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Vibrant’s Crisis Emotional Care Team

Presents…

Disaster Behavioral Health Just In Time Training:

Ukraine

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Introduction

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Crisis Emotional Care Team

Just In Time Training Overview

Meet your trainers
Crisis intervention strategy
Relevant cultural information
Typical deployment experience
Wrapping up
Questions

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Crisis Emotional Care Team

Trainers

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Dr. April Naturale

VP of National Programs at Vibrant Emotional Health

Dr. Alexander Dimitrevich

Lead Consultant / Coordinator for MHSS Eastern Europe – Mental Health Support SolutionsDr.

Grant Brenner

CEO & Founding Partner, Neighborhood Psychiatry & Wellness, Co-chair CECT Advisory, CECT Volunteer

Craig L. Katz, MD

Director, Mount Sinai Program in Global Mental Health

Co-Founder Disaster Psychiatry Outreach

Dr. Sander Koyfman

Chief Medical Officer, Athena Psych

Co-chair CECT Advisory, CECT Volunteer

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Breathing Exercise

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Crisis Intervention

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Crisis Intervention

What is Disaster Behavioral Health?^1,2

Providing disaster survivors and responders…

mental health
substance abuse
and stress management services

Crisis Support in Emergencies

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Crisis Intervention

Be a…^1,2

Human being
Health professional
Mental health professional

Think Triage, not Diagnosis

Crisis Support in Emergencies

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Crisis Intervention

Approach to help in the immediate aftermath of disaster or terrorism
Appropriate for survivors, witnesses, and responders
Reduces initial distress and fosters short- and long-term adaptive functioning
Does NOT assume development of severe mental health problems

Evidence-Informed Best Practices: Psychological First Aid³

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Crisis Intervention

Evidence-Informed Best Practices: Psychological First Aid³

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Contact and Engagement

Safety and Comfort

Information Gathering: Current Needs and Concerns

Practical Assistance

Connection with Social Supports

Information on Coping

Linkage with Collaborative Services

Stabilization

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Crisis Intervention

Psychological theory
Five tiers (bottom to top)

Physiological needs
Safety needs
Love & belonging
Esteem
Self-actualization

Evidence-Informed Best Practices: Maslow’s Hierarchy of Needs^4,5

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About ~2 minutes

Presented by Craig

Broad overview of each one

Maslow’s Hierarchy of Needs was developed in the 1940s as a motivational psychological theory. Maslow theorized that we must satisfy lower-level, base needs (like food, water, shelter) before we could move up to worrying about higher-tier needs (i.e., security, friendship, respect, or desire to grow as a person).
Often depicted as a pyramid, there are five tiers that go, from bottom up:

Physiological needs, such as air, water, food, shelter, sleep, clothing, and reproduction
Safety needs, such as personal security, employment, resources, health, and property
Love and belonging, such as friendship, intimacy, family, sense of connection
Esteem, such as respect, self-esteem, status, recognition, strength, and freedom
Self-actualization, such as the desire to become the most that one can be

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Crisis Intervention

Designed with a focus on the weeks and months after a disaster
Appropriate for survivors, witnesses, and first responders
Aims to provide skills to manage and reduce ongoing distress and effectively cope
Understands survivors will experience a variety of reactions over differing periods of time

Evidence-Informed Best Practices: Skills for Psychological Recovery⁶

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Crisis Intervention

Evidence-Informed Best Practices: Skills for Psychological Recovery⁶

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Skills include:

Gathering information and prioritizing assistance
Building problem-solving skills
Promoting positive activities
Managing reactions
Promoting helpful thinking
Rebuilding healthy social connections

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Crisis Intervention

Five principles of psychosocial care

A sense of safety
Calming
Self- and community-efficacy
Social connectedness
Hope

Evidence-Informed Best Practices: 5 Essential Elements of Post-Disaster Care⁷

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About ~3 minutes

Presented by Craig

Broad overview of each one

5 Essential Elements of Post-Disaster Care was developed by Stevan Hobfoll, et al., in 2007 to provide psychologists with the basics of disaster mental health work. The five principles are to promote: 1) a sense of safety; 2) calming; 3) self- and community-efficacy; 4) social connectedness; and 5) hope. These are meant to be a guiding framework in developing disaster mental health care approaches and preventions (like PFA and SPR) based on what the authors found in the literature at the time.
Based on a synthesis/meta review of existing literature at the time, these principles were presented to psychosocial care givers, but have since gone on to influence policy makers and scholars as well.
Hobfoll emphasizes that these principles are not complete, nor should they be; there is always room to deep the principles and make them a more salient fit depending on cultural factors and resource contexts.
Give a brief description of each of the five principles and examples of how to implement them.

