tamc.dodi6200.03.presentation
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Disaster Mental Health in the Military Treatment Facility Setting
LCDR Brian Lees, Clinical Psychologist
HSO USPHS
“I have no financial or other significant relationship with any manufacturer of any product or organization I intend to discuss”
Disclosure
At the end of this presentation, attendees will have a better knowledge of 1. gain knowledge about DODI 6200.03 2. develop a basic understanding of
triage/assessment and early intervention treatment principles
3. discover important in-depth resources
Objectives
“Public Health Emergency Management within the DoD.”
3rd version: Incorporating Change 2, Effective October 2, 2013
DODI 6200.03
Defines what constitutes a “public health emergency”
Created the position of Public Health Emergency Officer
Third revision, mandates every installation has a Disaster Mental Health Response Team.
WHY?
DODI 6200.03
Galea, Nandi, & Vlahov (2005)“Studies conducted in the aftermath of disasters during the past 40 years have shown that there is a substantial burden of PTSD among persons who experience a disaster.” prevalence of PTSD among
direct victims of disasters is 30–40% rescue workers is approx 10–20% the general population is approximately 5–10%“PTSD is persistent for a few years after the disaster among victims with early PTSD onset.”
Norris et. al, (2002) review of 160 samples of disaster survivors also found a substantial minority also develop PTSD, MDD, substance abuse, and medical problems
Disasters can lead to PTSD and other disorders
Community hospital near WTC buildings was inundated by non-injured but psychologically distressed people (Wang, 2005)
Impact on the MTF
Alleviation of current suffering and prevention of long-term conditions such as PTSD, MDD, substance abuse that lead to significant social and occupational dysfunction
Objective of Disaster Mental Health
h. Establishes DoD policy for Disaster Mental Health Response (DMHR) and the roles and responsibilities of DMHR teams. (p.1)
DODI 6200.03 Purpose
k. Every DoD installation will have access to a DMHR team and disaster mental health (DMH) services in the event of an all-hazards incident. (p.5)
Brings up issues of local vs. non-local response (e.g. Navy SPRINT deploys out of Naval Medical Center San Diego)
DODI 6200.03Policy
a. Military Commanders. The Military Commanders shall: (12) Ensure DMH services are available through a DMHR team in response to an all- hazards incident by: (a) Appointing a licensed mental health provider as the DMHR
team lead, who is trained in disaster mental health services, and who has overall responsibility for DMHR team training and service implementation.
(b) Integrating DMH preparedness and response with other DoD installation and military command emergency response plans.
(c) Entering into agreements, as needed, with other installations, Reserve units, National Guard units, and/or civilian providers for DoD installations to ensure access to a DMHR team when the personnel and resources necessary to form a DMHR team are not present on a DoD installation.
(d) On installations where an MTF exists, the installation commander may delegate the appropriate responsibilities in subparagraphs 4.a.(12)(a) to 4.a.(12)(c) of this enclosure to the MTF commander.
4. Command Responsibilities
(1) Be comprised of a multidisciplinary team, to include, at a minimum, individuals in each of the following areas: (a) Mental health (e.g., a psychiatrist, psychologist,
social worker, psychiatric nurse practitioner, a mental health technician, and/or licensed provider who is trained in acute mental health intervention).
(b) Spiritual support (e.g., a chaplain and chaplain’s assistant).
(c) Family support (e.g., a community readiness consultant).
f. DMHR Teams. DMHR teams shall:
(2) Have a licensed mental health provider serving as the DMHR team leader.
(3) Have the following responsibilities: (a) Coordinate with family assistance centers on
the installation and other agencies as appropriate to arrange DMH services to family and community members impacted by an all- hazards incident. (poses problem for non-local DMHR Team)
f. DMHR Teams. DMHR teams shall:
(b) Establish standard operating procedures (SOP) in accordance with the National Institute of Health Publication [NIMH, 2002] that will include, at a minimum: 1. The composition and role of the team.2. A listing of the available, locally trained resources with contact information. 3. A description of local conditions and any identified high-risk groups.4. A response plan for team activation.5. Plans for conducting DMH needs assessments and surveillance.6. Required initial/periodic training.
f. DMHR Teams. DMHR teams shall:
(c) Establish a plan for maintaining individual DMHR team member psychological health….
