Lessons Learned Since 9/11 about PostPost-Disaster Intervention Steven Marans, PhD, MSW Childhood Violent Trauma Center, Yale University Post Disaster Intervention: What Have We Learned Since 911? April Naturale, PhD Disaster Mental Health Management g and Trainingg Patricia Watson, PhD National Center for PTSD National Center for Child Traumatic Stress Juliet Vogel, PhD North Shore University Hospital Patricia Watson, PhD National Center for Child Traumatic Stress [email protected] How Do We Know How to Respond Following Disasters? Assessment and Screening • Cross-disaster comparisons difficult • Groundbreaking work: • Recipients of services • Utilization of services over time • Assessment and referral tool • The numbers participating in post-disaster treatments are often small relative to the numbers screened • Those screened who did attend treatment show substantial reduction in symptoms First 2 Weeks Five EmpiricallyEmpirically-Supported Early Intervention Principles Accepted: • Primary goals should be to promote safety, attend to practical needs, enhance coping, stabilize survivors, and connect survivors with additional resources • Psychological First Aid and outreach appear evidenceconsistent, non-harmful Not universally accepted: • CISD (given the negative findings and the findings re: worsening of symptoms) • CBT and EMDR may be contra-indicated, given that they both encourage disclosure and emotional processing, take energy and resources, and may interrupt a necessary down-time 1 2 Weeks – 3 Months Psychological First Aid Core Actions 1 Contact and Engagement 2 Safety and Comfort 3 Stabilization 4 5 Information Gathering Practical Assistance 6 Connection with Social Supports 7 Information on Coping 8 Linkage with Collaborative Services • CBT for PTSD or ASD has strongest empirical support – Not recommended for routine use for all – Determined by: • the extent to which a sense of threat persists g g in the intervention • sufficient resources to engage – Use empirically supported, flexible, modularized approaches for the range of problems seen among survivors 3 Months Onwards Skills for Psychological Recovery (SPR) • Good research support for cognitive-behavioral approaches for a wide range of problems and after a broad range of disaster types • Empirically-derived skill sets • • • • • • Information Gathering / Prioritizing Problem-Solving Positive Activities Managing Distress p Thinkingg Helpful Building Social Connections • Further evaluation and research would help clarify which components of CBT are best tolerated, work most quickly, and are most efficacious • 1-5 sessions, each “stand alone” • But encouraging multiple visits • Build skills, between-session tasks • Flexible, tailored approach Children and Adolescents Immediate phase: • Psychological First Aid (focused on warmth, support, safety, education, access to resources) Later phases: • Growing body of evidence supports CBT interventions • School based, group approaches may be efficient and effective option Innovations • • • • • • Brief telephone interventions Virtual reality strategies Single-session simulations Writing exercises I Internet-based b d iinterventions i School-based interventions 2 Expert Consensus Guidelines Expert Consensus Guidelines •Inter-Agency Standing Committee Guidelines (2007) •The European Network for Traumatic Stress Guidelines (TENTS, 2008) 1. Be proactive / prepared ahead of time, pragmatic, flexible, and match services across the entire recovery period for individuals and the community. 2. Promote sense of safety, connectedness, calming, hope, and efficacy at every level of intervention. 3. Do no harm: – – – – – •The Disaster Mental Health Subcommittee (2009) Expert Consensus Guidelines 4. 5. 6. 7. Maximize local participation, resources and capacities Integrate programs and services Use a stepped care approach Provide multi-layered supports, both individual and community level (work with media, facilitate communal, cultural, memorial, spiritual healing) Expert Consensus Guidelines Provide a spectrum of services, including: a) Provision of basic needs b) Assessment at the individual and community level c) Psychological first aid / resilience-enhancing support d) Outreach and information dissemination e) Technical assistance, consultation and training f) Treatment for individuals with continuing distress or decrements in functioning Summary Advances: • Clarification of risk, protective, and resilience factors • Identification of varying outcome trajectories • Understanding of coping strategies p knowledge g about timingg of interventions • Improved • Interventions for cultural, ethnic, and minority groups • Improving training • Development