Well, I think it's 1.30, so aloha, or you can do better than that, aloha. And one of the reasons I'm doing that is because it's traditional where I've lived for 30 years, but also one of the lessons I learned is that culture is very important in disaster response and I had personal experience with that when we responded to the lava disaster in 2018 on the Big Island. So thank you all for being here on the very last day, in the last afternoon, so we're really happy that you're here. So I bring you greetings from Maui, from our beloved Haleakala Crater and our unique Ahinahina silver sword plant. I have no disclosures and title is Demystifying Disaster Psychiatry, What Can DBs Do? So this is really a group effort and Katie Koh in Boston was part of this last year, but it never happened because of the pandemic, and so I thank all the chairs and the co-chairs of the three district branches which are being represented here today. So my name is Leslie Guise, I'm a clinical professor in the Department of Psychiatry at the John A. Behrens School of Medicine at the University of Hawaii, and I'm originally from New York, but my husband and I moved to Maui 30 years ago, and I'm currently a member of the APA Committee on the Psychiatric Dimensions of Disaster, CPDD, where we had a whole bunch of district branch disaster representatives yesterday, all day long we met. Anyway, I'm the mental health lead for the Maui branch of the American Red Cross for about 20 years, a member of the Medical Reserve Corps, we wound up giving the first COVID shots on Maui in the parking lot of the community college, outside, which was challenging, eventually they went inside, but that's a long story, and also a new interesting organization which you should check out, Vibrant Emotional Health, it's vibrant.org, it's trying to be like the Red Cross without the bureaucracy, and very interesting, so check it out. I got involved with disaster psychiatry after September 11th, just two days before, on September 9th, I was in Washington D.C. at an APA components meeting, and flying home on American Airlines Flight 77 from Dulles to Los Angeles, the very flight which, two days later, crashed into the Pentagon. On September 11th, my daughter was fresh out of law school at her dream job near the World Trade Center, and she saw the second plane hit the South Tower from the window in her office. She was evacuated by emergency responders who were handing out wet tissues for people to put over their faces, and for one hour after I heard the news, I did not know whether she was dead or alive. Communications were down, cell, landline, internet, I was looking at a map like this and trying to figure out if my daughter was in any of the buildings that were going to fall down, and we actually have an amateur radio expert in the audience who knows all about the communication. Communications and mental health are the two things that usually go down in disasters, so I was stressed out about my daughter, so when I was asked to make two presentations at our one and only local hospital, along with a child psychiatrist and the police chaplain, I was really angry. I'm laughing now, but I wasn't laughing then, but having something to do actually helped me cope, and poof, I was a disaster psychiatrist. I started attending the APA Disaster Committee, and Barbara Sano was the head of it. He was the sort of disaster psychiatry guru, and he's, well, Alyssa Benedict had a task force for two years, and then two years later, Barbara Sano formed the committee, and I went there for many years, and so since I was in the assembly in Area 7, I was able to get a district branch disaster rep in every one of the 13 Western states and Western Canada, including Arizona, who's represented here, and so later, Josh Morgenstein, who's the current chair of the committee, reiterated the call for a disaster rep in every 72 DBs, and now I think it's about half of them. It's amazing, which now have a disaster rep, which is an official position in the DB. It has a position description, and it's on the APA website listed in the components directory, and if something happens in the area of your DB, you're the DB disaster rep, you can get resources, guidance, support, and access to all the members of the disaster committee, which is very helpful. That's what people have said, so there's a multitude of resources on the APA website. We're still working on making it more user-friendly, but in the moment of a disaster, feedback has indicated that a few short, targeted resources are helpful, and these are usually the one-page fact sheets from the CSTS, the Center for the Study of Traumatic Stress at USIS, the military medical school, which is in Bethesda. So some DBs, in addition to having a disaster rep, also have a disaster committee, and some committees have been functioning for a long time, and others are new or recently reactivated, so today we have the privilege of hearing from three DBs which have disaster committees. First is going to be North Carolina, then Massachusetts, and then Southern California, and first we have Therese Garrett, who's co-chair of the North Carolina DB disaster committee. She's the medical director of Carolina Outreach, affiliated with UNC, and president of the North Carolina Council of Child and Adolescent Psychiatry, which is a local chapter of ACAP. Her interests include early child development, trauma, foster youth, crisis assessment of youth, and women's mental health. She got her undergraduate degree in philosophy, and her MD at UCSF, residency at Harvard, and child adolescent fellowship at UCSF. Therese is the co-chair of the North Carolina DB disaster committee, along with Alan Chrisman, who's been a very active member of the national committee, and please welcome Dr. Garrett. I don't know how to get rid of this. Yeah, good afternoon. I'm Therese Garrett. Just a couple of things that, to correct, that I thought I had sent over to Dr. Geist, but perhaps not. My current role is I'm the behavioral health medical director for managed Medicaid in North Carolina, called WellCare North Carolina, and I'm no longer the president of our child regional organization. I'm the immediate past president of that, and I guess as of today, I'm the president-elect of our district branch for North Carolina. And so as we're talking today, I think what we're wanting to show is a variety of different district branches that are in different stages of development, because one of the things that has come up in other settings around getting disaster reps or getting folks that are interested in doing this is fear about, like, I don't know anything. I can't do this. Like, I hear all this stuff that's happening at these other places, and we're nowhere near that. That's okay. What we're wanting to happen, what the committee is wanting to happen, is for there to be a disaster rep from every district branch, so that when something happens in Iowa, we know who to call. And ideally, that disaster rep will have some continuity, because even, like, a president or, you know, president-elect or VP, all of that's going to change in some of the DBs, and so, you know, they don't want to be sending out an email or calling somebody that's no longer affiliated. And so that's, so the role can be many different things. It doesn't have to be responding to shelters. It can be working with media. It can be something longer term in terms of working with folks that have been impacted. It can be doing education. There's a variety of different ways, and I think part of it as well is us wanting to say that you can all be disaster psychiatrists if you're not currently involved in disaster mental health, and it's really about finding not only, one, the place that you want to get involved, how you want to do that, but also what fits into your kind of life as it is right now, and that may change across time. So I'm going to be talking about how things have been running in the North Carolina district branch. Sorry about that. I have no relevant financial disclosures to report. So first, I wanted to go over what we have in North Carolina that is larger than our North Carolina district branch disaster committee, which is we have an overarching sort of interprofessional organization that is not like any 501C, this, that, or the other. It's really an informal group of folks from a variety of mental health professions, as well as the Red Cross, as well as some individuals from the state to really get together on a regular basis to talk about things related to disaster mental health. Some of the reason, at least in my opinion or what I think about why North Carolina may have a more formed and it may have more history with some of this, is we have regular disasters. Like if we don't have a hurricane this year, we'll have one next year or two years from now, and if we don't have one this year, there will at least be a hurricane scare of some sort, I would imagine. So the need to prepare and respond is more regularly prominent than may be the case in some other places, but what happened with the Disaster Behavioral Health Task Force is this initially came out of the Psychological Association, and the Psychological Association's foundation has actually for all of their regionals, I'm not sure what they call their district branch equivalents, they have a disaster response network that are psychologists that have volunteered and offered to help out in disaster settings, and they set this up quite a long time ago, long