Background

There is much literature available on training in treatment for PTSD, both short-term and long-term, (1, 2, 3) but less literature is available on the topic of early intervention shortly after a disaster. Given the scale of recent disasters, health care professionals may benefit from quick training (just-in-time) while traveling to, or preparing to travel to, a disaster site.

Most “disaster mental health training” programs deal with specific groups of workers such as emergency first responders (4) and school psychologists ^{(5). There is also extensive training available through the American Red Cross (ARC) (6). The American Psychiatric Association (7) offers online courses to its members and easily accessible fact sheets to any practitioners. The American Psychological Association (8), along with the ARC, has offered disaster response training at past annual conventions and has a network of volunteer responders. Psychological First Aid (PFA) training is also available (9). Private groups also provide training (at cost). Despite these programs there is still little available for a health professional who may be called on to suddenly assist in a disaster situation, and who need urgent “just in time” training that can be literally undertaken in the hours before arrival at the disaster site.}

Just-in-time training, similar to psychological first aid (PFA), could also be used for training paraprofessionals, professionals, community volunteers, and emergency responders (9). Web-based training offers convenience and accessibility. However, there are few formal, readily accessible, low or no cost curricula that cover the practice and principles of disaster mental health shortly after a disaster.

In California, the Department of Mental Health commissioned the development of such a curriculum, to be available on-line and for face-to-face training. Anyone may view the training modules, at no charge. The curriculum we have developed is fully accredited for CME and CE credits for physicians, nurses, psychologists, social workers, and marriage and family therapists. Anyone may view the modules, but only professionals in these fields may receive CME and CE credits for viewing.

The seven modules (described below) can be viewed separately or together and each takes about an hour to complete. Each module can stand alone; responders can view all the modules, only those that are needed, or view portions of a module. Studying can be done rapidly on-line, before an individual is assigned to a disaster site or while traveling to a disaster site. The modules discuss different disaster phases and are designed to be consulted at those various phases as needed. There is no charge for reviewing these modules.

Instructors’ manuals are available (at no charge) with learning objectives, discussion questions, and CME-type questions for group instruction, which may be useful for county mental health agencies. Instructors can add in additional resources for the types of disasters most likely to occur in their community, and can add in additional training to match community needs, special population needs in their community, and specific services available to their community.

The modules can be viewed at www.ucdmc.ucdavis.edu/cme then by selecting “Online CME” on the left side of the screen, then scrolling down the list to the modules to be viewed. An online overview of the modules is also available, and module content, along with learning objectives, is listed below.

Module One—Mental Health Response System and Federal Funding Overview provides information about the National Response Plan and National Incident Management System; disaster classification and key response agencies; immediate and regular services programs such as Federal Emergency Management CCP services; California Emergency Plan and Standardized Emergency Management System (SEMS). One discussion question in the Instructor’s manual asks how the local community is vulnerable to natural disasters and human-caused disasters at county, region and state levels. Another question would facilitate discussion concerning how different response teams would work together in a disaster. (See Table 1.)

The educational objectives for Module One are:

• Acquire a general understanding of the California disaster response system and the way mental health services are provided within that system.

• Describe the characteristics of natural and human-caused disasters.

• Become familiar with funding that may be available for disaster mental health services and programmatic features of the Federal Emergency Management Agency Crisis Counseling Program.

Figure 1

Table 1

Module Two—Basic Clinical Principles covers basic clinical principles of disaster mental health based on best practices; phases of disaster response; intervention strategies; psychological responses to disaster; psychotherapy versus disaster mental health; relating to victims; ethics for professionals; emerging responders; Department of Mental Health team deployment; assessment considerations; initial and delayed responses to trauma; and when to refer someone to professional services. One discussion question in the Instructor’s manual promotes discussion of the specific obstacles and challenges that individuals in the community would have to face in the different phases of disaster response. (See Table 2.)

Module Two’s Learning Objectives are:

• Understand basic disaster mental health principles and the methods, strategies, and best practices for delivering disaster mental health services.

• Recognize typical reactions to disasters and their time scope.

• Understand differences between disasters.

Figure 2

Table 2

Module Three—Weapons of Mass Destruction discusses the effects of intentional disasters with weapons of mass destruction, which are unconventional agents or conventional agents used in an unconventional way; the biopsychosocial view; problems specific to chemical, biological, radiologic, nuclear and explosives weapons; physical and psychological damage to survivors, family members, and community; short and long-term implications of bioterrorist attacks; and beginning treatment. Discussion questions in the Instructor’s manual ask individuals to think like a terrorist, and to discuss how terrorists could attack that particular community and how triage issues would be managed. (See Table 3.)