of metrics and methodologies Consider human rights and cultural sensitivity Stay updated on the evidence base Match interventions to information and resources Participate in coordination groups Commit to evaluation Recommendations • • • • • • • Systematic prospective longitudinal research Factors related to adaptive recovery Theoretical models More sensitive statistical analyses and methods More structured and systematic evaluation of services Wide range of individual and group outcomes Increased delivery of evidence-based interventions and evidence-informed services • Research to guide services that are acceptable and feasible for both recipients and providers • Focus on family and community resilience 3 CVTC Responds Acutely to 9/11 9/11 and Beyond Steven Marans, Marans MSW, MSW PhD Harris Professor of Child Psychiatry Professor of Psychiatry Director Childhood Violent Trauma Center Yale University School of Medicine In the Aftermath • Developing guidelines for parents, teachers & health care providers re helping children re terrorist attacks – Work with Congresswoman Rosa DeLauro to distribute materials through members of Congress – Development of materials for anthrax scares • Interviews with news media about affected children Consulting with Agencies (cont’d) • Application of training for schools on disaster preparation & response developed in New Haven to all of NYC over 2 years • Preparing for casualties that never came • Consulting with providers in NYC, DC, CT • Organizing responses with CT, Yale colleagues, Steven Southwick & Julian Ford (UConn) – Availability at train station – Develop state-wide training for mental health & others re preparedness & response • Consulting with CEO’s of companies in WTC Consulting with Agencies • NYC Board of Education & State mental health authorities along with Bob Pynoos, Marlene Wong & other NCTSN members • Attempted to help ongoing & coordinate with Mental g in NYC & Federal Agencies g re Health agencies response to affected children – Pre-existing limited resources & coordination – Work with CDC & Christian Haven per needs assessment & follow-up – Creating competition when cooperation is paramount Recommendations • Need for integration of behavioral health perspectives • Consultation with members of Congress, DOE & Justice • Need for integrated treatment informed training for federal, state & local leadership, 1st responders, medical personnel, educators, mental health providers, & others • Member of Federal Commission under Secretary Tommy Thompson re children & disaster • Funding allocated to states would need to include provision/requirements for above training & integration 4 Recommendations • Attention to needs of first responders & families if we expect them to respond effectively • Need for behavioral health screenings as part of medical assessment of victims • Availability of school based, clinic based, etc. trauma informed interventions – Necessity of needs assessment & longitudinal follow-up for children & families at greatest risk for long-term posttraumatic difficulties *The worst time to develop new collaborations is in the middle of a crisis Decade following 9/11 • Birth of NCTSN led to development and proliferation of interventions with proven effectiveness in helping traumatized children & families • Increased knowledge about roles/contributors of various professionals – mental health, first responders, p p courts, education, medical personnel, social service, political leaders in promoting recovery Decade following 9/11 Forward • Learned about the limitation of continuing to operate in silos & the necessity of applying the wealth of what we have • Recognized the necessity to establish policies that address the needs of all citizens when the ability to optimally navigate life & the world are undermined by traumatic events • There is much more work that needs to be done as we celebrate & capitalize on the achievements & contributions of NCTSN members over this past decade. Acknowledgments Lessons Learned from Intervention after 9/11 In the Metropolitan New York Area A View from Long Island Juliet M. Vogel, Ph.D. Division of Trauma Psychiatry North Shore-LIJ Health System Manhasset, NY • People – Sandra Kaplan, MD – Victor Fornari, MD – Alan Cohen, MD – Peter D’Amico, Ph.D. – The Staff of the North Shore LIJ CATS and Red Cross Programs – Our NCTSN and CATS Program collaborators – The families, individuals and community groups with whom we had the privilege of working • Support – Project Liberty – Nassau County SERV grant – NCTSN – Child and Adolescent Trauma Treatment and Services Consortium (CATS) sponsored by NY Office of Mental Health and SAMHSA - Red Cross September 11th Youth Resilience and Recovery Program grant - New Yorkers for Children grant 5 Overview: Importance of… 1. Identifying local impact 2. Pre-disaster planning/relationships 3. Cooperative/collaborative efforts among providers a. Working in teams b Collaboration b. C ll b i across iinstitutions i i 4. One size does not fit all 5. Collaboration around resilience building 6. Honoring both resilience and needs over time Demographics of Metropolitan NYC WTC Deaths (NYC Dept of health records as of Oct 2002) Location of residence Percent of Total Deaths New York City 43% Long Island (Nassau/Suffolk) 14% (approx. 