before I was in North Carolina, and set up an agreement with the Red Cross back in 1994 to be able to support and help provide disaster mental health resources during a variety of different disasters. More recently, some of the things that the Disaster Behavioral Health Task Force and members of the various professional organizations have been involved in are some of the responses, well quite a long time ago to Fran and Floyd, but then more recently within the last decade to Hurricanes Matthew and Florence, as well as to smaller scale things that come up, and then most recently the largest thing I think we've been involved in is after Hurricane Florence, the state had set up through some federal crisis money the Hope for NC hotline, which is a hotline that any North Carolinian could use, which was originally around sort of disaster mental health kind of things and stress that was coming up in that setting. That has continued. I honestly don't know exactly whether the funding sits under state or federal grants or what how exactly it's funded right now, but what we were able to do because of that is when COVID happened and there started being incredible stresses on folks that were in any sort of a first responder job or in any sort of a setting in which they were needing to be out and about all the time, which included first responders, which included health care workers, which included educators, especially those who were working almost from day one in some of the child care settings, was to help to manage some of the things that would come up for them. So it's a hotline that continues to exist. They can call. The main number is the number for Hope for NC, and if it's somebody calling in one of these categories, they get funneled over to the group of us that have agreed to be volunteers for Hope for Healers, and we'll get back in touch with them sort of in a warm line fashion after the fact and help them go through whatever is happening or help get them connected to resources if it seems like they're going to need mental health resources in the community. So that's kind of how the Disaster Behavioral Health Task Force has functioned. In terms of the development of it, the Psychological Foundation had set things up with the Red Cross back when it began and then invited the other professional organizations to join in 2000, so that's inclusive of psychiatry, MFTs, social workers, and other mental health professionals in North Carolina, and that group gets together quarterly to meet and also has some conversations on email outside of that, and part of what we do with that larger group is in June of each year, we have a meeting that's inclusive of all the members of the group as well as some of the local Medicaid MCOs that are the disaster response leads for their MCO to talk about, you know, just some new things, maybe to talk about how previous responses have gone, to do some smaller trainings, to talk about like how shelters work in North Carolina, because there's people that transition and turnover, and if you weren't there during Hurricane Matthew or Hurricane Florence, you probably don't have a sense of how some of the really large sheltering ends up happening in North Carolina. So that's one thing, and then the other thing that we try to do each year is for our fall meeting, that's usually after hurricane season, we'll talk about if there was a hurricane or even sort of like a hurricane threat, kind of talk about what were things that went right, what were things that went wrong. That's a place, for example, where we found out from the larger scale that some of the disaster mental health workers that were being deployed there because they were being deployed by a larger group, but then when they presented to the shelter, they were saying that they were from their smaller provider agency were getting turned away from the shelters because the shelter managers are trying to be protective and keep away the random people who want to come in to help, but in this setting, because there was a miscommunication, they weren't always getting in, which helped us to figure out, okay, this is something we're going to need to address in the future and probably will come up in another shelter, so how can we make sure this doesn't happen again so that we're able to get folks where they need to go? So in looking at how we tie into some of the other pieces and how one of the most important things with disaster mental health is being prepared for being unprepared and being prepared for the unpredictable is that when Hurricane Matthew happened in 2016, there were a lot of calls that we were having with the Disaster Response Network. American Red Cross was doing all kinds of stuff in their world, not just in North Carolina, but South Carolina, Florida, all these other places. It wasn't supposed to hit North Carolina. A lot of the American Red Cross resources had been deployed elsewhere because it wasn't supposed to hit us, and because at that point they thought, given the impact that was expected, that local resources such as our disaster behavioral health or other local community resources would be adequate. That didn't end up being the case because at the last minute, the hurricane moved, and in addition to that, it went really slow. And so the problem was, even though it was not particularly powerful, the amount of rain that was dropped over the course of a number of days led to a vast amount of flooding, both in that first initial four days, but then a week later when all the rain that had gone into the rivers further up ended up coming down. So throughout, there was a lot of meetings and phone calls and working with the state, connecting with the Emergency Operations Center, connecting with the professional groups, finding out where there were places that we could deploy resources. So, for example, when there was a church that was more of an impromptu shelter but had, I think, like 60 Spanish-speaking folks from their community, we were trying to make sure that we could get somebody to go out there who spoke Spanish who was able to be available to them, and there wasn't anybody within the sort of smaller group of volunteers that was readily available, but that was something we were able to disseminate out to larger groups of behavioral health professionals to say, hey, who can speak Spanish, can do this work, and is available over the weekend to do this. So that was kind of how we worked through all of that, but it ended up being more chaotic than was expected. And so some of the lessons that were learned at that point is that there are going to be times where the scale of a disaster and the rapidity of a disaster overwhelm available resources and capabilities. So, you know, even going back to something like 9-11, there are probably small disasters or small events that happen in New York that the local resources could pretty quickly respond to and support. Something giant like that, there is no way that's going to just overwhelm the capabilities of any local operations or local support. But it's also important that there is local prep that's available for mobilization and deployment of volunteers who ideally have some previous training in disaster mental health, so that it's not the people who are going who are like, I'm going to do EMDR, or I'm going to do trauma-focused CBT on day one with all these folks that have just been in the middle of a major trauma, because that's what was, you know, happening, this and the debriefing and all kinds of things that folks would come out of the woodwork to volunteer. But if you don't know what's harmful, then you may be a part of doing some of the things that are harmful rather than what's more evidence-informed. And so also people who have training and connection are going to be much easier to plug in when a disaster happens in your community. The way that the North Carolina Psychiatric Association has aligned with this is the things in black here are part of the goals in our strategic plan, but one of the first things that we were working on is we, or one of the things we've been working on recently that aligns with our three-year strategic plan is our involvement in some of the work, the state work, of the state work groups around the 988 line, which has now been live since July, and that we've been able to have input in with some of the larger stakeholder groups, but then also be able to get information out to our members about that resource, also through the disaster response network, as we talked about, and then some things that came up during COVID that were new. COVID work groups, a DHHS, Historically Marginalized Population work group, we had a couple of early-on position statements around long-acting injectables not being elective and ECT not being elective because early on everything elective was being, with COVID, was being canceled, and so we wanted to attend to what are some of the disaster pieces that relate to psychiatry that we need to be pushing forward. And then we're also doing what we can to educate both our members as well as others around the disaster mental health piece in forums such as this, in forums such as sort of general media or also psychiatric-specific media, with the most recent from our group is specifically from Dr. Christman in Psychiatric News. I believe it was the April Psychiatric News where he wrote an article around disaster response for children and being a helper. In terms of how we're disseminating this information, one