The Learning Objectives for Module Three are:

• Learn nomenclature for human-caused disasters that may result in mass casualties.

• Understand the psychological impact of human-caused mass casualty disasters.

• Understand the appropriate disaster mental health response following a human-caused mass casualty event.

Figure 3

Table 3

Module Four—Anxiety and Related Topics covers acute stress disorder; anxiety-related disorders; how individuals may present to a primary care physician; screening for PTSD; group and individual responses to a disaster; unique features of biological and chemical agents which can produce psychiatric symptoms; pharmacologic treatment for PTSD; and when to refer out for psychotherapy. Discussion questions ask individuals to consider short-term and long-term effects of disasters and how individuals successfully rebuild their lives or fail to do so. (See Table 4.)

The Learning Objectives for Module Four are:

• Understand how anxiety presents in various ways for the short-term and long-term after a disaster.

• Understand how to screen quickly for PTSD.

Figure 4

Table 4

Module Five—Medically Unexplained Physical Symptoms, Coping Skills, and Long-term Psychosocial Implications discusses coping skills; types of coping; effect of coping styles on PTSD development and course; teaching coping skills; medically unexplained physical symptoms (MUPS); treatment of MUPS; triage; short and long-term treatment including medications; referring out for psychotherapy; long-term psychosocial implications of a terrorist-caused disaster; chronic PTSD; disaster characteristics that may affect PTSD; and long-term physical problems. Discussion questions examine different types of coping styles and how they could influence the development and/or course of PTSD. (See Table 5.)

Module Five’s Learning Objectives are:

• Distinguish among various coping styles and how they can help or harm an individual.

• Help patients cope with and understand medically unexplained physical symptoms (MUPS) and understand the role anxiety plays in their causation.

• Understand long-term psychosocial implications of different types of disasters and how these will affect patients in different ways.

Figure 5

Table 5

Module Six—Delivering Bad News covers delivering bad news and assisting in providing death notifications; debriefing for medical professionals; debriefing for first responders and for volunteers; mass casualties; and setting up family resource and family assistance centers for short and long term services to survivors and families of victims of a mass casualty (the term “debriefing” here does not refer to critical incident stress debriefing). Discussion questions ask about cultural issues in the individual’s community for families of victims, both at an individual level and at the community level. (See Table 6.)

The Learning Objectives for Module Six are:

• Learn how to present bad news to families of victims and survivors.

• Learn how to support families of victims and survivors.

• Learn how to provide support in cases of mass casualties.

• Learn how to support yourself and volunteers.

Figure 6

Table 6

Module Seven—Risk Management, Isolation and Quarantine Issues discusses risk management and risk communications; topics and challenges unique to bioterrorism; enlisting the general public as a capable partner; thinking beyond the hospital for mass casualty care; issues around quarantine and isolation; evacuation; sheltering-in-place; and how the public views government readiness plans. Discussion questions again ask the individuals to think like a terrorist, work on an evacuation plan, and provide a scenario which could be individualized to the community. (See Table 7.)

Module Seven’s Learning Objectives are:

• Learn the behavioral health issues related to quarantine, isolation, and evacuation.

• Understand risk communication in the context of public health education and in conjunction with state health and law enforcement authorities.

Figure 7

Table 7

Conclusion

The just-in-time concept for disaster mental health training is a field with few inexpensive, easily accessible, web-based resources. Both immediate and long-term mental health responses are needed to provide support for those affected by disasters so they can begin the healing process. These services need to match the community affected by the disaster, and organizations need to work together to meet both individual and community needs. Responders also will need short-term and long-term mental health services after a disaster for their own healing. The curriculum described here provides quick, readily available training for health professionals, paraprofessionals, and others who are called upon to provide support, on short notice, for a disaster.

Competing Interests: This work was funded in part by a grant from the California Department of Mental Health to Dr. Yellowlees, Dr. Hilty and Dr. Ayers to develop a curriculum and training program for primary practitioners in disaster mental health. Contact Dr. Yellowlees for a copy of the instructor’s manual.

Additional disclosures for Dr. Hilty: Wyeth, Eli Lilly, Abbott Labs, Sepracor, AstraZeneca and GSK speaker’s bureaus.