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Crisis Intervention

Complex, multi-layered affect on multiple populations

Effected populations range from active military and internally displaced persons to refugees to second- and third-generation immigrants
Destruction of physical, psychological, social, and ecological health^8,9

Psychological Effects of War

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About ~3 min

Presented by Grant

An active war zone is not a simple trauma experience or disaster, nor is it comparable to other disasters you may have experienced (i.e., wildfires, earthquakes, or even mass shootings).
Wars involve multiple layers that compound and wrap around each other to cause a complicated web of trauma. This can greatly affect individuals in the moment and in the future, particularly if the trauma is not dealt with in appropriate and culturally sensitive manner in the moment or in the months right after escape or de-escalation.
There are multiple populations that are affected by the war. First is those on the ground: The active military, veterans, and civilians who may become internally displaced or refugees. Second is those with close cultural identity ties, such as people who have previously emigrated from the area. Third is those with slightly looser ties, such as second- and third-generation family members of immigrants or immigrant’s friends and loved ones.
War covers effects on four different aspects of a person’s life: Physical health, psychological health, social health, and ecological health.

Each of these contributes to the complex trauma that the person is experiencing, and is important to keep in mind when providing support, creating an intervention, or offering referrals to ongoing mental health care.

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Crisis Intervention

Physical^8,9

Nutrition
Non-communicable diseases
Infectious diseases
Injuries

Psychological Effects of War

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Psychological^10,11,12

PTSD & CPTSD
Anxiety and depression
Medically unexplained symptoms
Substance use

Social^8,9

Displacement
Food insecurity
Financial insecurity
Community breakdown

Ecological^8,9

Water, soil, and air pollution
Destruction of infrastructure
Uninhabitable environments

About ~3 min

Presented by Grant

War endangers physical health in terms of nutrition; disease exposure and immune response; injuries directly or indirectly related to military fighting (such as those in the military or civilians caught in the crossfire; research shows that current wars display a civilian:soldier injury rate of 10:1).

It also includes things like proper access to healthcare, particularly those with pre-existing conditions, pregnant people, newborns, and pediatric care for children and adolescents.

This can then be compounded by multiple identities. For example, while able-bodied children in Ukrainian foster and government care were fleeing, many children with disabilities were trapped in Kyiv and neighboring cities, unable to leave because of the increased needs and help they require to leave (such as wheelchair-accessible transportation, medical supplies, and chaperones). Poland and neighboring countries have provided the needed assistance to get many out of Ukraine, thankfully.

Given the two years we have spent under a global pandemic, the toll of this war will be even greater than ones previously researched.

On a psychological level, war can increase symptoms of anxiety and depression, cause dissociative states and hysteria, increase substance abuse issues, and cause PTSD and CPTSD.
The internal displacement of people causes breakdowns of community and prior support structures, as well as food and finance security
Ecologically, the bombing, smoke, and other weaponry can cause pollution of the area’s water, soil, and air, further exasperating health and food problems.

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Crisis Intervention

Human Stress Response¹³

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Stretch Break

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Cultural Competency

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Cultural Competency

Ukrainian Nationals

Civilians and military in Ukraine
Who emigrated prior to invasion
Refugees and immigrants post-invasion
Second- and third-generation Ukrainian immigrants
Non-Ukrainian loved ones and friends

Who is Impacted?