of the things that we've found out is that a lot of folks, again, who want to volunteer and who are going to be able to do good work haven't done anything beforehand because they're not really involved or knowing about this until a disaster occurs. So we actually just finished up recording a training for individuals in North Carolina who are interested in doing what we call just-in-time training, which is more for folks that are going to, that have not been ongoing volunteers but might be event-based volunteers. We'd love it if any of the folks who are interested watch it on the front end before anything happens, but it's also short enough that folks could watch it in a time before they ended up deploying in some sense. And we also, with that, were able to get the state to come and have with us an ASL interpreter. So right now it's in English and in ASL. We're talking about ways to address some of the other language pieces, including Spanish. So what can you do within your district branch to develop your disaster rep or to develop your disaster branch? I think preparedness is a big piece, being persistent in building some of the contacts. So if you're trying to connect with somebody at the state and you don't get a response, figuring out, is that the right person? Is that person still there? Is there somebody else I should try? Did they just miss that email because they were reading it while they were on the train on their way to work? So it's continuing to try to build those connections, even if at first there's some failure with that. It's also recognizing within your district branch, what are some of the things that are important? How are disaster kind of situations run? Are things run on a county level? Is most of your stuff run at a state level? Is it run even lower sort of at a city level that you're gonna see much of this response? Because that's gonna help you know where are some of the relationships to build. And then also knowing what kinds of disasters are most common in your community. Obviously there are some, in particularly some of the man-made disasters and shootings and such that we can't predict where those are gonna happen. But if you're in California, probably much more likely to have an earthquake than we are in North Carolina. And in North Carolina, we're much more likely to have a hurricane. And if you're in Missouri, you're much more likely to have a tornado. So understanding some of the things that are more unique to the way that those disasters play out. Because planning is very different for an earthquake, which is just gonna happen, versus a tornado where you might know an hour ahead of time perhaps that there's a storm coming, maybe, versus a hurricane where usually it shouldn't be the case that it magically appears. So this slide, I'm not gonna go through this, but this is typically what we see in terms of the disaster impacts on mental health in terms of things starting at a baseline with an initial sort of honeymoon period where everybody's sort of feeling pretty good and connected, then leading later on to disillusionment and some of the building back and recovery later on. In terms of DMH, disaster mental health interventions, they're using psychological first aid and very things that you probably already know based on your training. You just don't know what it is or how exactly to do it in this way. And so some of the disaster mental health includes identifying where and when there are mental health needs. What are some of the ways that you can promote resilience and coping? And identifying targeted interventions. I have a couple slides here that I'm gonna go through relatively fast that I can send to folks later if they want that are about self-care, compassion fatigue, secondary traumatic stress because like as before when I said you need to try to figure out what works within your life, you also need to identify sort of what are the things that you're able to do that you can manage within the various stresses that you have right now without things going to a point of having compassion fatigue or secondary traumatic stress which happens when your emotions mirror the emotions of the people you work with. It changes your view. It can decrease your sense of personal safety and disrupt your sense of meaning. These are some of the secondary traumatic stress indicators which hopefully you all have seen in other settings before and have some awareness of but these are some of the red flags in my mind. So these are the things that if I'm seeing that, if I were to see them in myself or see them in other disaster mental health workers that's gonna tell me, hey, it might be time for me to check in on them and see how they're doing. Are they able to continue whatever work they're doing? Do they just need a break to go home and sleep tonight? What is it that's gonna be the best setting? This is actually a really interesting slide. There is a rating scale, the professional quality of life scale which goes through, you can get it, it's free online, which goes through sort of where you sit with regards to compassion fatigue versus compassion satisfaction. And compassion satisfaction is the other side of this in that in the work that any of us are doing with folks that have experienced trauma and in disaster, there are many positive things that we can experience with that in terms of traumatic growth, in terms of the sense of doing something meaningful in a way that is sort of building self-confidence and competence. There is with that some sacrificing of self-care. So where do you figure out how can you ensure that you're actually doing what you need to do? And finding ways for even in a setting where things are really difficult happening, what are some of the ways that you can have positive feelings that balance some of your frustrations, disappointments or despair? And then my last slide here, I have up a couple of the disaster trainings. I know that Dr. Geis already had some up. These are some of the others that are some of the large national ones that are the easiest to kind of get to. Also on here I have the APA Online Disaster Psychiatry course, which I believe that Bepi is gonna talk about in his video course. All right, thank you. I think we have time if there's at least one question or comment from the audience. I can say that what Therese says that there are many roles for psychiatrists in disaster. It's not just deploying. Messaging is particularly important. People binge watching terrifying scenes of disasters and shootings just makes them worse. And the disaster representative is really a contact person. I think Therese has said that too so that we know who we can contact in the DB and also that disasters are unpredictable like the Hurricane Iniki which took out the entire island of Kauai was headed right for Oahu until the last. I was on Maui at the time on vacation before we moved and it was heading right to Oahu that has 80% of the population in Honolulu and the last minute it shifted to Kauai. So that was not predicted. Floods are the most common disaster but Therese also said that. Part of the thing is to know the kind of disasters that are most typical in your area. And disaster is defined by overwhelming the local resources. But actually everything we do in disaster mental health is psychological first aid. There's many versions of it. There's a couple of apps. But mostly it's five principles. And if you just in the app store on your iPhone if you put psychological first aid it comes up. The VA one is very good and the one from SAMHSA is a little bit different. And also Therese just said we do have now a monthly column in Psych News on disasters. And the classic slide that everybody shows are the phases of disasters. It's very important. But now with so many disasters all at the same time that they're all going and overlapping. So it doesn't really fit in those strict phases anymore. But I think the importance of memorials and anniversaries and things like that, the long lasting effects are still really important. And I never heard the phrase compassion satisfaction. I love that, that's great. When I was giving COVID shots outside I just asked people their name and we knew who was coming. We did up to 800 people a day. And one day it was only for first responders, police and fire. And so we knew something about the people. So I just asked them if they were working or if they were retired depending what they looked like. And by the time we did that, a few seconds, I had already jabbed them. And people said to me, oh, I was so nervous about getting a shot but you made me relax and I wasn't scared at all. So that was fulfilling. I mean, here I was just jabbing people but you still talk to people. But I like that term, compassion satisfaction. And the APA has been teaching the disaster course that Therese mentioned every year. And I went to it every year. And I thought it was boring. I just sat and knitted my baby sweaters. But then when I went to Katrina with the first mental health team from SAMHSA, it was like back there, it's like, oh, that's what they were talking about. It was really, really helpful. But this version, it has just been released and it's online and it's free and it's in short segments and it's through the Learning Center. So that's worth looking it up. Thank you. And please say your name and where you're from. I'm Thomas Gossda from Scottsdale. And when I lived in Vermont and was in family medicine and deciding to do a