Disaster Psychiatry Emerges as DOD Field of Study

By Cheryl Pellerin

American Forces Press Service

WASHINGTON, Jan. 17, 2014 – At the Center for the Study of Traumatic Stress, experts in the emotional toll of disasters help the Defense Department, government agencies and first responders worldwide understand how best to help communities struck by terrorist attacks, mass casualties and natural disasters.

The center is part of the psychiatry department at the Uniformed Services University of the Health Sciences in Bethesda, Md. The USUHS serves the Army, Navy, Air Force and U.S. Public Health Service by educating health professionals for DOD and USPHS career service.

“The center was established essentially to address concerns by the Department of Defense about psychological impacts and health consequences that might result from the potential use of weapons of mass destruction during combat [and] acts of terrorism or hostage events,” Dr. Joshua C. Morganstein told American Forces Press Service during a recent interview.

Morganstein, a commander in the Public Health Service, is an assistant professor in the USUHS psychiatry department and a scientist at the Center for the Study of Traumatic Stress.

“There was growing interest by DOD in the general psychological impact and health consequences resulting from a broad category of traumatic events,” he said, including peacekeeping missions, operations other than war, and natural disasters such as hurricanes, earthquakes and tsunamis. DOD also was interested in more common stress-producing events like physical assaults or boat, plane and car accidents for uniformed and civilian communities, he said.

The center was established in 1987 as part of the USUHS psychiatry department. Since its inception the center has been run by department chairman Dr. Robert Ursano, who Morganstein said is internationally renowned in the field of disaster psychiatry, which differs from general psychiatry in important ways.

“Traditional psychiatry is, for the most part, hospital or clinic based, taking place in a traditional treatment setting and generally one on one … to focus on problems that an individual has sought care for,” Army Col. (Dr.) David M. Benedek told American Forces Press Service.

Benedek is associate director for consultation and education at the center, and professor and deputy chairman of the USUHS psychiatry department.

“Disaster psychiatry is an effort to target the range of possible responses to a disaster without people necessarily seeking care,” he said, adding that the population-based approach in disaster psychiatry is to do “things that help all people regardless of whether they have identified themselves as having an illness” or as needing mental health care.

Benedek and Morganstein explained that a key element underlying disaster response is a set of principles that together are known as psychological first aid.

These five early intervention principles promote a sense of safety by helping people meet basic needs for food and shelter, promote connectedness by keeping families together, promote self-assurance by giving practical suggestions that help people help themselves, promote hope by directing people to government and other kinds of services, and promote calming by being friendly and compassionate even if people are being difficult.

Examples of what not to do, according to the center’s fact sheet, include not forcing people to share their stories, not giving simple reassurances such as “Everything will be all right,” not making promises that may not be kept, and not criticizing existing services or relief activities.

Psychological first aid, Morganstein said, “is designed to encourage health-seeking and decrease the incidence of more severe psychiatric symptoms or emotions and distress behaviors in the wake of a disaster.”

After the terrorist attacks on 9/11, the scientist added, “people really sought Dr. Ursano out to address the impact of that event and the nation’s need for disaster planning and preparedness for future events.”

In 2003, the center, whose multidisciplinary team had expertise in disaster psychiatry, military medicine and psychiatry, social and organizational psychology, neuroscience, family violence, workplace preparedness and public education, established an Office of Public Education and Preparedness.

“Before this,” Morganstein said, “Dr. Ursano and other senior leaders here at the center played a role during disasters [like the 1986 Chernobyl nuclear accident in Ukraine, the 1988 Lockerbie, Scotland, Pan flight 103 jumbo jet crash, and the 9/11 terrorist attacks in the United States]. They provided expertise, consultation and spoke with people about the best evidence for managing psychiatric aspects of a disaster scenario.”

But the center needed a better way than individual consultation to get its expert information out to more people affected by disasters and to those involved in disaster response, he said.

An answer to this, and part of the new office’s multipronged approach to education and outreach is producing and disseminating rapid-response fact sheets tailored to ongoing situations such as last year’s Navy Yard shootings.

