. The article below, entitled Emotional Health Issues for Disaster Workers (American Red Cross), reprinted here in its entirety, explains the importance of self-care.

As disaster workers seek to meet the needs of victims and communities following any type of disaster, they are surrounded by and exposed to disorganization, confusion, scenes of destruction, and the tears and the pain of victims.

Disaster workers have the potential to become "secondary victims," as they work long, hard hours under poor conditions. In some cases, physical dangers exist for responders. Worker accommodations may be poor when they are near or within the affected area, or may require an hour or more of travel when located outside the affected area. Personal support systems are left at home, and new supports must be formed while on the operation and while time is scarce. Supervisory styles are different from person to person, administrative organization and regulation often must change with little warning, adding additional stressors as workers try to sat- isfy the needs of the clients and of the organization.

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Most disaster workers are dedicated individuals who also tend to be perfectionists. Because of this, they are at risk of pushing themselves too hard and of not being sat- isfied with what they have accomplished. With so much yet to do, they often fail to take credit for the amount of work completed and the effort contributed to the operation.

Frustration is common, and our usual sense of humor is often stretched beyond limits. Workers become exhausted, and anger comes easily to the surface. The anger of others -- workers, victims, and media -- becomes difficult to deal with, and may be seen as a personal attack on the worker rather than as a normal response to exhaustion. Survivor guilt may emerge as workers see the losses of others when they have suffered none themselves.

Coping: Remember that you are giving those victimized by the disaster a gift of yourself -- your time and your caring -- a gift you could not give if you were also a victim.

This may be your first experience with scenes of great destruction or high levels of injury and death. These are realities we don't often face, and methods of coping with these are not developed overnight. In each of us, there is an unconscious fear that a victim could be you or a loved one. You need to understand and appreciate the intensity of your emotions, and talk about your feelings to others.

Although we may function in superhuman ways during a disaster operation, the stress associated with our jobs takes its toll. We get tired . . . and confused . . . and hurt . . . and scared. It is critical both for ourselves and those we try to help that we understand the effects of stress and make every effort to deal with it.

Stress-relieving activities are not as difficult or time consuming as we may think. A 15-minute walk during a lunch or coffee break; talking to a co-worker, supervisor, or mental health worker; going out to dinner or a movie; or just learning and using deep breathing exercises can significantly reduce stress.

During the operation, it's important to eat nutritional foods, avoid drinking large amounts of caffeine and alcohol, get some exercise whenever possible, and get as much sleep as you can. That way you'll be better able to continue meeting the challenges of your job.

Your supervisors will be attempting to juggle schedules so that you can have some time off to yourself to sleep, read, or just sit in the sunshine. If you feel that you need this time off before you're scheduled for it, just ask. If you need a change of assignment or setting, just ask. And, hard as it may be to turn over your duties to someone else, when it is time for your shift to be over, leave and take time to recharge. (Source: American Red Cross, Emotional Health Issues for Disaster Workers, http://www.trauma-pages.com/h/arcwrk.php)

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Common Stress Reactions and Management Techniques Recognizing and managing your own stress and signs of stress among those you work with is an important ongoing process. Many publications about stress associated with emergency work emphasize having a buddy system so workers can help monitor each other’s stress levels. To help behavioral health workers recognize specific signs of stress in themselves and others, refer to the information below, excerpted from A Guide to Managing Stress in Crisis Response Professions.

Common Stress Reactions Behavioral • Increase or decrease in activity level • Substance use or abuse (alcohol or drugs) • Difficulty communicating or listening • Irritability, outbursts of anger, frequent arguments • Inability to rest or relax • Decline in job performance; absenteeism • Frequent crying • Hyper-vigilance or excessive worry • Avoidance of activities or places that trigger memories • Becoming accident prone

Physical • Gastrointestinal problems We instructed workers to never go • Headaches, other aches and pains into a house alone, not to commit to • Visual disturbances anything beyond their ability, and to • Weight loss or gain take care of themselves. • Sweating or chills Ralph Worley, Colonial CSB, • Tremors or muscle twitching Project Rebound • Being easily startled • Chronic fatigue or sleep disturbances • Immune system disorders

Psychological/Emotional • Feeling heroic, euphoric, or invulnerable • Denial • Anxiety or fear • Depression • Guilt • Apathy

Thinking/Cognitive • Memory problems • Disorientation and confusion • Slow thought processes; lack of concentration • Difficulty setting priorities or making decisions • Loss of objectivity

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Social • Isolation • Blaming • Difficulty in giving or accepting support or help • Inability to experience pleasure or have fun (Source: A Guide to Managing Stress in Crisis Response Professions, 2005, U.S. Department of Health and Human Services/ Substance Abuse and Mental Health Services Administration/Center for Mental Health Services, , Pub. No. SMA 4113)

There are certain aspects of behavioral health work during a public health emergency that can make it particularly stressful. Below are lists of specific sources of stress for behavioral health responders, individual approaches to reduce stress, and self-care examples.

Sources of Stress for Responders Checklist (These can increase stress.) • Role ambiguity • Lack of clarity of tasking • Mismatching skills with tasks • Lack of team cohesion • Discomfort with hazardous exposure • Ineffective communication within team, with non-team members, with head- quarters • Lack of or too much autonomy • Intense local needs for information (media/health officials) that cannot await clearance delay • Database issues, linkage between epidemiology, laboratory, and environmental sampling • Laboratory specimen tracking, reporting • Resources/equipment shortages • Command and control ambiguities • Re-integration barriers • Coworkers had to pick up your work…or no one did and it is overwhelming • Lack of understanding of or appreciation for what you have been through • Domestic/family conflict

Individual Approaches to Avoid/Reduce Stress Checklist (Things you can do to help maintain your own mental, emotional, physical, spiritual balance.) • Management of workload • Set task priority levels and create a realistic work plan • Delegate existing workload so workers not doing usual job too • Balanced Lifestyle • Exercise and stretch muscles when possible • Eat nutritionally, avoid junk food, caffeine, alcohol, tobacco • Obtain adequate sleep and rest, especially on longer assignments • Maintain contact and connection with primary social supports • Stress Reduction Strategies • Reduce physical tension by deep breathing, meditating, walking

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• Use time off for exercise, reading, listening to music, taking a bath • Talk about emotions & reactions with coworkers at appropriate times • Self-Awareness • Recognize and heed early warning signs for stress reactions • Accept that one may not be able to self-assess problematic reactions • Be careful not to identify too much with survivors/victims’ grief and trauma • Understand differences between professional relationships and friendships • Examine personal prejudices and cultural stereotypes • Be vigilant not to develop vicarious traumatization or compassion fatigue • Recognize when own disaster experience interferes with effectiveness

Self-Care Examples Checklist (Examples, by category, of things you can do.) • Physical Diet, exercise, sports, sleep, relaxation… • Emotional Stay in contact with family, friends, social support • Cognitive Training, reading, perspective • Behavioral Civic involvement, personal & family preparedness • Spiritual Meditation, prayer, fellowship, volunteerism (Source: Disaster Mental Health for Responders: Key Principles, Issues and Ques- tions, CDC, http://www.bt.cdc.gov/mentalhealth/responders.asp)

Behavioral health workers can watch for signs of stress in each other and in themselves. What follows are recommendations for managing stress before, during, and after a crisis, excerpted from A Guide to Managing Stress in Crisis Response Profes- sions.

Before the Crisis • Your entire family should be involved in developing and maintaining a family emergency preparedness plan. Excellent materials on home emergency preparedness are available from the U.S. DHS, FEMA, local chapters of the • American Red Cross, and local Offices of Emergency Services. For more information on personal preparedness, go to www.ready.gov.