little moonlight, moonlighting in the emergency room, I went down to Boston and did what was called advanced trauma life support. And it was so crucial to have that training to think differently as an ER doctor. And it seems like maybe the SAMHSA course is the answer to that. Hello, my name is Dr. Giuseppe Graviola. I'm invited by BEPI. I was just trying to. Multi-professional training course. I'm trying to get rid of this now. With certifications and really thorough training that you could do over a day or two. Can you help me stop it? I think if I went right now, that would be perfect. Okay. Anyway, that's my comment. Oh, no. Yeah, no, I think that's a really great comment and a really nice comparison as well. I haven't had a good comparison in my mind about how it relates to other pieces, but that would be very similar in that the training for that is not for what's happening every day though, unfortunately. Probably in a lot of ERs, it is every day, but it's for what happens when there's a major crisis. And that's what much of this is about. And at the same time, also all of this applies to a small crisis within a community and something quite large. I'm Robin Cooper and I am from San Francisco. You're in my hometown. I'm sorry that you have to face some of the horrors of homelessness downtown here. It is horrific and it's not everywhere in the city. But I specifically, my knowledge, you're beginning to understand something about climate, about disaster psychiatry came from the formation of our caucus on climate change and mental health, of which I was one of the founders, and then attended the disaster psychiatry committee for a period of time. So the elephant in the room is the disasters that we're seeing so cumulatively are heavily driven by the climate crisis that we're in and we will continue to see that. But on a more practical level, I think I'm a tad phobic about disasters. It's easy for me to think a lot about climate change, but when I face directly the human suffering, it's something that I wanna go, ooh, ooh, ooh, what will that be like? So it's maybe even pre-anxiety or pre-burnout or something that makes it hard to get involved. And particularly, I brought to my district branch here in Northern California, the profound need to set up a sustained disaster response team and an organization, and I've had no luck. And I'm wondering if it's this pervasive sense. I mean, we're all tired, but when there is a wildfire here, people go, oh my God, what can we do? And I'm wondering if you can speak a little to how you built the engagement of others in your district branch that brought them in to form the responsive group that you have. And then a second question I have is, is there a relationship with FEMA that stays around for a while or Red Cross for a while, but doesn't have ongoing response to it? Responsiveness to the disasters, the mental health disasters that are with people for a good deal of time? Robin, I'll let Therese answer that. But first of all, just now, through AWP, the Association of Women Psychiatrists, there were two people in Palo Alto, which is Amy Alexander and somebody else who are interested in being disaster representatives. So that's, yeah, so that's, we're gonna follow up on that so that Northern California can have a DB disaster rep. First, putting a little bit of a fire in the back. Okay, let's try this. Right, so engagement is a very important issue because, and disaster is a hard sell because it doesn't happen all the time. It's not a fellowship, it's not a specialty. Nobody thinks about it till it's happened. So lots of times, you know, till it happens and then there's no preparedness. Red Cross is pretty short term. I don't know too much about FEMA, except it was challenging in Katrina and on the Big Island, the million dollars for mental health ran out in one month. So it wasn't really available. So there are all these little glitches. So. So, I'm trying to recall now what exactly the second question was because when you were asking it, it was like, oh, that's an easy one to answer and I'll answer that one first. Got it, right. Well, and I think that's where. Repeat the question, either go to the microphone. Yeah, that was the question that you had around FEMA or Red Cross or other sort of shorter term folks that are then gonna leave. And I think that's where it really is important to have previously developed some of these relationships with different groups that are gonna be coming in. FEMA, I don't have a good answer for, we're not really strongly connected with FEMA, but hopefully through being connected to the Red Cross and connected to the state, that as things would happen through FEMA, that we would have more connectivity on. But one of the things I think that we would try to do is ensure that the American Red Cross staff that were in some of the shelters that were open for a long time, because some of them were open for a couple of months, that they knew certain things about how the mental health system works in North Carolina and how and who they might contact in order to refer somebody for ongoing services. Because I think that's a big piece is that in a large scale disaster, there will be people coming in from outside just by virtue of the size of it. And none of those people are likely to know the locality in which you live and work. And so you have expertise around that, that you're able to kind of help folks to figure out and see if there are ways to be able to support any transition across time. And I think that's also where some of these things like the Hope for NC and Hope for Healers have become these enduring products that are kind of out of a number of disasters on the front end that have come up. So I think that's one piece. The first question I think was about how to develop some of these relationships and lack of interest at the DB, was that it? Yeah. Yes, yeah, how to develop some of that within the DB. And. Engagement. Right, well, I mean, honestly, it's having like one or two champions that kind of won't let it go, in essence, you know? And when I moved to North Carolina from San Francisco, I was here, and I actually had gotten interested in some of that here through working in the Department of Public Health. And as that, you are a disaster service worker, your ID basically said that. Part of your performance eval each year, you actually needed to have developed your disaster plan and talk about what you would do if there was an earthquake and how you would get back to whatever work setting they might need you in, which could be anything. Thankfully, we didn't have an earthquake during that time, but that got me thinking about a lot of things. But when I moved to North Carolina, Alan Chrisman, Dr. Alan Chrisman, who's been doing this for many years, I got connected to him over a short period of time because I got connected to the Red Cross, and then they were like, hey, we should connect you with this guy. And then, despite the fact that I was at a point in my life where I had a lot of stuff going on that make it hard to have extra time, Dr. Chrisman sort of didn't stop in terms of being like, hey, we've got this going on, hey, this is going on, hey, do you wanna come and be the co-chair of the disaster committee? All these ways in which sort of continuing to champion some of that helps to bring folks in. I think that it is a little bit complicated here, and in San Francisco, at least from my historical perspective, and I don't know whether some of that ties into the fact that it still has a really solid community mental health system. There are challenges, right? But, yes, but I also think that that allows perhaps other psychiatrists to look at it and say, this is not my problem, because there is a Department of Public Health that would take care of things if they come up. And so, how do we change some of the perspectives of folks to realize, actually, these kinds of things are gonna affect the whole community and are not the responsibility of any segment of the healthcare system or any segment of society, but there are all ways in which we can impact that. So, Robin, thank you for your questions and for your wonderful answers. Now, we're gonna move ahead to the second speaker. Unfortunately, Bepi Giuseppe Raviola in Massachusetts, his co-chair isn't here, Katie Ko, who's actually stellar work in homelessness, Robin, worth looking it up. She's home for health wellness issues, and unfortunately, Bepi's wife had a terrible accident last week, so he's not here, but he sent a video with his slides embedded. I think it's only eight minutes, and I'm gonna try to get it back to the beginning. Bepi Raviola is the Director of Global Mental Health and Social Change at Harvard. He's the Associate Director of the Division of Global Psychiatry at Mass General and Director of Mental Health for Partners in Health, which is an international healthcare delivery organization that works across 10 countries, including Haiti, Liberia, Rwanda, Mexico, Navajo Nation. For 20 years, Dr. Raviola has participated in emergency response to humanitarian crises, including HIV-AIDS in Africa, the 2010 Haiti earthquake, the 2014-2016 West Africa Ebola response, and COVID-19, leading the mental health component of the Commonwealth of Massachusetts, a contact tracing collaborative, and over the past year, his team has reformed the oldest psychiatric hospital in Africa, in Freetown, Sierra Leone, and started a new psychiatry residency there, increasing