34% emergency/rescue workers; 66% building occupants) Other New York State 8% New York State Total 65% Lessons Learned #2 The Importance of Planning! Lesson #1: Trying to Understand the Disaster Experience: The View from Long Island Manhattan Queens Staten Island Suffolk Nassau Brooklyn Demographics of Metropolitan NYC WTC Deaths by County (NYC Dept of Health records as of Oct 2002) County Manhattan (NYC) Bronx (NYC) Brooklyn (NYC) Queens (NYC) Staten Island (NYC) Nassau (LI) Suffolk (LI) Number of deaths 340 93 293 258 195 243 143 Lesson #2: The Importance of Planning and Relationships (Cont.) Nassau County • During acute response phase: working with schools – Importance of pre-existing relationships – Importance p of collaboration around disaster p plans BEFORE the event – 9/12/01 Meeting with over 100 school district representatives; follow-up meetings & SERV grant – Built on prior relationships •NSUH/ Mental Health Association/BOCES •School districts re preparedness Manhattan and Queens - Range of efforts, including activation of schoolagency relationships 6 Lesson #3: The Importance of Collaboration: Two levels Lesson #3b (cont): The Power of Collaboration : Toward the Child and Adolescent Trauma Treatment and Services Consortium (CATS) • 10/13/2001 Meeting – Included hospitals serving Ground Zero schools, other key medical centers including NSLIJ – NY Office of Mental Health (Peter Jensen, MD) – Expertise from beginning leadership of NCTSN a. Working in teams: An important part of self-care b. The power of collaboration across programs and institutions • Follow up: key ingredients – Collaboration: • conference calls re joint efforts (OMH sponsored) • Willingness to “buy into” shared assessment, trainings, maybe shared protocols – Expertise: Shared + NCTSN begins and has impact – Funding helps: • If you cooperate, there may be funding Toward a Consortium The Child and Adolescent Trauma Treatment and Services Consortium (CATS) Lesson #4: One size does not fit all a: Model of continuum of care evolves • An RFP: NYS Office of Mental Health/SAMHSA – collaboration of academic medical centers, community organizations – Continuum of services: relationship with FEMA crisis counseling • From the ivory tower to the streets --and schools of New York… and Long Island • Community outreach and psychoeducation • Crisis counseling • Liberty Enhanced: brief CBT skills interventions • CATS: evaluation pus full trauma treatment b: Working with individual differences even within a family! History Project Liberty – 2001 • FEMA awarded the State 22M for crisis services and outreach; largely adult focused, some child services. Project Liberty – 2002 • FEMA awarded d d 132M to t continue ti crisis i i services i and d outreach, and provide brief interventions for adults and children. History CATS 2002-2005 • SAMHSA awarded 3M to the State for trauma treatments and services specific to children and adolescents, including an evaluation. • RFP process; consortium created to develop common screening and assessment protocol, and core evidence-based treatments • 9 funded programs (45 sites) • CATS was “in the field” 2003-2005, demonstrated effectiveness 7 Lesson #5 : Collaboration around Resilience Building Example: working with the North Shore LIJ Health System’s Center for Emergency Medical Services – Crisis Intervention week of 9/11 – Request for assistance from their peer support team; – Collaboration on identifying needs: • backup for their peer support team • Staff psychoeducation • How to address needs of children – Collaborating on creating parenting guide: Strategies to Manage Challenges for EMS Families (2008) (http://www.nctsn.org/products/strategies-managechallenges-ems-families-2008) Lesson #6: Planning for the long term: Honoring both resilience and needs over time • Understanding long-term needs of – Bereaved families – Those with most direct exposure (e.g., emergency workers) • Sensitivity to: – Importance of anniversaries and individual/familyspecific milestone events and reminders – Importance of developmental changes for