Minimizing Your Stress Before the Crisis • Post a weekly schedule at home so that family members can be located in an emergency. • Develop a home safety and evacuation plan, and review and practice it regularly. • Create child care and pet care plans. • Design a plan for how family members will contact each other during a crisis. • Familiarize yourself with the disaster plans in your children's schools and in each family member's workplace. • Gather and store emergency supplies including food, water, first aid kits, bat- tery-operated radio, flashlights, and extra batteries. • Prepare an emergency bag in advance in case you are deployed. • Take advantage of any pre-disaster training and orientation that your organization provides, including cultural sensitivity awareness.

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During the Crisis It’s normal to experience stress during a disaster operation “or public health emergency”, but remember that stress can be identified and managed (Aid Workers Net- work, 2003). You are the most important player in controlling your own stress. There are many steps you can take to help minimize stress during a crisis.

Minimizing Your Stress During the Crisis • Adhere to established safety policies and procedures. • Encourage and support coworkers. • Recognize that “not having enough to do” or “waiting” are expected parts of disaster mental health response. • Take regular breaks whenever you experience troubling incidents and after each work shift. Use time off to “decompress.” • Practice relaxation techniques such as deep breathing, meditation, and gentle stretching. • Eat regular, nutritious meals and get enough sleep. • Avoid alcohol, tobacco, drugs, and excessive caffeine. • Stay in contact with your family and friends. • Pace self between low and high-stress activities.

After the Crisis You may finish a behavioral health response project in a state of physical and emotional fatigue, and you may feel some ambivalence about giving up your disaster role. Be aware that you may experience some “letdown” when the “emergency” is over (CMHS, 1994). It is important to give yourself time to stop and reflect on the experience and how it changed you. Following are some action steps that may be helpful to get closure in the weeks after the crisis.

Minimizing Your Stress After the Crisis • Consider participating in organized debriefing or critique. • Reconnect with your family. • Have a physical checkup. • Continue normal leisure activities. Stay involved with your hobbies and interests. • Consider stress management techniques such as meditation, acupuncture, and massage therapy. • Draw upon your spirituality and personal beliefs. Take advantage of faith-based counselors and workplace counseling units. • Avoid using alcohol, tobacco, or drugs to cope with stress. Seek professional substance abuse treatment if necessary. • Use Employee Assistance Programs if you need to. (Source: A Guide to Managing Stress in Crisis Response Professions, 2005, DHHS Pub. No. SMA 4113)

PERSONAL SAFETY Protecting yourself from too much stress is important when responding to a public health emergency and to the needs of the community. However, behavioral health

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workers may face other personal safety issues when conducting outreach in a public health emergency. What follows is information adapted from the Helping to Heal: A Training on Mental Health Response to Terrorism, developed through Virginia’s De- partment of Mental Health, Mental Retardation and Substance Abuse Services crisis counseling project, the Community Resilience Project, after the 9-11 terrorist attack.

In order to reach people affected by the event, behavioral health workers may need to go door-to-door in isolated, high-crime, and/or unfamiliar areas, sometimes in the evening. It is important to keep safety in mind at all times and to help other team members stay safe. It is also crucial that one also trusts his or her instincts. Some methods of protection in potentially dangerous situations include: • Conducting outreach in teams, if possible • Making sure to carry a cell phone and a local map • Determining the safety of an area before going there alone • Dressing appropriately (i.e., counselors should not stand out from the crowd) • Checking in with supervisors, other behavioral health workers, and/or friends and family at pre-agreed time intervals or maintaining a daily log with arrival/ departure information • Assessing the environment (e.g., being alert for unusual or dangerous activity/ persons, honor any request to leave) • Determining with managers, team members, and/or other mental health workers before a mental health worker starts going out into the field what situations he or she absolutely should never get into (e.g., approach a house with a big dog in the yard), what possible dangers could be encountered, and which areas should not be entered under any circumstances (Source: Helping to Heal: A Training on Mental Health Response to Terrorism, 2004, page 112)

Depending on the nature of the event, the disaster mental health worker also may need to monitor his or her surroundings for potential environmental dangers and be ready to immediately evacuate the area if necessary.

SUMMARY Stress management services for behavioral health responders needs to be a focus of planning and preparedness activities. Staff need to be encouraged to take care of themselves in order to be able to help others. CSBs need to be receptive and responsive to the changing needs of staff over time. No one who works a disaster or emergency is untouched by it. The experience can be extremely rewarding if staff work in a safe and supportive environment.

RESOURCES

Department of Health and Human Services HHS, Disasters and Emergencies http://www.hhs.gov/emergency/index.shtml

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HHS, Mental Health and Traumatic Events http://www.hhs.gov/emergency/index.shtml#post

HHS, Faith-Based & Community Organizations Pandemic Influenza Preparedness Checklist http://www.pandemicflu.gov/plan/faithcomchecklist.html

Substance Abuse and Mental Health Services Administration Training Manual for Mental Health and Human Service Workers in Major Disasters http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/ default.asp#toc

Tips for Managing and Preventing Stress: A Guide for Emergency and Dis- aster Response Workers http://www.mentalhealth.samhsa.gov/publications/allpubs/KEN-01-0098/

Field Manual for Mental Health and Human Service Workers in Major Dis- asters http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/ Default.asp

A Guide to Managing Stress in Crisis Response Professions http://www.mentalhealth.samhsa.gov/media/ken/pdf/SMA-4113/ Stressmgt.pdf

Centers for Disease Control and Prevention Disaster Mental Health Resources http://www.bt.cdc.gov/mentalhealth/

Disaster Mental Health for Responders : Key Principles, Issues and Ques- tions http://www.bt.cdc.gov/mentalhealth/responders.asp

Surviving Field Stress for First Responders http://www.phppo.cdc.gov/phtn/webcast/stress-05/

Traumatic Incident Stress: Information For Emergency Response Workers http://www.cdc.gov/niosh/unp-trinstrs.html

Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services Department of Mental Health, Mental Retardation and Substance Abuse Services http://www.dmhmrsas.virginia.gov/Default.htm

Helping to Heal: A Training on Mental Health Response to Terrorism http://www.dmhmrsas.virginia.gov/CWD-HelpingToHeal.htm

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INTRODUCTION This module highlights lessons learned from over 30 years of Federally-funded disaster behavioral health projects and recent experience with terrorist events. Public health emergencies may create a greater need for behavioral health services than has been experienced for past natural disasters and terrorist incidents. The psychological consequences of September 11, 2001, required the response of over 2,000 behavioral health workers to meet the needs of the over 8 million residents of New York City and 120 behavioral health workers to serve the 1.5 million people of Northern Virginia. Over 1,000 behavioral health workers responded to the Northridge Earthquake in Los Ange- les County-- home to over 9 million people. A public health emergency has the potential to psychologically impact to some degree all of the over 7 million people in Virginia, as well as the whole nation. All CSBs throughout Virginia could potentially be responding at the same time to a Pandemic Influenza. Past catastrophic disasters have demonstrated that outreach and public education are effective methods for quickly helping millions of Americans.

Even though the demand for services following a public health emergency may be much greater than other types of incidents, the basic elements to a behavioral health project are the same for all hazards. This module provides some basic, practical advice based on past experiences in Virginia and other states for CSBs who may need to quickly gear up to assist their entire service area.