(d) Provide DMH services to include prevention, outreach, screening, triage, psychological first aid, education, and specialty referral(s) to individuals and groups who have had or may have had exposure to an all-hazards incident. These services are not medical services, and therefore do not involve medical or mental health record documentation.
f. DMHR Teams. DMHR teams shall:
(e) Train annually as part of the overall installation IEM exercises in accordance with Reference (k). (f) Train at least quarterly as a DMHR team, using evidence-based practices if available, to develop and maintain the competencies necessary to provide DMH services. Training will cover, at a minimum, prevention, outreach, screening, triage, psychological first aid, education, and referral services …command consultation and ethical issues during disasters.
If not medical services, does HIPAA apply?
f. DMHR Teams. DMHR teams shall:
(g) Identify and train primary and alternate DMHR team members for each role to ensure continuous access to DMH services.
(h) Coordinate efforts with the PHEO and integrate efforts of the DMHR team into the overall public health emergency preparedness and response.
f. DMHR Teams. DMHR teams shall:
4 trajectories of Acute Stress Disorder/PTSD Risk factors for PTSD Acute Stress Disorder symptom checklist
Disaster mental health assessment/triage
Time 1 Time 2Acute Stress Disorder PTSD
Subclinical Subclinical
4 trajectories(Bryant, 2013)
High exposure to the traumatic event Population exposure model
Secondary stressors (financial, marital, health probs)
Prior mental health condition/ prior trauma history Lack of positive social support Poor coping skills (low self-efficacy/hope,
avoidance) Demographics : female gender and racial minority
(Norris et al., 2002; or see National Center for PTSD Mental Health Effects Following Disaster: Risk and Resiliency Factors )
Risk factors
Risk/Resiliency FactorsHHS, 2004
HHS, 2004
Changes in diagnostic criteria in DSM-5
Severity of Acute Stress Symptoms—Adult and Child versions National Stressful Events Survey Acute
Stress Disorder Short Scale (NSESSS) http://www.psychiatry.org/practice/dsm/dsm5/
online-assessment-measures
Assessing Acute Stress Disorder
Assess Extent of exposure to the event Other risk/resiliency factors Acute stress symptoms
NO CURRENT ASSESSMENT FORM captures all of this
Knowing who to refer to follow-up care
Assessment conclusion
First four weeks after a traumatic event (NIMH, 2002) Non-traditional model. Similar to Combat and
Operational Stress Control, PIES (Proximity, Immediacy, Expectancy, Simplicity) BICEPS (Brevity, Immediacy, Contact/Centrality,
Expectancy, Proximity, Simplicity). Outreach!
Widespread acceptance of Psychological First Aid Controversy regarding CISD/CISM
Early intervention
Caveat, evidenced-based practice literature is sparse
Difficulties conducting treatment efficacy research in disaster setting,
Psychological First Aid (PFA) is widely accepted evidence-informed early intervention Meant to be utilized by anyone involved (not just
MH) Non-mental health providers may have better
success with those survivors who don’t want to talk to mental health
Can be done very informally Meant for survivors AND fellow disaster responders Mental health providers expertise is providing the
more in-depth follow-up care if needed
Early intervention
Here are some… BUMED (COS First Aid) SAMHSA National Center for PTSD National Child Traumatic
Stress Network Center for Study of
Traumatic Stress, USUHS Medical Reserve Corps NY State Office of MH Florida Center for Public
Health Preparedness American Red Cross Australian Red Cross
International Federation of Red Cross/Crescent
World Health Organization
National Fallen Firefighters Association
US Department of Homeland Security
Schultz & Forbes, 2013
26 published PFA manuals/field guides published by various organizations
Hobfoll et. al., (2007). 5 essential elements of immediate and mid-term mass trauma intervention.
Try to instill1. Calmness2. Safety3. Connectedness4. Self and community efficacy5. Hope
Psychological First Aid
1. Contact and engagement2. Safety and comfort3. Stabilization4. Information gathering (needs/current
concerns)5. Practical assistance6. Connection with social supports7. Information on coping8. Linkage with collaborative services
PFA: 8 core actions
Online PFA training video available at National Child Traumatic Stress Network6 CE/CMEs! http://learn.nctsn.org/enrol/index.php?id=38
PFA Field Operations Guide via NCTSN/NC-PTSDhttp://www.nctsnet.org/nctsn_assets/pdfs/pfa/2/PsyFirstAid.pdf
Great PFA training
PFA Mobile smartphone app
http://www.samhsa.gov/dtac/dtac-resources Multiple “tip sheet” topics in various
languages Have master copies pre-printed in a binder,
just need to print them up as needed Have readily available where survivors and
first-responders are congregating
PFA handouts from SAMHSA
Research shows can be effective if done right…
Extensive training and implementation process
“One-off debriefings” (CISD done minus the larger CISM program) have the potential to re-traumatize some.