the number of psychiatrists in the country from one to eight, for a population of eight million people in a post-conflict context. Dr. Giuseppe is the Co-Chair of the Massachusetts TB Disaster Committee, and I talked about how Katie helped prepare this, and so we're gonna try to welcome him by video, and I'm gonna try to get this back to the beginning. Hello, my name is Dr. Giuseppe Raviola. I go by Beppe, and I will present to you today the experience of the Massachusetts Psychiatric Society Disaster Readiness Committee, and I'm going to share my screen now, and get my PowerPoint started so that we can proceed. As I said, I represent the Massachusetts Psychiatric Society and my Co-Chair of the Disaster Readiness Committee of the Massachusetts Psychiatric Society is Dr. Katie Koh. Our committee is one of a number of committees in the MPS, and it's an active committee that meets quarterly for 90 minutes in the evening, around 6 p.m., alternating on a Monday or a Thursday evening on Zoom. The committee originally took shape in its current iteration in 2016, when Drs. Fred Stoddard, Todd Holzman, and Margaret Thompson, each an expert in disaster psychiatry in their own right, met to revitalize the disaster readiness component of the Massachusetts Psychiatric Society. They started by going out to residency programs, giving a one-hour lecture on an introduction to disaster psychiatry. The next year, the group organized a conference, which was attended by about 60 people, most of whom were psychiatrists. There were several significant natural disasters that year, including Hurricane Harvey, Hurricane Maria, and Hurricane Wilma, and a bigger committee was convened because there was growing interest, including Sally Sveda, Paul Plasky, Catherine Ziotto, and Cornelia Cremins. By 2018 to 19, there were ongoing meetings. Several talks at MPS on various topics, including on Puerto Rico after Hurricane Maria, tele-mental health, and immigration. And then there was a second conference with topics including gun violence, refugee trauma, self-care and resilience, burnout, legal and ethical issues, and experiences of nurses in global disaster response. In 2020, COVID-19 arrived, orchestrated three different MPS town halls, which were well attended based on the collective level of distress and challenge among our community. Drs. Koh and myself were then asked to step forward to run the committee. And over the past several years, we've had ongoing quarterly meetings and a very active set of discussions regarding the rapidly evolving context and how to move forward together. In the background, there's a remarkable global trend in the evolution of natural disasters, for example, which have increased significantly over the past century, with the U.S. experiencing the greatest number of climate-related disasters over the past 30 years. At the same time, over the past several decades, the number of active shooter incidents in the U.S. has increased in what seems to be a linear fashion. And then COVID-19 presented itself with, as we all know, significant short- and longer-term impacts on mental health, including now ongoing psychological trauma, exacerbation of mental illness, adverse economic impacts on families, and burnout across sectors, including within the health sector. In Massachusetts, there was a community contact tracing collaborative and a mental health component of that effort, which I led, training several thousand non-specialists in psychological first aid. This included taking an inventory of the emerging landscape of new resources, emerging lines, and tools to support mental health in crisis in the community, such as state call-in lines, as well as new national resources. And Dr. Koh, our co-chair, works with Boston Healthcare for the Homeless. And as our discussions as a committee have evolved, we've agreed to a broader definition of what constitutes disaster, for example, when we consider the changing life expectancy in the U.S., the evolving fentanyl crisis and the ongoing issue of deaths of despair in the U.S., as well as the physical and mental health impacts of climate change, which are very real. And at the current moment, there are 1.2 billion people at immediate risk of displacement due to lack of food and water relative to population and natural disasters. And of course, a number of these people also come to the U.S., and we see them within our health system. And whether it's presented in the New York Times or by the U.S. government, it's clear that there's a cross-cutting, cascading set of global challenges that spans pandemics, droughts, floods, megastorms, wildfires, extreme heat and cold, accompanied by food and water shortages, conflict, and other crises, and by extension, human migration and growing refugee emergencies, with new conflict over resources, as well as unstable political and national actors. All of this demands that we attempt as best we can to meet the need for preparedness and enhance societal and social resilience. Another aspect includes the fact that stress and trauma are manifesting in similar and different ways, with technology also informing our global and local experience of the rapidly shifting social climate as well. Our committee keeps tabs on new emerging tools, trainings, and protocols. For example, this past week, a new and free eight-hour online APA training on disaster and preventive psychiatry has been unveiled, and that is very welcome, and we can draw from that. And members of our committee are also active in the development of various tools, including a new APA textbook on disaster psychiatry, readiness, evaluation, and treatment, second edition. And our committee plans to continue to meet quarterly and engage and discuss as a group these various issues. We have four to six people on average to each meeting, with sharing of individual work and reflections on the rapidly evolving landscape. Some of us have continued to provide presentations at medical schools and residencies in Massachusetts. We're engaged on national committees, including the Committee on Psychiatric Dimensions of Disaster at the APA and the Disasters, Trauma, and Global Health Committee at the Group for the Advancement of Psychiatry. Some of us continue to engage with the Red Cross on approved trainings to teach preparedness and treatment. Members are writing books, book chapters, and papers, and with everything else happening in the world, we continue to make future plans for Mass Psychiatric Society town halls and courses while trying to acquaint ourselves and get updated with all the great materials that are coming out. I just want to thank my colleagues on the committee, and we share in a variety of questions that we ask ourselves, and these include how to adapt optimally to remote engagement and in-person time in terms of our effective use of meetings, how to best optimize our efforts collectively and serve the psychiatrists of the Commonwealth of Massachusetts, as well as the public, and respectively, which of these to focus on more. And the issue of burnout among providers themselves is a significant issue that one could focus on entirely, for example, how to best optimize emerging web-based resources, as one I've just described, and how to make best use of our society website as well with regard to making resources easily available. Thank you so much for your time and attention, and I hope you've had a great meeting. Well, I hope you could all hear that. I can't overemphasize, I think it was mentioned in Beppi's presentation, the challenge of self-care, which is enormous, so now I know the term compassion satisfaction as well as compassion fatigue, but that's very challenging in a disaster, and I think the slide showed that disasters are increasing, but they're actually also getting worse as well, and his reference to Katie's work in Boston on homeless people is really, if you're interested in that at all, this writer, Tracy Kidder, who wrote a book, The Soul of a New Machine, a long time ago about the people who worked on computers, but this book is about the homeless program in Boston, and I forgot his name, but this one guy who really shepherded it, and it's called Rough Sleepers, and if you have any interest in homeless people, and also they're walking around doing street medicine and checking who's alive and who's dead and stuff like that, but it's a very amazing book. I couldn't put it down, and the textbook that was on here from Fred Stoddard, who's one of our leaders from way, way back, is coming out in a new edition this fall, but it's an excellent book. So those are my comments about that, and I hope that either Bepi or Katie could present here next year, and I have at least three other DBs, I think, who will be able to present, so this is an ongoing process of recruiting new DB reps and presenting the accomplishments and challenges in the different places, and now I'd like to introduce our final speaker from Southern California, and that DB had been inactive, and it was activated, which is common across the country, I've heard that, other places as well, and so our third speaker is the last, but definitely not the least, Danielle Cheng, MD, MSW, works at the Olive View Mental Health Clinic in Southern California, and she'll be transitioning to the LA County's Homeless Outreach Mobile Engagement, or HOME, team in July. Danielle enjoys working in an urgent care environment, especially with those who had never received mental health care before. She's on Southern