The following recommendations are covered in this section: • Maximize resources • Reach the masses • Apply risk communications strategies • Train staff on worker safety • Coordinate with other agencies • Assure services are accessible to everyone • Be flexible to changing needs • Prepare for psychiatric casualties • Organize volunteers • Prepare to develop service and cost estimates

Maximize Resources Pandemic influenza and other large scale public health events have the potential of impacting millions of Americans in a short period of time. The CSB will need to determine who to assist and how best to help on an ongoing basis. The local resources of the CSB may quickly become overwhelmed with the public’s need for psychological support. Needs may change over time as the health risk escalates or declines and in response to information being reported by leaders and the media.

CSBs may need the assistance from other resources. Interagency agreements and Memorandums of Understanding (MOU’s) may be used to reach agreements with state and private hospitals and facilities, local health departments, universities, non-profit organizations, businesses and others with resources that can assist the CSB in a mas-

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sive response to a public health emergency. There is a precedent for receiving Federal funds to cover the cost of shared resources. Several states and territories have em- ployed non-profit organizations to provide behavioral health services following natural disasters. The State of California established MOU’s for disaster mental health response between local county authorities in the late 1980’s. In response to Northridge Earthquake, county mental health offices from Northern California were deployed to Los Angeles to assist with the immediate behavioral health response. The travel and per diem costs of the staff from Northern California were reimbursed by FEMA through an Immediate Services grant. If all CSBs are responding, sharing resources may not be feasible. But the California experience is still pertinent, because it established the precedent of moving resources within the State to meet an overwhelming demand for services. There may be resources available from other county agencies, nonprofit organizations, universities, or businesses that may be able to provide behavioral health expertise, materials and other resources to the areas in greatest need of assistance.

Planning and pre-event preparedness will improve the CSBs ability to expand and maximize community resources. The question for each CSB is if you need resources beyond your internal resources, where can you get that assistance? Being able to clearly identify the need and estimate costs early on will enhance the State and local mental health authorities’ potential for receiving Federal fiscal support.

Reach the Masses Offering services to a large percentage of the community population is a demanding task, but it can be done. The Community Resilience Project provided over 800,000 crisis counseling contacts to Virginians in a little over 2 years with only 120 staff of which over two thirds were paraprofessionals. Group education and counseling services, public information and community outreach are all tools for quickly reaching large numbers of people. These tools can be cost effective strategies.

Many people will only require information regarding reactions and coping strategies, supportive listening or comfort and empathy, all of which may be disseminated by many different individuals, groups and organizations within the community. The CSB can train or provide training materials to prepare other organizations such as, primary care providers, hospitals, first responders, schools, religious organizations, businesses and others that work with community to provide information and referrals. The CSB can reach the masses by encouraging the distribution of preparedness and response information, especially as it is related to psychological recovery and by offering training and support for those who are or could be providing services. Train-the-trainers can be used to more quickly train large numbers of behavioral health professionals and others responding to the emergency on important behavioral health issues and strategies.

CSB staff can be supplemented by trained paraprofessionals who can outreach community wide with stress management strategies, supportive listening, and psychoeducation materials.

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Apply Risk Communication Strategies Risk communication is an important element of all types of disasters responses. The more people impacted by the emergency the greater the need for effective risk communication. Behavioral health responders can play a valuable risk communication role by helping leaders to understand how people react to a crisis and preparing the public for the truth. There are many misconceptions, such as, people will panic, the public doesn’t want to hear the facts and fear must be eliminated. Behavioral health responders can help the public understand that their fears are normal and to plan and prepare for the degree of risk. Public messages should encourage community support and responsiveness by increasing the general public’s awareness of the public health risk and protective actions that will reduce exposure.

Train Workers on Safety DHHS and CDC offer on-line handouts and information on worker safety for different types of health risks. Training for behavioral health responders should include self- care information to reduce the risk of exposure to infectious diseases and other health risks. Also, by addressing worker stress the CSB can reduce attrition and retain staff for longer periods.

Coordinate, Coordinate, Coordinate The National Response Plan (NRP) will be activated if the public health emergency is of national significance. Coordination with other departments and agencies at the Fed- eral, state and local level is the cornerstone of the NRP. The CSB will need to work closely with DMHMRSAS, VDEM, VDH, as well as the local emergency management and health departments to assure they are included in meetings, information gathering and other coordination activities. Planning efforts prior to the public health emergency should emphasize coordination activities within the CSB’s service area. Community leaders and existing community organizations can assist behavioral health responders to identify and reach out to individuals and groups in need of assistance.

Behavioral health has been recognized as an important element of emergency management in recent years. Even so, behavioral health representatives often need to be pro- active in order to assure they are included emergency planning, training and exercises.

Relationships are key to the successful implementation of any emergency plan. Sitting down and discussing plans with other organizations prior to an event is guaranteed to improve the effectiveness of any plan.

Assure Services are Accessible Providing services to a population that may speak up to 100 different languages, travel- ing over mountain terrain and reaching out to communities that may be impoverished, untrusting of government or experiencing other social challenges are realistic expectations in Virginia. Experience has found hiring indigenous workers who speak the language, understand the culture and customs and can travel the roads safely can be the most productive way to make services accessible.

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September 11, 2001, demonstrated how important it is to assure services are accessible and accommodate people with disabilities. Following the September 11, 2001 terrorist attacks, too many Americans were unable to receive warning communication and instructions, and had difficulty escaping damaged buildings. Behavioral health response to large scale incidents relies heavily on communication. Messages need to reach people who have limitations in sight, hearing or cognition. Past crisis behavioral health projects in Virginia have hired outreach workers fluent in American Sign Language to reach out to the deaf and hard of hearing community. Organizations that support people with disabilities can assist the CSB to identify who is in need of what type of service. Services need to accommodate people with disabilities. When people with mobility or physical limitations cannot get to behavioral health services, behavioral health services need to go to them.

Be Flexible to Changing Needs Planning for any type of emergency or disaster requires flexibility. It is impossible to predict or plan for all types of obstacles and needs that may arise. Hurricane Katrina demonstrated how quickly even the most comprehensive plans can fall apart when the needs exceed the resources. Practical experience in Virginia has demonstrated that managers of behavioral health response efforts should reassess the psychological needs and the appropriateness of the behavioral health services on a regular basis. Experi- ence has demonstrated when behavioral health response projects don’t continually assess needs in terms of workload and demand for services, valuable time is wasted providing services that do not meet the current needs of individuals and the community. Needs assessment can be incorporated into in-service trainings to involve all behavioral health responders in the process.

The needs assessment should consider the adverse impact and strain of the public health emergency on individuals, families and the community. In addition, the needs assessment should identify which service providers are experiencing an increase in the workload due to the public health emergency (i.e., health workers, first responders, clergy and community leaders). Service providers may benefit greatly from training and support.

Prepare for Psychiatric Casualties Even though many people will recover from a public health emergency with little or no assistance, there will be those in need of a referral to a medical or behavioral health professional. It is expected that many people with acute symptoms will first be seen by their primary physician. Primary care providers will benefit from updated information on normal and acute symptoms, early interventions and referrals. Based on the experience of local mental health authorities following previous large-scale incidents across the nation, such as Hurricane Katrina, September 11, 2001, terrorist attacks, and the Northridge Earthquake, it reasonable to assume DMHMRSAS and the CSBs will be playing a coordination and leadership role in the delivery of longer term interventions.