NIMH (2002) consensus group indicates to stay away from “debriefing”
CISD/CISM
Outreach on affected populations (Naturale, 2006) Face-to-face (walking around, planning
visits/talks) May require information from the Incident
Command Within the MTF and outside the MTF Coordinate with other resources to avoid
over/underlap Using social media, print, TV/radio
Early intervention
Outreach is psycho-educational in nature. Follow PFA principals Provide awareness of acute stress reactions normalize reactions provide tips on positive vs. negative coping
strategies when/how to self or buddy refer.
Early intervention
USUHS National Center for Disaster Medicine and Public Health/ Center for the Study of Traumatic Stress “This curriculum recommendations
document provides a useful strategy to help educators, program directors, and curriculum developers form curricula for educating health professionals.”
https://ncdmph.usuhs.edu/Documents/BehavioralHealthRecommendations-201401.pdf
Curriculum to develop competence
SAMHSA Disaster Technical Assistance Center (DTAC) http://www.samhsa.gov/dtac Monthly and quarterly e-bulletins and
newsletters, webinars/podcasts, tip sheets Developing Cultural Competence in Disaster
Mental Health Program. http://store.samhsa.gov/shin/content//SMA03-
3828/SMA03-3828.pdf
Curriculum to develop competence
SAMHSA Disaster Behavioral Health Interventions Inventory (May, 2015) http://www.samhsa.gov/sites/default/files/dtac
/supplemental-research-bulletin-may-2015-disaster-behavioral-health-interventions.pdf
SAMHSA Disaster Behavioral Health Preparedness and Response Resources (catalog of many manuals, tipsheets, etc) http://store.samhsa.gov/shin/content//DTAC11-CATALOG/DTA
C11-CATALOG.pdf
HHS (2004). Mental Health response to mass violence and terrorism. A training manual. https://store.samhsa.gov/shin/content/SMA04-3959/SMA04-3959.pdf
Curriculum to develop competence
Bryant, R. (2013). An update of acute stress disorder. PTSD Research Quarterly, 24(1). Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, Watson, P. (2006). Psychological First Aid: Field Operations Guide. 2nd Edition. National Child Traumatic Stress Network and National Center for PTSD Galea, S., Nandi, A., & Vlahov, D. (2005). The epidemiology of Post-Traumatic Stress Disorder after disasters. Epidemiological Reviews, 27, (1), 78-91. doi: 10.1093/epirev/mxi003Hobfoll, et. al. (2007). 5 essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70(4), 316-369.Naturale, A. (2007). Outreach strategies. An experiential description of the outreach methodologies used in the September 11, 2001, disaster response in New York. In Ritchie, Watson, and Friedman’s (Eds) Interventions Following Mass Violence and Disasters. Strategies for Mental Health Practice. Guilford Press. NY.National Center for PTSD Mental Health Effects following Disaster, Risk and Resiliency Factors retrieved from http://www.ptsd.va.gov/professional/pages/effects-disasters-mental-health.asp
References
National Institute of Mental Health (2002). Mental health and mass violence: Evidenced-based early psychological intervention for victims/survivors of mass violence. A workshop to reach consensus on best practice. NIH Publication No. 02-5138, Washington, D.C.: U.S. Government Printing Office.Norris et. al. (2002). 60,000 disaster victims speak: Part I. An empirical
review of the empirical literature. Psychiatry, 65(3), 207-239.Shultz, J. M. & Forbes, D. (2013) Psychological first aid: Rapid proliferation and the search for evidence. Disaster Health, 1(2), P1-10.Wang, W. (2005) The hospital in its community. In Danieli and Dingman’s (Eds.) On the Ground After September 11. Mental Health Responses and Practical Knowledge Gained. Haworth Press, NY.U.S. Department of Health and Human Services (2004). Mental Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
References
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