children leading to new questions and issues Group A (697, or 82.2%): Family member of a person who died in the 9/11 attacks Group B (6, or .7%) : Family member of a survivor, impacted resident or recovery worker who died later of related injuries Groups C-F (145, or 17.4%): Other impacted individuals TOTAL RESPONDENTS: 848 Lesson #5 : Collaboration around Resilience Building (cont.) Example: Parenting groups for Tuesday’s Children (foundation for 9/11 bereaved families) • Their needs assessment had identified need for assistance with limit setting • Provided parenting groups: series of three given twice (once in Nassau County, once in Suffolk County) • Follow-up: – Group for parents of adolescents – Individual referrals 9-11Healing and Remembrance Program NEEDS ASSESSMENT December 2010 Assisting those affected by 9 9--11 as they participate in 10th anniversary events Response totals for all Groups A-F: Yes 504 (60%) Don’t know yet 254 (30%) No 90 (10%) Approximately 90% of all respondents (a total of 758 out of 848) answered either “Yes” or “Don’t know yet.” 8 OT H E R FA MILY ME MB E R S : T o ind ic a te fa mil y me m b e rs who wo uld a tte nd with y o u, p le a s e s ho w the ir R E LA T ION S H IP to Y OU , a nd the ir A GE GR OU P : R e la tio ns hip to Y o u A ns we r Op tio ns s p o us e / p a rtne r s ib ling s o n/ d a ug hte r p a re nt g ra nd p a re nt o the r R e s p o ns e Co unt A B C D E F T o ta l R e la tiv e s 245 20 17 10 6 3 301 48 76 65 48 29 21 287 227 317 194 81 30 10 859 57 27 27 27 18 7 163 0 3 1 2 3 2 11 42 59 94 105 94 70 464 619 502 398 273 180 113 2085 A ns we r Op tio ns 0-5 0 5 6-11 6 11 12-15 12 15 16-21 16 21 21+ R e s p o ns e Co unt A B C D E F A g e Gro up T o ta ls 2 13 16 13 14 3 61 23 43 47 26 11 4 154 30 47 28 15 11 5 136 55 60 35 18 12 11 191 495 327 261 188 128 85 1484 605 490 387 260 176 108 2026 A g e Gro up “Other” included responses such as these: nieces, nephews, cousins, aunts, uncles, godfather, friends. Includes all Groups A-F Approximately 300 respondents (about 80%) self-identified as Christian, and then further self-identified as Roman Catholic, evangelical, Greek Orthodox, Baptist, and non-denominational. Approximately 30 (8%) identified as Jewish, and 25 (6%) as “other,” including agnostic, atheist, Buddhist, Hindu, Shinto, and Tibetan. W/A • • • Mobility assistance: 160 requests (50 - “You”; 110 - relatives “All Other Responses”). (wheelchair dependence, limited walking capacity, diminished stamina for standing or sitting for long periods of time, chairs. “Language”: 30 respondents, Chinese, Japanese, Russian, and Spanish translation. “Sight” and “hearing”: about 25 times each. A total of 277 respondents in Groups A and B who are planning to attend answered this question. (Note that Group B, represented by scarcely visible blue bars, figures only in “massage,” “prayer room” and “pet therapy.”) Approximately 129 respondents listed 95 children who would need child care, distributed across these age ranges: • Ages 0-5: 34 • Ages 6-11: 41 • Ages 12-15 20 Of the 415 respondents in Group A who PLAN TO ATTEND, 354 responded to this question. Of these 354, about 25% (90) indicated they would need a transportation subsidy. 9 T R A N S P OR T A T ION N E E D S : IF Y OU A N S W E R E D " Y E S ," p le a s e c o ntinue with the s e q ue s tio ns : A , H o w M a ny M ile s ? A ns we r R e s p o ns e 0-100 100-250 250-500 500-2000 2000+ Op tio ns Co unt 24 12 9 B . W ha t Fo rm o f T ra ns p o rta tio n? A ns we r Ca r P la ne B us Op tio ns 28 37 C. T ra ns p o rta tio n in N Y C A ns we r T a xi S ub wa y Op tio ns 14 25 79 R e s p o ns e Co unt 7 12 84 B us P a rk ing g Ga ra g e R e s p o ns e Co unt 44 9 1 D . E s tim a te d T OT A L R o und -T rip A ns we r $500$0-250 $250-500 Op tio ns 1000 21 9 T ra in 14 3 57 $10001500 $15003000 $3000+ R e s p o ns e Co unt 9 11 12 81 • Information and Resources (Newsletter) • Hotline and website access Anecdotes: Written Written--in Comments and Concerns from Victims’ Family Members Rank Order: 1. Elderly parents wanting to see memorial before they pass fear this is their last opportunity pass-fear 2. Will we have security? Will we be safe? 3. Wanting to have all their family with them 4. How do I tell my children about 9-11? Those who were young at the time of the event don’t understand context 5. Standing during event and other health concerns Anecdotes: Written Written--in Comments and Concerns from Rescue/Recovery Population Rank Order: 1 Wanting to participate in official commemorative 1. activities-feeling outside 2. Wanting to read names of those who died 3. Concerns about security 10
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