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Organize Volunteers Americans have a long history of coming to each other’s aid during traumatic times. Following a large scale incident, many people and organizations are willing to help out. CSBs will likely be contacted by behavioral health professionals wanting to assist with the response. Screening and training volunteers at the time of the emergency is extremely difficult and time consuming. The decision on whether to use volunteers should be made during the planning process. If the CSB decides to deploy volunteers, procedures should be established for screening, training and managing the volunteer cadre. Insurance and licensing issues should be addressed in the planning process. All volunteers should sign a form stating that they will not receive any form of compensation and that they have read and understand all procedures. Ideally, volunteers should be trained prior to the event, though this is not always feasible.

Volunteers can be a resource beyond providing behavioral health services. Community members may be willing to volunteer time to assist with developing or distributing public information, provide space, food or beverages for educational and counseling sessions, serve as liaison with a particular group of people, serve as a translator, as well as, many other functions.

Prepare to Develop Service and Cost Estimates Federal assistance may be needed to meet the demand for behavioral health services following a large scale public health emergency. It should be assumed that the Federal government will require documentation of the need and estimated costs before award- ing any assistance. Federal applications typically require a description of the psychological consequences of the event, needs assessment, service plan, staffing plan and budget. The application deadlines are generally immediate to expedite grant awards. It is feasible the Commonwealth of Virginia will be asked to submit funding applications or information to more than one agency or Federal department.

VIRGINIA TALKS: BEST PRACTICES The following best practices from Virginia’s behavioral health response to natural disasters and terrorism is provided to illustrate what has worked in the past. The type of services provided for natural disasters and terrorist events can help prepare the CSB to respond to a public health emergency. Public health emergencies may be due to a natural disaster or terrorism and directly relate to the following information.

Outreach Outreach is the cornerstone of a behavioral health response. CSBs implementing behavioral health response to a past disasters have found unique and innovative ways to conduct outreach, recognizing that they cannot wait for disaster survivors to come to them, but that they have to go where the people are. Below are some examples of how CSBs throughout Virginia have conducted outreach through FEMA CCP grants, as well as ways they have provided information to encourage people to open up and discuss their experiences.

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One of the best ways we reached people was by simply knocking on doors and talking to people. —Colonial CSB, Project Rebound

The teams attended fund-raising events, which were excellent opportunities to talk to people. —Colonial CSB, Project Rebound

We had CCP staff located in the FEMA centers, which helped since people who came in for assistance often already knew the outreach workers and that made them more willing to talk. —Colonial CSB, Project Rebound

Outreach activities that were conducted by locally familiar providers that had knowledge of the community impacted were most effective. —Cumberland Mountain CSB

We found that the use of community Hurricane Gaston (2004), Damage to Shockoe Bottom, Richmond Photo by Jack leaders and neighborhood watch Beilhart, VDOT commanders in our CCP was the best way to engage people on a personal level. By having the community leaders tell us what works best for their community/ neighborhood we were able to have a ready “buy on” from the community. Clearly a “one size fits all” approach was not going to work when there was so much disparity in the areas that were damaged by the Hurricane. Conducting our outreach with Faith- Based communities and in the local shopping malls allowed us to reach very specific target population such as young people. —Hampton-Newport News CSB

Know your community and the various “Community Leaders” who have access to the community. Respect and value the diversity of every community that you plan to do outreach in. Different populations respond very differently to stress and frustration. It is essential that this is recognized and the CCP being develop reflects the differences. —Hampton-Newport News CSB

Planning and scheduling school programs had a deep impact on the staff of Commu- nity Recovery and on the children in the schools that we visited. The results of the flood preparedness programs that we did in each county definitely shows the difference in how children living in an area that is totally surrounded by steep rugged mountains such as Buchanan County are more aware of the dangers of flash floods vs. children who live in areas like Tazewell County which is not nearly as rugged. The realization that Community Recovery had the ability to bring a significant program of prevention

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On a beautiful September day Community Recovery set up a display of photos depicting the flood in Bishop and Hurley, Virginia. Our booth had approximately 700 visitors throughout the day. Folks stopped by to chat with outreach workers and tell their personal stories about how the flood had affected them or someone they knew. Many still told of the floods that had happened years ago in which they had lost their home or personal items. Others who suffered no damage at all would stand for quiet awhile and look at the photos and talk among themselves about the devastation and how they were glad it had not happened to them. They also spoke compassionately for those who had to endure the ravages of nature and had no choice about their predicament. The tool we used to get them to talk to us personally was an oven stick with Community Recov- ery information printed on it. The stick had telephone numbers to contact if an individual wanted to call for additional information or schedule a visit from an outreach worker. Most of the visitors did not know what an oven stick was, so that opened the door for easy conversation and made them feel more comfortable in talking to us in public about their concerns. For any reader of this missive that may not know what an oven stick is – it is a marked ruler with a notch on one side near the end of the stick that is designed to hook over the edge of a hot oven rack and pull it out of the oven; the main end of the ruler has a small notch designed to fit against the rack and push it back into the oven. This way the user hopefully would not get burned. —Community Recovery, Tazewell and Buchanan Counties (2002 floods)

On one Saturday morning, about 350 people came out in the drizzling rain to get their blood pressure checked, their eyes probed and their cholesterol checked. Community Recovery took the opportunity to display flood photos and provide an information table with handouts and flyers to the visitors. We were able to chat with individuals in this arena that we would not have been able to reach otherwise. Most people coming to the health fair seem open to suggestions about what they could do in getting ready for a weather related disaster in the future as well as how to deal with the loss they incurred during the flood. This group of individuals also seemed to be more interested in the brochures and handouts provided by FEMA This fair, much like the others, brought numerous children who stopped by for the Disaster Twins booklet as well as the Disas- ter Preparedness coloring book printed by FEMA and the American Red Cross, and crayons provided by Community Recovery. The health fair was a great place for many flood victims to have themselves checked for diseases and health risks due to flooding in the region,. Many residents of the area that were involved in the floods have no health insurance and cannot afford these tests if they were to make an appointment at a doctor’s office. Community Recovery was there with information and a helpful ear when needed. —Community Recovery, Tazewell and Buchanan Counties (2002 floods)

Outreach workers were assigned to particular geographic areas and/or target populations utilizing workers’ strengths and connections in their own communities whenever possible. —Project Rebound, Project-wide (Hurricane Isabel)

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Primary focus was placed on anniversary issues with the quick approach of September 18; the empowering of individuals through preparedness activities (which, of course was an effective segue into lingering recovery issues and needs); assessing future recovery needs of individuals and communities; revisiting contacts/victims of the disaster who had received outreach and other services; and a final intensive effort to reach special populations, particularly school-aged children, seniors, and, in one locality, His- panic and Latino populations. —Project Rebound, Project-wide (Hurricane Isabel)

Overall, residents have been receptive to visits in their homes. It is difficult for most families to stop their day-to-day activities and attend group meetings; So, to make it more convenient for the residents, the outreach workers visited in the homes. In addition, the area residents are an extremely proud group and will not ask for assistance so our one-on-one visits provide much-needed support and a time for the residents to tell their stories privately. —Colonial CSB, Project Rebound

Target audiences ran the full spectrum from young children, to after school programs, to neighborhood groups and civic organizations, to the elderly and businesses. Partici- pation in community recovery organizations, citizens’ preparedness initiatives, and city/county planning committees was the norm for staff across the program area. The development of trust and confidence in staff by the community and community leaders assisted with access to even greater numbers of group opportunities during the last quarter of the grant period. —Project Rebound, Project-wide (Hurricane Isabel)