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Russian Nationals

Currently in Russia
First-, second-, and third-generation immigrants

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Cultural Competency

Everyday social norms
Important Ukrainian institutions
Cultural beliefs and habits

Ukrainian Beliefs, Norms, and Institutions

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Cultural Competency

Cultural competence is essential to increasing access and improving standards of care
Culturally-Informed Care means

Having capacity to provide care that acknowledges, respects, and integrates individual cultural values
Understanding cultural context goes beyond race and ethnicity markers

Being Culturally Informed¹⁴

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About ~5 minutes

Presented by Alex

Best approach to disaster response care is a culturally-informed one. This means incorporating an intervention that acknowledges, respects, and integrates the individual’s cultural values, beliefs, and practices.
Looking at all the aspects of the individual’s identity is needed to see them as a whole person, since we are treating the whole person.

These aspects will also affect the way we assess or the interventions we choose to provide

Cultural differences will also affect communication styles and habits. We should keep these in mind rather than approaching support as a one-size fits all.
Remember trauma does not occur in a vacuum, but develops and is understood in a particular cultural matrix. Understanding the role of beliefs in the interpretation of trauma and the recovery process is important when providing support.
Practicing self-awareness is the best way we can check our own assumptions, values, and beliefs, and how they might be influences our engagement and support of individual’s experience

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Cultural Competency

Strategies for culturally informed care includes:

Being Culturally Informed¹⁴

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Listen

What is your understanding of what’s happened?
What is most worrying you?
Have you experienced something like this before?

Be Open

Who do you normally turn to for support?
Are you open to outside referrals and resources?

Respect

Who typically makes decisions for you and your family?
Is there anyone else you would like to talk to?
What would be helpful for you and your family at this time?

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What to Expect

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What to Expect

An established command structure

Facilitates effective collaboration and communication across agencies
Minimizes potential confusion caused by high turn-around of volunteers/command

Remember

Every deployment is different
To follow leadership on the ground
To check in with volunteer team every day

Incident Command Structure

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About ~3 minutes

Presented by Grant

Incidence Command Structure is an established hierarchy designed to facilitative effective interdisciplinary response to a critical incident/crisis
This structure facilitates collaboration and communication, provides admin and logistical support, minimizes confusion re: chain of command, offers flexibility according to specific needs, and provides cost effective and efficient responses
Stress importance that every situation/deployment is different, and therefore the leadership and command structure will change frequently

Always ask who the leaders are in every deployment, even if it’s something you’ve done before

There is high turn-around due to the volunteer nature of this work; it’s important to keep up-to-date with names and contact information for the people you report to, and to note who is a permanent worker and who is a volunteer
Follow the command and leadership of those on the ground first, as they are the most apprised of the situation as it develops/changes

If something seems off or wrong with their commands, reach out to the volunteer team lead on the ground first (unless they’re the issue) and volunteer team organizers second

Check in with your volunteer team, both virtual and on the ground, every day

It’s important to check in with each other, updating on the situation and your experience, as this will allow you to decompress some of the stress of the situation and allow you to ask clarifying questions or inform of ill behavior/misdirection by ground leadership

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What to Expect

Disaster mental health is a team effort

We work in concert with our fellow volunteers, workers and leaders on the ground, and leaders back home
More effective to work with different agencies than parallel or against them
Always ask where you are most needed, not assume

Create a support group on the ground

Meet regularly with other volunteers
Use the buddy system in the field
Mentor others and be a mentor yourself

Collaboration

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About ~3 mins

Presented by Grant

Disaster work created a complex layer due to the myriad of problems that arise and the multitude of programs, businesses, and agencies that will work to respond
It is important to establish yourself as part of a team, not as an individual

Always check in with your leaders and fellow volunteers to assess what areas/issues are already being addressed and where holes have begun to form
Find the people who share your skills and expertise and figure out where you fit in with them, rather than working in parallel alone

Forming a supportive group not only makes the work more effective and efficient, it also helps protect disaster relief workers and volunteers from burnout, vicarious trauma, and secondary traumatic stress.

Once you’ve figured out who your fellow volunteers are, meet with them. This can be sharing a meal at some point in your day, going on walks, or texting each other throughout the day.
While in the field, use the buddy system. Make sure someone knows where you are and where you plan to go. This will protect you in case there is an accident.
Whether you’re an experienced disaster mental health volunteer or fresh to it, it’s important to be open to being mentored and being a mentor. There are always areas in which you can learn and adapt, and areas in which you can teach and guide.