California Psychiatric Society Council, is counselor for the San Fernando Valley region, she's a health sciences clinical instructor at UCLA's School of Medicine, and teaches at the Olive View Medical Center's Psychiatry Residency Program. She's psychiatric consultant for the LA County Office of Diversion and Reentry, and she received her MD at Michigan State University College of Human Medicine. Her focus is on making health care easy and streamlined. She's the chair of the Reactivated Disaster Relief Committee of Southern California Psychiatric Society, and associate member of the California Disaster Mental Health Coalition. So it's my pleasure to please welcome Dr. Cheng. Thank you so much. I just wanted to say I don't have any financial disclosures either. So I'm here representing SCPS, or the Southern California Psychiatric Society, and we're one of the newer kids on the block when it comes to disaster relief psychiatry. I just wanted to say that when we reactivated in 2019, one of the reasons I personally wanted to get involved as a chair is, similarly to Dr. Geis, I'm originally from New York and was really impacted by 9-11. And my background in social work, I had seen many of my social work colleagues deploy actually to provide supportive services to first responders at 9-11, and just saw how much of an impact that was for many of those important first responders. And so that was one of the reasons why I got involved. So since 2019, I've been chairing the committee, and we've had between four to six active members and have been meeting about every one to two months. Our charge is to develop and implement plans for SCPS's response to disasters, to provide assistance to members and the public in response to disasters, and to share disaster relief resources and develop relationships with other local medical and professional organizations engaged in disaster relief mental health work. As a committee, most of our members had little to no experience with disaster relief prior to becoming involved. So it's been quite a learning experience, and we've met many challenges and are still working through some of those challenges. We've taken a posture of learning over the past few years. One of the ways we've learned is by building relationships with various other organizations and people who we've met along the way who have much more experience than we do. We joined the California Disaster Mental Health Coalition, which is a statewide multidisciplinary alliance established to improve disaster mental health services across professional disciplines. And many of the members of the coalition have had decades of experience with disaster mental health work. We also became involved with the APA Committee on the Psychiatric Dimensions of Disaster and built connections with committee members from DBs across the country. And these relationships became especially important during one of the first disasters that we encountered as a newly active committee, the beginnings of the COVID-19 pandemic. What we soon learned during COVID was that disaster relief response is very complex. It involves countless players in the public and private sectors at global, federal, state, and local levels. And we learned that the Red Cross was perhaps the most direct way to access training and deployment opportunities for some of our members. Some of our members also signed up to volunteer and become active in other ways, such as the Federal Disaster and Medical Assistance Teams, or DMAT. But we found that many of them weren't actually called upon to deploy during that time. Others were trained by private sector organizations, such as Care for Caregivers, in order to provide confidential peer coaching or support to warm lines during the pandemic as a means of managing burnout. And one of the things that became clear to us was that there really wasn't a clear pathway specifically for psychiatrists to receive training and provide support during times of disaster in California or during recovery periods. So we began trying to coordinate and provide trainings for SCPS members in psychological first aid. And we partnered with the Red Cross to provide Red Cross volunteer trainings for people who wanted to get involved with that direct line of volunteering. We built a landing page on our website as a place where members could find trusted information and resources about COVID and disaster-related materials. And we surveyed our members. We really did the only things we knew how to do at the time, being so new to this work. We asked our members what they needed, and they responded. And some members really just wanted information. Others actually required more personal care. And we were able to do that by reaching out directly to some of the members who needed it the most. We also processed. We had a panel during which, towards the end of the pandemic, we talked about what we learned as a community about the COVID-19 pandemic. And since then, we've been continuing to try to educate our members and provide more experiences around disaster mental health by creating a series of events designed to give more exposure to the work. We held a panel on various psychiatrists and work that they've done globally with refugees and asylum seekers, and some who've done work with many various disasters around the world through the Red Cross. And we co-hosted an event which focused on war, trauma, and bias. We've also been working with L.A. County firefighters since wildfires are one of the most active disasters that we have in Southern California. We wanted to learn how to best support our first responders. And we built a relationship in which we've been able to provide our members some trainings on providing culturally competent care to firefighters. And we've been able to also support the firefighters by providing trainings in sleep deprivation, which apparently is one of the biggest challenges that they face in their work. So, you know, like I said, the challenges that we face, we're still learning, we're still overcoming. But really what we've learned is that relationships are where it all starts. And that disaster relief work, it's not just about being able to respond to disasters when they're happening in an emergency time, but being able to be prepared before, during, and actually the recovery process is one of the most important periods of time that we have as well. So the last thing I wanted to share is just one of the most important things that we've learned and been able to do as a younger disaster relief committee is just start dialogues with varying stakeholders and try to carve out more opportunities for psychiatrists in our areas to deploy and train. And it's really something that I think many of you who are interested in doing the same in your local areas can do pretty easily. So thank you so much for having us. APPLAUSE Well, thank you, Danielle. And the comments I have is that in terms of working with the Red Cross, now all their trainings are now online, so it's not that hard to do. And, Danielle, you're typical. A number of people I've talked to in this field who got connected to disaster work because they had connections to New York City. But if you have four to six people meeting every month or two, I mean, that's pretty much as much as Massachusetts. There's not a lot of psychiatrists in DMATS, the Disaster Medical Assistance Team, was in that originally. It's a volunteer federal team that basically sets up field hospitals. There are a few psychiatrists who are in it. But I think doing local training as well as the APA course is a great thing. The Medical Reserve Corps is a place where you could meet infrequently and you don't have to do anything, but you get to know everybody. So if something happens, you see people who you knew before, also drills do that. So we have some time for questions or comments or challenges. Please say your name and where you're from. And challenges regarding engagement, getting people connected to this field, which is not in the center of our field, but it's very related. Mary Ann Geiger. I practiced psychiatry in Rockford, Illinois, but I moved to Newport, Oregon to retire. One organization that comes to mind is the International Critical Incident Stress Management Organization. I took some of their courses. It was pretty cool. There are also regional little groups that are part of them that are sporadically spread around the country. I was part of one in Illinois for a time. That would be another good source of some training and ideas. But you're right, it's hard to get people interested. I shared with you, Dr. Giles, that I'm a ham radio operator and I was the head of the Amateur Radio Emergency Service in Northern Illinois. Went around, talked to sheriffs, talked to mayors, talked to fire chiefs, everybody, okay. Oh, but gee, we have cell phones. Cell phones. And that could never go out. So it's a source of frustration. All right, thanks. We know the cell phone towers do go down. And the two things that are most challenging usually in disaster response is mental health and communication. But Maya Lopez is the DB disaster representative in Oregon. So maybe you could get to, I don't know if you know her, but if you get together with her, maybe you could start a committee. Could start with two of you. A lot of DBs don't have committees, but it could start with two people. Kurt? And one other thing I wanted to say about that before your question is the prevailing model used to be the critical