During this final phase of the grant, programs made special attempts to reach out to their identified “Special Population” groups. Chesapeake continued to reach out to children with their group educational series, developing new workshops entitled “Expressing Yourself through the Arts” and “ Grief and Loss.” These were also modified and presented to Community Services Board staff and mental health and substance abuse treatment consumers. Colonial CSB workers focused their outreach to children during their home visits and through participating in community events like the Safety Town series for preschoolers and their parents and through neighborhood meetings. Hampton-Newport News intensified their outreach to children through participation in community health fairs, “Welcome Back” programs in the schools, and presentations to PTAs, Boys and Girls Clubs, Boy and Girl Scout troops, and public housing neighborhood centers. The Middle Peninsula-Northern Neck group, which had previously focused primarily on door-to-door outreach, developed presentations for youth and parent groups as well as intensifying outreach to schools, which more readily received support during the final months of programming. Western Tidewater, as well, stepped up their outreach to youth, schools and families. —Project Rebound, Project-wide (Hurricane Isabel)

Senior citizens, as well, received special attention, with special efforts to reconnect, ensuring that seniors had a plan for support in the event of future emergencies and had been linked to appropriate community resources and neighborhood supports. Senior

Module 10 260 centers, elderly housing communities, churches, home health aides, and caregivers were targets for educational programs. —Project Rebound, Project-wide (Hurricane Isabel)

The Hampton-Newport News area also focused on its outreach to their Hispanic and Latino populations. This was accomplished primarily through the church communities. And, many of the programs successfully targeted the business community, visiting business sites, talking with management and other personnel and leaving literature. —Project Rebound, Project-wide (Hurricane Isa- bel)

The fall provided many opportunities for staff to distribute thousands of brochures and pamphlets to residents as they engaged them in brief discussions. In addition to the events previously mentioned, staff participated in James City County’s Hurricane Isabel (2003), Flooding in Alexandria Liz Roll, FEMA Newtown After Hours and Senior Citizen Day, Poquoson’s “Spring Back from Isabel fall series, Tell a Story Day and “Bounce Back Bash Block Party.” Information was distributed at local restaurants, libraries, businesses, youth ball games, doctors’ offices, apartment complexes, churches, daycare centers, senior centers, recreation facilities, Community Services Board program sites, city and county offices, and others. —Project Rebound, Project-wide (Hurricane Isabel)

Middle Peninsula-Northern Neck’s anniversary displays at their public libraries, and similar displays at other public events did much to encourage conversation and reflection within the population. —Middle Peninsula-Northern Neck CSB, Project Rebound

Project Rebound participated in the Oyster Festival on the first weekend in November, where officials estimated the attendance was over 75,000 people. The display boards created a lot of attention and there were many contacts and conversation with victims at this event. —Middle Peninsula-Northern Neck CSB, Project Rebound

Project Rebound staff intensified their outreach in the community through participation in numerous Community Health Fairs, neighborhood events and welcome back programs in the schools. —Hampton-Newport News CSB, Project Rebound

Educational presentations were made with to PTA’s, After school programs, retirement communities, neighborhood community centers, Boys and Girls clubs, churches, Boy and Girl Scout troops, and public housing neighborhood centers. —Hampton-Newport News CSB, Project Rebound

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Staff made consistent contact with individuals who they previously worked with to ensure that they were following through with recommend referrals with other agencies. —Hampton-Newport News CSB, Project Rebound

The four CSB’s involved with the Community Resilience Project in Northern Virginia were uniquely positioned to respond quickly to the sniper attacks. Almost immediately after the attacks began, brochures were developed and tailored for each community, including translation in four different languages (English, Spanish, Korean, and Vietnamese). Crisis counseling was provided through a telephone bank at a major local media outlet (NBC Channel 4). Work- shops, forums, and outreach efforts targeted locations such as at gas stations, malls, schools, and other public venues throughout the Northern Virginia area. A special section of the Community Resil- Hurricane Isabel (2003), Damage in ience Project website was developed to include specific information Poquoson and Claremont Photo by Andrea Booher, FEMA that would assist people in coping with the sniper attacks. Press releases were issued to local media to help people recognize and cope with their emotional reactions. By utilizing as many resources as possible from the existing infrastructure of the project (television, radio, newspapers, telephone, press releases, and the website), and by positioning themselves in key locations, Community Resilience Project staff were able to maximize their outreach to help inform and support a frightened community. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

Although individual counseling and group counseling were offered, informal counseling was often the best way to make contact with hard-to-reach populations, such as ethnic populations and the elderly, who are not always conveniently or centrally located. By making themselves readily available in places such as convenience stores, strip malls, local clinics, churches, mosques, senior centers, and English as a Second Language classes, staff members were able to bring their services to the people rather than waiting for the people to come to them. Through this type of counseling, which is one of the hallmarks of the FEMA/Center for Mental Health Services (CMHS) model, the diverse population was better served by the project. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

All four CSBs involved with the Community Resilience Project conducted outreach designed to reach specific populations impacted by 9-11, including the military, employees of airlines, people of Middle Eastern descent, Pentagon employees, emergency workers who responded to the attack, children, older adults, and caregivers. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

More than 8,000 flyers about the Loudoun County Community Resilience Project were distributed on Domino’s pizza boxes to advertise program activities. —Loudoun CSB, Community Resilience Project

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On the first anniversary of 9-11, staff made themselves available at the United Airlines Reservation Center in Sterling, VA from 8:00 a.m. to 8:00 p.m. to help people cope with their reactions. Staff also went to United Airlines and American Airlines stations at Dulles Airport, handing out stress management information, counseling people, and monitoring a reflection room for airline personnel. —Loudoun CSB, Community Resilience Project

Promotion/Public Information and Education Effectively promoting the behavioral health services can help increase awareness for the project, which can help build trust and recognition for the effort and the outreach workers; reach more groups and individuals affected by the public health emergency; help more people understand and recognize reactions; and encourage people to get help to cope effectively with the reactions—for themselves or for their loved ones. There are several ways to promote a behavioral health response to a public health emergency, and these efforts will be more effective with a comprehensive approach that uses frequent and consistent promotion. The examples below are promotional efforts that CSBs have found to be the most effective for their CCPs.

We promoted the project by passing out flyers at doctor’s offices, post offices, stores and other places people gathered, as well as through newspaper articles, and by attend- ing various community and organization meetings (i.e. Lion’s Club, Kiwanis) held throughout the communities. —Colonial CSB, Project Rebound

Our project was promoted through the weekly community newspapers, local radio stations and most effectively by door-to-door neighborhood visits to “check on” how people were doing. —MH Director, Cumberland Mountain CSB

We placed ads in the local daily newspaper and we sponsored 30 second radio announcements on our local public radio station. In addition, we printed up a variety of brochures and notices that we had distributed at Social Services, the Health Depart- ment, the public libraries, churches and other community partner agencies. The brochures were created to address issues with various age groups. We had this information posted on our two City Web Pages as well. We attended every meeting that the City Emergency Management staff held for the public in the aftermath of the hurricanes and set up a display table with brochures and referral assistance. —Hampton-Newport News CSB

Programs posted information on their respective Community Services Board’s websites. Photographs, Project Rebound contact and resource information, community services, telephone information and preparedness information was accessible on these sites. —Project Rebound, Project-wide (Hurricane Isabel)

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Hampton-Newport News completed their publication, “When Disaster Strikes, You Are Not Alone,” which was designed to fit into a standard telephone book. The booklet provided information about how to cope in the aftermath of a disaster and provided essential contact information, as well as how to prepare (emotionally and physically) for future disasters. It was printed in both English and Spanish in recognition of a growing Hispanic/Latino population, and special efforts were made to distribute the Spanish language version to Hispanic/Latino churches and grocery stores. It, too, was made available in an electronic version on the CSB and city websites. —Hampton-Newport News CSB, Project Rebound