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What to Expect

Assessment Basics

Check in with yourself first
Utilize humanity
Assess needs
Apply Psychological First Aid and Skills for Psychological Recovery

Needs Assessments

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About ~3 mins

Presented by Grant

It is important before you even approach anyone to provide support that you first check in with yourself and provide self-care if needed. Remember, you wouldn’t put on someone else’s oxygen mask before your own, and you shouldn’t provide mental health support if you need support yourself.
Equally important is to make sure that you have all the facts before you go to help someone. Checking in with your leaders every morning is vital to keep you up-to-date on situations so you can answer questions with as much information as possible.
Remember the basics from the beginning: Be a human, then a health professional, then a mental health professional. Use your empathetic humanity when coming up to people, asking first if you can enter their space before you say or do anything else.
Conduct a functional assessment

What basic needs are not being met?
Is there any important information they’re waiting on about the situation or loved ones?

Apply PFA and SPR standards

Remember that this is about triage, not diagnosis. Talking to people in the moment can help alleviate some of the stress and trauma that could develop into PTSD if not addressed. Listen to them, provide actionable steps that they can take to manager their emotions, and help them create an action plan they can implement to address their physical and mental health needs.
If you know you will be able to, promise to follow up with them later or the next day. If you cannot but they look like they need more conversations, lead them to another volunteer who can.

Conduct a referral

If someone is in clear need of more assistance, then make a referral to a mental health agency. If nothing is available, there may be a support group of other survivors they could join.

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What to Expect

Engage in active listening

Understand what is being said
Respect the people you speak with
Be nonjudgmental
Establish trust
Be patient as people work through their feelings
Consider the subtext

Critical Communication Skills

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About ~3 mins

Presented by Grant

It is important to build a rapport with the people you provide support and show that you understand what they are going through, even if you have not lived through it yourself. This alone can go far in helping people heal and recover after a crisis/disaster.
Active listening is a great way to build rapport

Make sure everyone is understanding what the other is saying
Have genuine respect and regard for the people you help
Be nonjudgmental and accepting of others, even if they hold beliefs/attitudes you do not agree with or find offensive
Establish trust by not answering questions you don’t know, providing information you’re unsure of, or making promises you can’t keep
Often, people need to tell their stories multiple times as a method to work through their emotions about it; be patient and actively listen, even if you have heard the story before.
Remember that communication is not always direct nor verbal; pay attention to what people aren’t saying and what their body language and expressions are saying

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What to Expect

CERC means…

Building trust and credibility
Preparing to answer questions
Staying on message
Being consistent
Acknowledging uncertainty
Fact-checking

Crisis and Emergency Risk Communication¹⁵

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Be First. Be Right. Be Credible.

People want to know that you care before they’ll care what you know.

About ~4 minutes

Presented by Sander

Developed by the CDC, Crisis and Emergency Risk Communication is an evidence-based framework and best practices for anyone who communications on behalf of an organization responding to a public health emergency. Primarily, this is meant to advise on talking to other organizations, media, or the government.
When doing disaster mental health volunteer work, your focus should first always be on following Psychological First Aid guidelines and best practices. You should not be talking to media in any official way.
Still, the guidelines in CERC are useful to keep in mind when you are providing behavioral health support to survivors and their loved ones. The guiding principle of CERC is to “be first, be right, be credible.” This means communication information quickly as you verify it, since information and situations change rapidly in disasters; establish credibility of all information before you share it; and maintaining honesty and truthfulness always to show the people you help that you are an ethical and credible source.
In disaster situations, you should always be ready to answer a multitude of questions—where loved ones may be, what’s going on, latest news on the ground—and equally prepared to tell people that you don’t know but will do what you can to find out. If you cannot find out, it is important to follow-up with people and tell them no one available knows the answer, but that they should keep asking in case more information comes in.

Your regular meetings with incident command should provide you latest information and messaging around the disaster—when answering questions, remember to always stay on message and follow the directions of those in charge.

Lastly, remember that people first and foremost want to know that you care about their story and their situation. If they don’t trust or believe that you care about them, they won’t care about the factual information that you have.