incident stress management and critical incident stress debriefing, which is not effective and has risk of being harmful when provided to individual non-selected groups of people. So it is the prevailing model really is psychological first aid. There are some settings and some groups in which CISM or CISD would be okay, but it's not what should be happening sort of on broad scale to individuals in a disaster setting. I think that it would require. Yes. Oh, absolutely. Yes. For the first responder, you know, groups that are more homogenous in their experience. Absolutely. Yeah, that's where it's settled across time. But there was a period of time where it was like, hey, let's do this with every single person. And that did not end up being good. Hi. I always do this, I get too close to the mic. Hi, I'm Kurt West. I'm actually a member of the Psychiatric Committee on the Dimensions of Disasters. And Leslie, I wanted to ask, did you already say something about the course? Well, I think, Kurt, before you came in, I said a little bit about it, that I, 32 shoes that I am, year after year, I went to all the disaster courses at APA for a very, very long time. And I basically, they were mostly lectures at that time, and I thought they were boring. And I said- No, no, the online course. Yeah, the online course, that was mentioned in a couple of the presentations, the new online course was. So hopefully folks will go and utilize that, especially since it is free. So if you're interested in disaster psychiatry in your district branch, and you don't have to make a commitment to take the course, you can just be, I guess we could call this disaster curious. And so you can put your foot in the water and learn a little bit about the principles of disaster and preventive psychiatry. It is absolutely free. APA made it that way for a reason, to get as many people engaged with the content as possible. Well, and Dr. West, I believe you all had said that it's not just available to APA members, but it's available to the public as well, was that right? If folks- That is what I am told, so yes. Which that's excellent, so. Haven't tested that. And for average psychiatrists who are used to practicing in traditional psychiatric settings, like traditional inpatient, outpatient psychiatric settings, disaster psychiatry relates more to CL, community, child and adolescent, with some specialties which are connected to outreach and going out and working in non-traditional settings. So it's different than what most psychiatrists learn, and it's more like public health. Instead of focusing only on individuals, it's looking at populations of people. And so I think that what I've heard about the new course that I understand is not at this meeting, but it was released on May 19th, and it's through the Learning Center on the APA website. And I'm hoping to go again when I go home next week and check it out and see what it's like. Any other comments or questions, or if you're in, well, many international people are here, so thank you for being here, but I don't know too much about that. Maybe you could tell us, but of the people from the different states in the United States talking about if there is a disaster representative in your DB or how to get people engaged with this field, thinking about disaster preparedness and response. The Red Cross is always doing booths in shopping centers and fairs and things like that, trying to educate people. And so I'd be interested to hear from people from other countries, but also from states in this country about the status of disaster mental health where you are. Please say your name and where you're from. Dr. Harrington from California, Lafayette. My question is- Where are you from? Lafayette, California, Lafayette, East Bay. It's new with individual approach versus community approach. I was very impressed by this simple statement talking about critical review of individuals. Group applications apply to individuals. Seemed pretty catastrophic. I just heard you say that. But I bring that from more... This is very involved in what's called operations research where they apply engineering principles to make processes more efficient. And that's been brought from manufacturing to hospital systems. And some of the problems there, I know this, I just heard from, I'm not involved in. I have friends who work in those areas, so I have some ideas about it. How you define a goal from individual versus community and where the money flows and you follow the money kind of thing, it's quite disastrous. I mean, just application of that in a community sense versus individual sense. And it's kind of some of the theoretical things that doesn't seem to cross boundaries and people are not aware of that. And US being a very individualistic system, it runs away with that. And in cardiology, they were doing like that. For instance, there's a index or a rating for how fast you get the patient from chest pain to cath. And they monitor that and they proceed to improve the time and it's kind of independent of all other factors that are involved in cardiac care. And when I brought that to their attention, they said, oh, we do apply community-based too. It's kind of afterthought, not implemented at all. So that balance came through when you made that point. Yeah, well, and I think that's where some of the longer-term community interventions can happen, whether it's utilizing some of the evidence-informed models for longer-term care, such as skills for psychological recovery or for individuals that do end up with a trauma or stressor-related disorder, more specific treatment. But I think what you bring up, that's a really important point and why it can't just be like, okay, we're gonna do the exact same thing for everybody within a group, is that even with the same exposure to the same objective level of trauma, the exposure to that trauma from the subjective perspective as well as the impact of that trauma on the individual is gonna be different no matter what. So much of this has to be meeting people where they are and identifying what the needs are in this moment. And as with many things, a lot of the mental health challenges aren't necessarily going to show up on day one. And what we often see in the early time, and I'm sure you saw a lot of this with Katrina, is that initially the biggest mental health problems are for the folks that are already struggling with severe mental illness or other significant mental health conditions with that worsening in the setting of trauma. And we know that there are definitely people who had no mental health challenges prior to disaster who do end up having challenges, but at the same time, resilience is normal. Most people are going to do quite well. Most people don't need to be connected to a course of long treatment of any sort or to even one or two sessions of psychotherapy. Oftentimes, in order to mediate the psychological distress, sometimes it's just very concrete things. So sometimes it's been walking around the shelter with a backpack that I've got that's got some of the clean socks that they've got over there and just going down and sitting down with people and saying, hey, can I sit here? Can I talk to you? Do you want a pair of socks? And just even that meeting the basic needs of folks can help to address some of what's going on and can also help to build those connections so that you're able to hear and connect with the folks that may be struggling more. Right, so when mental health services are set up for people, even after September 11th, nobody came. So really, there's the Kleenex and Water Brigade and walking around psychiatry and that kind of thing is very important. And Katrina, the people I saw who were suffering the most had significant trauma symptoms in the past from different traumas that were healed, like a wound, that were reactivated by the new trauma. So the flashbacks were to the old trauma. So please say your name and where you're from. Sure. I'm Dr. Katawari. I work in Atlanta. I've been in Atlanta for the last 30 years, but I'm originally from Syria. I've been involved in the crisis in Syria since it started in 2012. And I started or founded several clinics on a volunteer basis. In Turkey and in Jordan. And in the besieged areas inside Syria. I've had so far about five clinics for the refugees, for the Syrian refugees. I've done it under the, with the help of SAM, Syrian American Medical Society. And I've done it with another psychiatrist, Syrian psychiatrist. But mostly the foundation and the oversight and the supervision all by myself. And I'm here wondering how I can get more help and more support. Thank you. Well, thank you for your work. Kurt, do you have an answer to that? I can say that one of our members on the CPDD, the Committee on Psychiatric Dimensions of Disaster, Sandra Kaufman, is one of the founders of this new organization, Vibrant. And he's also been very involved with Ukraine and countries around the world and has a program of languages of care, having resource documents translated into all those different languages and continuing to accumulate more and disseminate them. Because some of these short documents have been feedback that I've gotten domestically has been that's been very helpful for response. Response. Well, I. Can you go to the microphone just so that everyone's able to hear this on the recording? The person that Leslie just spoke about is also very interested in repetitive disaster experiences. So that would definitely