Positive media coverage of the programs and hurricane-related issues continued throughout the grant period. Numerous newspaper articles were published in local pa- pers across the service area, as television coverage of the current storm season and the remnants of Isabel were aired. Hampton launched a final series of PSAs on the local public radio station to continue outreach to individuals who may have had anniversary related stress throughout the hurricane season. —Project Rebound, Project-wide (Hurricane Isabel)

We launched PSAs on the local public radio station to continue our outreach to individuals who might have “anniversary” related stress through out the hurricane season. —Hampton-Newport News CSB, Project Rebound

At the anniversary of the 9-11 terrorist attacks, the Community Resilience Project implemented a paid advertising campaign. A logo and tag line for the project were generated and adopted for use among the four CSBs involved with the project. Through the campaign, a 30-second television commercial was produced in English and Spanish, as well as scripts for radio advertising sponsorships. The television and radio ads ran for 7 weeks beginning in early September 2002. The campaign received 2,278 combined television and radio advertising spots, nearly 50% percent of which were donated. Pub- lic relations efforts reinforced the messages and information provided in the advertising, and included press releases, print ads, and a fact sheet on the Community Resil- ience Project for the media. All of these efforts included the project’s toll free number and web address for people to use for more information. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

Before the public education campaign was launched for the first anniversary of 9/11, the project web site, at www.communityresilience.com, was completed and live. It contained information about the project and free services available, information about common reactions and coping strategies for different groups, links to the CSBs involved with the project, and links to other resources. There was also a section where people could write and share their personal accounts of 9/11 and its aftermath. Throughout the life of the project, local media were contacted and asked to establish a link from their web site to the project’s site. Events that took place during the aftermath of 9/11, including the terror alerts, the war on terror, and the sniper attacks were addressed on the web site by developing special links with information specific to reactions and coping strategies for each terrorism occurrence. The official web site for the project (www.communityresilience.com) received over 175,000 hits between the start

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Managing a Behavioral Health Project Managing a behavioral health project requires a great deal of coordination, patience, and the ability to manage stress. CSBs that have managed CCPs offer the advice below about managing a CCP.

The information provided by Bill Armistead, DMHMRSAS, was very good. The training was helpful and it explained what was expected. We took this information and developed our own protocol so our CCP didn’t get into the wrong mode. We used this protocol and other information to provide guidance for our team leaders and outreach workers. We identified team lead roles and what they had to do for outreach. We developed do’s and don’ts, such as listening, connecting with resources, and dealing with stress, and provided contact information to workers for times when issues were beyond their training level. We instructed workers to never go into a house alone, not to commit to anything beyond their ability, and to take care of themselves. We also had workers keep logs of where they had been and where they were going. —Colonial CSB, Project Rebound

Make sure people know what they can and can’t do. —Colonial CSB, Project Rebound

Keep addresses of homes they visited, but not the names. And, keep records and update them daily. —Colonial CSB, Project Rebound

Have identification for your outreach workers. —Colonial CSB, Project Rebound

It is critical to meet with team leads at least weekly, meet with the entire team once a month to foster the sense of being part of a team, identify problems and issues, identify available resources, and make sure people take care of themselves. —Colonial CSB, Project Rebound

The team leaders attended meetings and were encouraged to go to the meetings in other areas covered by the CCP to see what others were doing and share information. —Colonial CSB, Project Rebound

Stick with the process. The paperwork is worth it, even though it seems like a burden at first, to get to the resources that a FEMA CCP can bring. Others have been there and can assist along the way, particularly DMHMRSAS (Bill Armistead). —Cumberland Mountain CSB

As part of the CSB’s quality assurance effort, Satisfaction Survey cards were given to community leaders and people visited. The cards were stamped and pre-addressed to

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Project Rebound to better facilitate their return for feedback and evaluation. —Colonial CSB, Project Rebound

Staffing a Behavioral Health Project Staffing a behavioral health project is a major component of managing the project. CSBs agree that one of the most important steps is to hire outreach workers who are familiar with and part of special populations impacted by a disaster to help gain trust from these groups as well as to better understand them. See below for more advice from CSBs.

Watermen, one of the groups impacted by the disaster, are a very closed group. They don’t seek a lot of outside help or assistance of any kind, and are very family-oriented. It was critical for us to have people familiar with this group so we could more effectively reach them. —Colonial CSB, Project Rebound

Hire local people. One of the best things we did was to identify people to hire who were in the local communities and who knew the community very well. To find people who were well-known in the communities, we went to local police and fire departments to ask for their recommendations. Our team leaders were the primary points of contact within the four jurisdictions served by the Project. Since the area being served was so large, it was easier and more effective to break it into smaller teams. —Colonial CSB, Project Rebound

We had a mental health counselor on standby who could respond in a major crisis, and counselors went out with outreach workers to provide assistance. —Colonial CSB, Project Rebound

Hiring outreach workers indigenous to the special populations in Northern Virginia, as well as collaborating with groups already established in these communities, helped the Community Resilience Project more effectively reach specific groups. Some examples include the Arlington CSB hiring Deaf and Hard of Hearing staff, the Fairfax CSB creating multi-cultural teams (Middle Eastern, Unity Community Ministries, Korean, Viet- namese, and Hispanic), and the Alexandria CSB hiring staff who came from and spoke the languages of the area’s largest immigrant communities. These and other efforts helped the project gain access and trust within these populations, and therefore more effectively provide information and services needed to cope with the attack. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

Building and Maintaining Relationships In addition to hiring staff from special populations within the community, CSBs that have implemented CCPs also agree that establishing and maintaining relationships with the local government, organizations responding to the disaster, and other groups is critical before, during, and after a disaster. See the information below.

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Coordinating with volunteer organizations was important. Early on, the teams took food from the American Red Cross and other organizations to families, which provided a great way to connect with the victims and establish rapport and trust. —Colonial CSB, Project Rebound

We connected early with the local governments, which was critical to helping ensure that we were included in the planning and response. We were also included in a governmental committee, which ensured that we got information when all others responding to the disaster got information. —Colonial CSB, Project Rebound

The team gave “Thank You” cards to the agencies that worked with us during the grant period and also sent cards to those places agencies where workshops series were conducted, i.e.: Tidewater Detention Home, Centerville Girls Home, Children’s World, Child Time, etc. —Chesapeake CSB, Project Rebound

The needs of the greater communities themselves were also the focus of attention. More than a year of consistent service, concern, and care provided to citizens helped to forge trusting relationships in even those communities where distrust was originally a common reaction. Workers met with county officials to share information and review lessons learned, participated in and advocated for CERT (Community Emergency Re- sponse Team) training, and participated in disaster preparedness meetings organized by their localities. They provided information, consultation, and encouragement to city, county and other organizations addressing community needs in the area of preparedness for disasters and emergencies. —Project Rebound, Project-wide (Hurricane Isabel)

Communities are forming long-term disaster recovery committees, Emergency Assis- tance Plans have been revamped, churches have taken lead roles, and salaried positions have been instituted to supplement formerly all-volunteer emergency services staff. One county purchased a back-up generator for the local radio station so that broadcast- ing during emergencies would be uninterrupted. In one very rural county, a document entitled “Lessons Learned—Hurricane Isabel” was published, and the County Adminis- trator has been charged with developing a more formalized Emergency Operations system, identifying specific response duties for individuals. In another rural county, an Emergency Services Committee meets quarterly and is seeking to develop a more active Red Cross presence, while a regional planning commission has taken on the task of coordinating CERT programming. —Project Rebound, Project-wide (Hurricane Isabel)