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Wrapping Up

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Wrapping Up

Secondary Traumatic Stress^16,17
Vicarious Trauma^16,17
Burnout¹⁸

Post-Deployment Experiences

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Wrapping Up

Recognize & value meaning in day-to-day
Practice self-reflection
Resilience & compassion satisfaction
Vibrant Self-Care Action Plan

Importance of Self-Care¹⁹

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Wrapping Up

Join the CECT cadre (or another organized response team)
Provide general availability (virtual & in-person)
Look out for emails from CECT
Deployment opportunity timeline

Next Steps

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References

Myers, D. G. (1994). Disaster response and recovery: A handbook for mental health professionals. DIANE Publishing.
SAMHSA - https://www.samhsa.gov/dtac/disaster-behavioral-health-resources
Brymer, M., Layne, C., Jacobs, A., Pynoos, R., Ruzek, J., Steinberg, A., ... & Watson, P. (2006). Psychological first aid field operations guide. National Child Traumatic Stress Network.
McLeod, S. (2020, December 29). Maslow’s hierarchy of needs. Simple Psychology. https://www.simplypsychology.org/maslow.html
Hopper, E. (2020, February 24). Maslow’s hierarchy of needs explained. ThoughtCo. https://www.thoughtco.com/maslows-hierarchy-of-needs-4582571
Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., Macy, R., Osofsky, H., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2010). Skills for Psychological Recovery: Field Operations Guide. The National Center for PTSD & the National Child Traumatic Stress Network.
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., ... & Maguen, S. (2007). Five essential elements of immediate and mid–term mass trauma intervention: Empirical evidence. Psychiatry: Interpersonal and Biological Processes, 70(4), 283-315.
Musisi, S., & Kinyanda, E. (2020). Long-term impact of war, civil war, and persecution in civilian populations—Conflict and post-traumatic stress in African communities. Frontiers in Psychiatry, 11(20), 1-20. DOI: 10.3389/fpsyt.2020.00020
Garry, S., & Checchi, F. (2019). Armed conflict and public health: Into the 21^st century. Journal of Public Health, 42(3), e287-e297. DOI: 10.1093/pubmed/fdz095

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References

Roberts, B., Makhashvili, N., Javakhishvili, J., Karachevskyy, A., Kharchenko, N., Shpiker, M., & Richardson, E. (2019). Mental health care utilisation among internally displaced persons in Ukraine: results from a nation-wide survey. Epidemiology and psychiatric sciences, 28(1), 100-111. DOI: 10.1017/S2045796017000385
Ioffe, Y., Abubakar, I., Issa, R., Spiegel, P., & Kumar, B. N. (2022). Meeting the health challenges of displaced populations from Ukraine. The Lancet. https://doi.org/10.1016/ S0140-6736(22)00477-9
Abu Suhaiban, H., Grasser, L. R., & Javanbakht, A. (2019). Mental health of refugees and torture survivors: a critical review of prevalence, predictors, and integrated care. International Journal of Environmental Research and Public Health, 16(13), 2309. DOI: 10.3390/ijerph16132309
Everly, G. S., & Lating, J. M. (2019). The anatomy and physiology of the human stress response. In A clinical guide to the treatment of the human stress response (pp. 19-56). Springer, New York, NY.
Health Care Toolbox - https://www.healthcaretoolbox.org/culturally-sensitive-trauma-informed-care
Centers for Disease Control and Prevention. (2019). Crisis and Emergency Risk Communication Manual. https://emergency.cdc.gov/cerc/manual/index.asp
Mcann, I., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131-149.
Quitangon, G., & Evces, M. R. (Eds.). (2015). Vicarious trauma and disaster mental health: Understanding risks and promoting resilience. Routledge/Taylor & Francis Group.
Maslach, Christina & Schaufeli, Wilmar & Leiter, Michael. (2001). Job Burnout. Annual Review of Psychology. 52. 397-422. 10.1146/annurev.psych.52.1.397.
Vibrant Emotional Health. Self-Care Action Plan.

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Questions?

Be sure to join the CECT at https://cectvolunteers.force.com/s/interest