“The fact sheets get information out there to [the DOD and military mental health leadership], potential patients or affected public, [health care providers] and other people who are in a position to provide leadership and guidance,” Benedek said.

The goal, Morganstein added, “is to offer educational resources to a wide range of folks who might potentially benefit from this information in response to a disaster that’s happening.”

During the Navy Yard event, the center got a request from the District of Columbia’s mental health department to consult with its leaders, and from the mental health team lead from Walter Reed National Military Medical Center that augmented Navy medicine’s SPRINT team response, Morganstein said.

“One of the personnel from our center, a Public Health officer, was asked to participate in the on-the-ground behavioral health response,” he said. “Then we had about a 12-hour turnaround where, based on the information as it rapidly evolved, we decided on what would be relevant issues to the military, the D.C. government and first responders.”

Fact sheets were tailored to issues unique to an active-shooter situation on a military installation in which many people were killed, the shooter was killed, and challenges likely would arise as the D.C. government and the Defense Department worked through managing a response to people on the base and in the local community, he said.

The fact sheets were developed, reviewed by center subject-matter experts and then disseminated to key leaders in DOD and the D.C. government, the services’ mental health leadership, and organizations such as the American Psychological Association, the American Psychiatric Association, the USPHS leadership and others.

“That was the first 12 to 18 hours after the news broke of the shooting as we watched it unfold,” Morganstein said.

The center’s consultive services and educational products such as fact sheets, written in language everyone can understand, help to fill a longstanding gap in medical education.

“Because disaster psychiatry is not something that over the past several decades has gotten a lot of education,” Morganstein said, “it isn’t built into the curricula of behavioral health or medical providers -- not even in DOD, and certainly not in the civilian sector.”

Receiving such disaster-specific information can be a paradigm shift for health providers, he added, “because what we’re saying to a psychiatrist or a psychologist, for instance, is the therapy you spent years learning to give and the medicines you spent years learning to prescribe may not necessarily be the most important tool in your arsenal right now.”

Still, Benedek said, many training programs increasingly recognize the need, in mental health and across medical disciplines, for specific disaster training.

“Certainly, we’ve been advocating that in academic channels and have published on the need for the development of an academic disaster curriculum,” he said, adding that the USUHS psychiatry department offers a disaster fellowship for one or two students a year.

The post-graduate training program is open to psychiatrists and some internists who ultimately receive a master’s degree in public health and then participate in rotations with agencies committed to disaster response.

“As far as we know, it’s the only disaster fellowship,” Benedek added, “but other residency programs are developing at least some training in this area for their psychiatric residents.”

In late March, for example, by joint invitation from Sheppard Pratt Health System and the University of Maryland, Morganstein will present a half-day seminar on disaster psychiatry for fourth-year residents from both institutions.

“We’re interested in partnering more widely in this region to begin with,” Morganstein said, “and potentially creating an educational curriculum for psychiatry residents and expanding that potentially even further.”

Agencies such as the Red Cross, the American Psychiatric Association and the American Psychological Association disseminate disaster information, Benedek said, but particularly in the last five or six years, medical training programs have recognized the need to for curricula.

One such organization is the National Center for Disaster Medicine and Public Health, established in 2008 by Homeland Security Presidential Directive 21 as an academic center of excellence in disaster medicine and public health.

The NCDMPH, also affiliated with USUHS, initially developed a curriculum for responding to children's needs during disasters, Morganstein said, then partnered with the Center for the Study of Traumatic Stress to develop a behavioral health curriculum toolkit called “Curriculum Recommendations for Disaster Health Professionals: Disaster Behavioral Health,” published this month.

Benedek said the new center, the fellowship at the Center for the Study of Traumatic Stress, and increasing interest in disaster-focused health curricula all are evidence that awareness of the need for such training is growing nationwide.

“The lengthy conflicts in Iraq and Afghanistan have certainly brought to the surface the reality of the emotional consequences of traumatic exposures,” he said.

“Certainly, at military and governmental levels there’s an awareness that bad events exact a psychological toll,” Benedek added, “and there’s a need for a response to those events and training to develop an appropriate and rational response across populations.”