The project has strived to maintain a close working relationship with elected officials and government leaders to keep abreast of available resources those residents. The CSB web site at http://www.colonialcsb.org/ posted updated information for residents of the communities to review —Colonial CSB, Project Rebound

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The 10 counties we serve have varied cultures, county structures, and population mix, but what they do have in common is a distrust of others. It has taken the complete 18 months to establish the trusting relationships with the county governments, community agencies, school systems, and general population. —Project Rebound, Project-wide (Hurricane Isabel)

Project Rebound helped to create a strong relationship between the county officials, community leaders and the CSB. The whole county is in a better place to face disasters and to cope with the many problems that come with them. Home health aides, senior citizen groups, and church groups were given presentations on coping with a disaster and identifying signs of trauma. —Middle Peninsula-Northern Neck CSB, Project Rebound

Project Rebound workers reviewed lessons learned with Richmond County officials. They identified several areas that needed assistance. Red Cross personnel was inadequate for the shelters. There is very little Red Cross in the Northern Neck area of the state. This highlighted the need for more active Red Cross. Now an Emergency Ser- vices Committee is meeting quarterly and the Deputy Director has the ultimate responsibility of coordinating the efforts in this county. Richmond County, along with North- umberland County will join Lancaster County with their CERT Program. This is being coordinated by the Northern Neck Planning Commission. —Middle Peninsula-Northern Neck CSB, Project Rebound

Staff from Project Rebound participated in meetings conducted by the City’s disaster preparedness teams in preparation for the 2004 Hurricane season. —Hampton-Newport News CSB, Project Rebound

Staff with the Arlington CSB established a collaborative working relationship with the Army Community Service (ACS) at Fort Myer. The military and civilian personnel at Fort Myer played instrumental roles in the rescue and recovery from the attack on the Pentagon and witnessed continued evidence of the trauma, such as the funerals for those killed. Resilience staff worked effectively with ACS staff to help address the effects of the traumatic events. For example, staff presented over 35 workshops to military and civilian personnel on traumatic stress, stress management, and psychological preparedness, and addressed issues of serious problems that may result after a trauma such as domestic violence and violence in the workplace. Staff provided individual psycho-educational services to personnel by staffing tables at Fort Myer, offering psychoeducational materials, and discussing 9/11 and reactions to it. Staff provided group counseling sessions with people involved in the rescue and recovery efforts during and after the attack. In addition, staff worked with the children and spouses of military personnel in several contexts to facilitate parents’ handling of their own, and their children’s reactions, to the attacks, and to provide a place for children to examine their reactions to 9/11. In addition to the work with Fort Myer, staff has provided services to other military facilities in the Northern Virginia area such as the Army National Guard in Arlington, the Navy Annex, and Henderson Hall Marine Corps Base. —Arlington CSB, Community Resilience Project

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Overcoming Challenges CSBs face a variety of challenges when implementing a behavioral health project, from getting started to reaching certain groups of people. CSBs have shared the information below about the challenges they have faced and overcome during their CCPs.

There were a lot of unknowns; it was a challenge to work through those and one way we worked through those was taking advantage of available resources. Our team leaders provided re- Hurricane Isabel (2003), Neighbor Helping Neighbor Andrea Booher, FEMA source lists for each area, since they were each from the different areas and knew best what was available. We used the information from the team leaders to develop a central bank of resources, and this information was available to everyone on the team. One example of the resources that were available was appliances such as washers, dryers, and refrigerators that had been donated by a local company. Information about these items was included on the resource list so the CCP teams could help get these items to those who needed them. The resource lists made it easier for the CCP teams help victims meet their basic needs, and therefore build trust and make it easier to provide crisis counseling. —Colonial CSB, Project Rebound

The grant is not easy to prepare. Call and talk to as many people as fast as possible, and use existing resources such as the FEMA website, information from DMHMRSAS, and grants written by other organizations. —Colonial CSB, Project Rebound

(One of the greatest challenges was the) usual reaction of people thinking that if they spoke to “those people” then others in the community would think that they had a “mental problem.” This fear of stigma was overcome by staff taking a casual neighborly approach and by staff helping to rebuild a playground with community residents. It was at these times of more personal non-professional interaction that sharing of trauma stories and counseling took place, without this being the identified purpose. —Cumberland Mountain CSB

Immediately following a disaster and in the weeks afterwards there is so much trauma and confusion regarding where to get help and what help is actually available. People are clearly far more interesting in how to obtain the “basic” survival services: food, shelter and water. There is an overlapping of roles and expectations of the disaster responders. There is also an unrealistic expectation about how much the government can actually do for victims and a lot of frustration and anger when the responses is unclear, inadequate or not what they expect. —Hampton-Newport News CSB

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It was also a huge challenge to conduct and implement a CCP in the midst of trying to maintain and ensure services to the rest of our 10,000 plus consumers and family members. Many of our consumers had to be evacuated to shelters and State Facilities due to potential damage to their residences. Coupled with that is our attempt to maintain round the clock crisis support of the Disaster Recovery Centers with limited staff, many of whom are likely victims of hurricane damage themselves. —Hampton-Newport News CSB

Anniversary The anniversary of the onset of a public health emergency can be a time of great stress and opportunity. Often, people face reminders of the event and increased feelings of anger, hopelessness, sadness, and other reactions. Below is information about anniversary activities various CSBs undertook through their CCPs to help survivors recognize and cope with their reactions to the anniversary.

Anniversary activities varied throughout the service areas, while each program made special efforts to re-connect with victims and to provide specialized material to all residents addressing anniversary reactions. Workers participated in commemorative activities planned by their cities and communities, although not all communities had such events. The Middle Peninsula- Northern Neck Project Rebound workers were especially active in Arlington, VA, September 11, 2002 -- Memorials are shown near the Pentagon on their localities. Their Glouscester the evening of September 11, 2002. Photo by Jocelyn Augustino/ FEMA News Photo County team created a float for the Guinea Jubilee called “Links to Re- covery” and won first prize in the parade. Their float and subsequent award generated many contacts and conversations with victims at the event. The Jubilee itself was a symbol of recovery for the community, one of the hardest hit, as it had been cancelled the year before. In Middlesex County, workers collaborated with the Red Cross to organize a meeting at the high school where victims could share their stories. Several community libraries provided space for pictorial displays of disaster and recovery while during which time outreach workers made themselves available for discussion and assistance. —Project Rebound, Project-wide (Hurricane Isabel)

In each of the five program localities, fall festivals and celebrations served as effective venues for addressing anniversary issues. The Western Tidewater area manned a booth at the annual Peanut Festival, which draws large crowds form throughout West- ern Tidewater and Hampton Roads. Chesapeake’s Jubilee, Hampton-Newport News Community Health Fairs and back to school programs, Poquoson’s Pounce Back-1 year

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Celebration and Disaster Relief Concert, and Urbanna’s Oyster Festival all provided outreach workers the opportunity to interact with hundreds of residents affected by Hurricane Isabel while anniversary issues were surfacing. —Project Rebound, Project-wide (Hurricane Isabel)