relate to what you're talking about in Syria, the over and over and over impacts of repetitive crises. Exactly. He might be someone that I would think might be someone to talk to about how to get some funding, because I think Sandra's pretty savvy in that regard. What's his name again? I can give you the name. And also from a recent panel that I did last month, I met a woman named Suzanne Song. Also, Bepi, the one who was on the video, he's also involved with global health. But Suzanne Song has been involved in global mental health, working a lot with immigrants and refugees for decades. And she's written a book and she's testified in Congress. She's not that old. She's writing another book. And so that could be another resource. And I could give you her name and contact as well. Sure, yeah, there is a huge need for funds. And now after, on top of the crisis, I don't know whether you're aware, there was recently a huge earthquake in the north of Syria where the refugees who were there, they had, I mean, they were the ones who were affected by the earthquake. And many of them lost their parents, their kids, their children, their houses, their belongings. And now many of them are in the streets and no schools and they lost everything. So, and because of the aftershock and because of the buildings that are already destabilized, they are unable to go back to their homes. Most of them are in the streets, in the tents, let's say. So they need, I'm trying to get some funds to go back to their, to have their basic needs, especially as a child psychiatrist and child psychiatrist, trying to get them some schooling for the children. And some, I know it's an old-fashioned kind of thing, orphanage for the children, because many children now are orphans. So this is what the two things I'm working on. But because, as I said, because they are refugees, their resources are very, very limited. And it's hard. And also, I was, I have one building that had women who were victims of repeated sexual assault while they were in prison, because they were the opposition, political opposition. So those are also I'm working with. We know that women are disproportionately affected in disasters, and IPV, intimate partner violence, increases in disasters as well. It's been documented in disasters all over the world. Robin? I just wanted to first applaud what you're doing, but also how you've described this makes it very real about how a disaster isn't a disaster, but it is so interconnected with so many other forces and draws in and exaggerates and multiplies so many of the other underlying issues and makes this discussion about disaster response a much more complicated conversation. And I want to just applaud you for all you do. Well, I agree completely with what Robin said. What you've done is absolutely remarkable. And one of the problems in acute disaster response, at least teaching psychological first aid for the Red Cross for 10 years live, was that people wanted to do lots for these people, but that in a short timeframe in disaster response, they felt very empowered to have boundaries of what you could do in the immediate phase in the short term, and that's part of the course. So it was really well-received, and unfortunately, it's all online. I thought the role plays were the best part of that class, but now it's all taught online. But self-compassion and not giving yourself a hard time about what you've done, at the same time, we know you want to do more and better. And I could, when this is over, which is pretty soon, five more minutes, I could give you the three names of contacts of people who might be able to help you. Appreciate it, thank you, thank you. I wonder from Israel, which is a unique place, whether you have any comments about stress reduction with chronic stress and disaster response that the country has lived with since the beginning. Yeah, not necessarily natural, but man-made. Say your name and where you're from. Iriam Shiff, I'm from the Hebrew University School of Social Work at Jerusalem. But in Israel, it's not the psychiatrist, it's the trauma center. So we have a trauma coalition who is working on it, and there are many other trauma centers that do it. So it's amazing that here it's a different structure, because in Israel, it's mainly psychologists and social workers who does the work. But I wonder also in Israel and also here, whether you back it up with research. Because I think you're doing a tremendous work, and I was very impressed. But the thing is, what really helps, I think also we need to investigate it, to do some research about it, not just randomized control trial like we hear all days, but also just to see what helps. Also about professional health, what helps them, what at least increases satisfaction and decrease compassion fatigue, things like that, very simple ones. So I think it's an idea, I think it's important. So as far as helping individuals that are doing this work to learn more about how to utilize self-care best in disaster settings and in this kind of work, there are some really good resources. The ASPR TRACI resource, which is A-S-P-R-T-R-A-C-I-E, has a lot about disaster behavioral health and self-care, particularly focused on health care workers and sort of goes through a lot of that discussion around compassion fatigue versus secondary traumatic stress, moral injury, various kind of ways in which things can impact, but also in talking some about compassion satisfaction and what are some of the things that can shift the experience for individuals that are going through this. I think the other thing that you had asked was related to what are the things that help, what are the things that are evidence-based, and PFA is an evidence-informed resource. I don't know that there would ever be the kind of evidence that we have for other things in terms of we can't ever have a randomized controlled study around some of this. It wouldn't make sense anyway, right? So there are ways in which we can utilize evidence that exists for the resources that are there, and I'm betting that Dr. West has some great stuff to add to that too. Sure, and I would say that this entity, the Disaster Committee itself, does not do the research, but part of what we do is help highlight and disseminate the work that others do, and there has been a substantial amount. PFA is becoming increasingly an evidence-based intervention. It was developed as an evidence-informed intervention, but then there have been multiple studies over the years that have looked at various domains or principles of PFA and how they're applied, and then how they make a difference in outcomes, but to the previous gentleman's point, one of the challenges in disaster mental health is what's your outcome, and far too much of the research to date has been focused on clinical outcomes, and that's not really where we focus our attention. Our attention is focused on, it's almost, if you want to think of it as restoration of function, well, how do you quantify that, that somebody could show up to work or that somebody could actually invest their mental resources into attending to their children, and so part of it is getting, and believe me, the field of disaster research has, I would say, blossomed in the last 15 years, and so the evidence is coming, but to the point is, yeah, it is very difficult. You have to have these investigations either set up ahead of time and waiting for something to happen or you sort of go back and gather, you take data that was collected, so for example, our group had done something with, we had collected a substantial amount of data in 2004 from first responders in Florida following a hurricane. We're still publishing papers off that data now, but it's going back and looking at some of the associations between particular factors and then interventions or risk factors that were demonstrated in the beginning and then sort of the outcome. Thank you, Kurt, thank you, everybody. In conclusion, what I could add just now in terms of immediate things that are helpful, part of psychological first aid is normal reactions, and a lot of people after a disaster think they're going crazy because they don't understand about nightmares and flashbacks and other symptoms that they're having, so even a one-hour executive summary just of normal reactions to certain populations has been very helpful in communities that, like the Japanese community in Honolulu, people who don't like to talk about how they feel bad and things like that, after the tsunami and the earthquake in Japan and they couldn't contact their friends and relatives, but just a one-hour lecture about normal reactions was actually, it was done eight times in two weeks through my mentor in the Red Cross there. He connected to these different organizations, churches and schools, and it was massively subscribed, so people got reassured just by a little education about what's normal, and as has been already said, after a month, the vast majority of acute stress reactions are better or gone by then, the symptoms. So thank you all for being here on the last day in the afternoon, and we're going to continue working on many levels to promote disaster psychiatry and disaster mental health. Thank you.

cultural considerations

disaster response

Leslie Guise

psychiatry

2018 lava disaster

disaster psychiatry

mental health initiatives

disaster preparedness

natural and man-made disasters

psychological first aid

resilience

community needs

mental health support