September was highlighted by the Anniversary activities and the hurricane activity that dominated the news. More emphasis was placed on working with groups through presentations and festivals and less on door-to-door activity. Project Rebound workers completed work with individual victims and guided the community agencies on how to continue to assist with the on-going needs of the community as a result of Hurricane Isabel. Assessments were made of each individual county regarding what has been done and what was in place if there was another disaster. This required heavier contact with county and community agencies. The result is a written assessment, compilation of emergency numbers for future use in the CSB, and review with each county of “lessons learned” from Hurricane Isabel. —Middle Peninsula-Northern Neck CSB, Project Rebound

The anniversary of the 9-11 terrorist attacks was a major focus for all four CSBs involved with the Community Resilience Project. In Alexandria, staff marked this time with a Labyrinth Peace Walk in which participants walked a labyrinth to meditate on the events of the past year as a way to encourage peace. In Arlington, staff joined Rev. Bill Minson of New York City in the We Remember Walk, a healing walk during which family members of the victims from New York, Pennsylvania, and Virginia gathered together in commemoration of their lost loved ones. In Fairfax, Community Resilience Project staff worked with George Mason University and an interfaith organization to host A Day of Remembrance: An Interfaith Gathering United for Peace, which involved several world religions participating in a program of spiritual readings, songs, dances, and other meaningful presentations, including one that honored the victims of the Pen- tagon attack. In Loudoun, staff participated in a memorial at the Shenandoah Building, provided reflection rooms both there and at the County Building, and attended events at Banshee Reeks as well as the Leesburg Candle Light Vigil. The Loudoun team members organized and participated in a labyrinth walk at the courthouse in Leesburg. —Community Resilience Project, Northern Virginia (9-11 terrorist attack)

Legacy Eventually, the behavioral health project comes to an end, and CSBs face the challenge of ensuring that individuals and the community understand that the services available through the project will no longer be available while leaving them with the tools to build resilience and continue recovery. Below is information about the legacy some of the CCPs in Virginia have left, and how CSBs have taken what they learned to be better prepared for the future.

The CCP had a positive impact, as the local governments know us better, have a better understanding of what we do, and that we are available. This has resulted in increased coordination, and now, we are included in the disaster planning process. And, with this better understanding, we have received more funding for the CSB so we are able to do even more for our community. —Colonial CSB, Project Rebound

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Keep in contact with the teams even after the project has ended so you don’t have to start all over again after the next disaster. I send emails once a quarter to the team members who worked on Project Rebound to check if they are still interested in helping after a disaster. That way, we can mobilize much faster to respond to the next disaster. —Colonial CSB, Project Rebound

The CCP impact was for the community to realize (and to know that they can count on in the future) local service providers at the CSB will be there for their recovery. We left behind a rebuilt playground as a symbol of recovery, support and sharing with the community. On another level, we left behind a community with confidence in the CSB as being prepared for future traumatic events. —Cumberland Mountain CSB

We are a CSB located in a rural Appalachian area. We are not safe from disasters. It is a false sense of security to believe that a natural or man-made disaster will not occur in any area. Disasters will happen everywhere. A flashflood in a small mountain community is as significant in its local impact as a hurricane on the coast. Staff training and planning is essential to be able to make a difference when disasters happen. —Cumberland Mountain CSB

If your CSB is in a disaster prone area, you should be pro-active rather than reactive. START PLANNING NOW! Begin planning how you will provide coverage of the Disas- ter Recovery Centers when asked to. We are already meeting with the City Emergency Management Staff to plan for our response for the hurricane season. —Hampton-Newport News CSB

I believe we had a very positive impact on our two communities. Our value was reinforced to the community by our CCP and staff involvement. —Hampton-Newport News CSB

Outreach workers re-connected with every individual/family possible to check in on them, to let them know of the program’s closure, to ensure that referrals and connections had taken place or to make additional referrals, to offer information on anniversary reactions and preparedness issues, to review and reflect upon their recovery, and to bring final words of encouragement and support. Western Tidewater developed an “Exit Interview” to assist with the process. Workers found the interview technique very effective in helping contacts gain perspective, while providing themselves with a useful tool for structuring the last contact and ending services. —Project Rebound, Project-wide (Hurricane Isabel)

Special efforts were made by every program to inform community agencies, city and county governmental contacts, churches and other sites where services had been provided that Project Rebound would be coming to an end. Meetings with community and program administrators were the norm. The Middle Peninsula-Northern Neck group used the final quarter to conduct their community assessments and talk with officials and agencies representatives, advocating for continued collaboration, interfacing, and

Module 10 272 building upon the trust gained. The Chesapeake group made personal contacts and also sent “Thank You” cards to the agencies and community program sites where programs had been delivered. —Project Rebound, Project-wide (Hurricane Isabel)

Program Managers were cognizant of the needs of their workers for closure as well. Each program held debriefing meetings and a celebratory recognition luncheon or dinner. Certificates were presented from the state’s Department of Mental Health, Mental Retardation and Substance Abuse Services acknowledging program managers and outreach workers for their hard work and dedication. These were signed by the Commis- sioner of DMHMRSAS and Bill Armistead, the Department’s Director of Emergency Preparedness. In addition, workers helped to plan and then participated in educational workshops to assist them in preparing for their transition to future employment opportunities. Examples of offerings include workshops on resume writing, Myers- Briggs training and training in emergency services. —Project Rebound, Project-wide (Hurricane Isabel)

We developed a kind of “exit interview” to use with people we had counseled over the course of the grant to help them review the problems they had had and the progress made. The staff found this interview technique very effective in helping people gain perspective. It also provided a useful tool for structuring the last contact and ending services. Workers made an effort to visit all the people and areas visited earlier to provide anniversary and preparedness information as well as to touch base and check on people. This was effective and appreciated by survivors. —Western Tidewater CSB, Project Rebound

Each CSB faces its own unique challenges when implementing a CCP, however, many of the basic elements are the same. For CSBs that have not yet implemented a CCP, use the information above and talk to other CSBs to be better prepared when a disaster does strike.

SUMMARY CSBs across Virginia have come to the aid of their communities following many major natural disasters and the September 11, 2001, terrorist attack. Virginia has responded to more natural disasters in the past ten years than even Texas and California, the two most frequently declared states for major disasters since 1953. A pandemic influenza could potentially produce challenges Virginia has never experienced before. Planning, preparedness and training are the best tools for assuring the people of Virginia are helped following any type of hazard. Virginians have demonstrated resilience in the face of many catastrophic events. A response to a pandemic influenza should build upon the strengths of the individuals and communities within the Commonwealth of Virginia.

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Virginia’s Department of Mental Health, Mental Retardation and Substance Abuse Services would like to thank the following individuals for their time and input for this manual:

Nora Butler Western Tidewater Community Services Board

Patty Gilbertson Hampton-Newport News Community Services Board

Henry Smith, Mental Health Director Cumberland Mountain Community Services Board

Ralph Worley Colonial Beach Community Services Board

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For questions or comments about this manual or about Virginia’s Department of Mental Health, Mental Retardation and Substance Abuse Services, you may contact Bill Armistead, Office of Planning and Development, at 804-786,5671.

You may also visit http://www.dmhmrsas.virginia.gov/Default.htm or contact us using the information below.

Street Address: 1220 Bank Street Richmond VA, 23219-1797

Mailing Address: P.O. Box 1797 Richmond VA, 23218-1797

Phone: (804) 786-3921 Voice TDD: (804) 371-8977 Toll Free: (800) 451-5544 Fax: (804) 371-6638

Neighbor helping neighbor after Hurricane Isabel in 2003. Andrea Booher, FEMA

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This training manual was produced through the Commonwealth of Virginia’s Department of Mental Health, Mental Retardation and Substance Abuse Services. November 2006