Helping Airport and Air Carrier Employees Cope with Traumatic Events (2009)

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17 The research team encourages any mental health professionals to read the project in its entirety to glean the most up-to-date information pertaining to Employees Coping with Traumatic Events. State-of-the-Art Model for Disaster Management Seven steps will be introduced and explained that will guide an organization through the development of a mental recovery plan. There are also five very important intervention principles that are essential for a manager to instill when an employee has been involved in a traumatic event. The seven steps are the following: 1. Awareness and Cultural Integration. 2. Assessment of Mental Health Resource Availability. 3. Embedding Mental Health Practitioners. 4. Preparations of the Mental Health Provider. 5. Employee Training Program. 6. Establishment of a Mutual Aid Assistance Program. 7. Assimilating the MHRP into the Critical Incident Response Training or Airport Emergency Plan. Introduction to the Planning Stage In spite of the many defensive strategies and sound operat- ing techniques employed, catastrophic aviation-related di- sasters occur. As any industry practitioner knows, it is vital to prepare for such events. Most preparation is aimed squarely on loss-of-life mitigation, scene preservation, and ultimately sce- nario reconstruction. However, an aspect that often gets over- looked involves the mental health monitoring, maintaining, and resilience of air carrier and airport employees. As with any critical incidence response, maintaining functional employee mental health is a vital component, and should be given due consideration prior to the occurrence of a catastrophic event. Throughout the aviation industry, there are many different management structures in place at airports and air carriers. Delineating factors between such structures include size, re- sources, and number of employees. Clearly, a large organiza- tion with several thousand employees will have different resources available than smaller operations with an employee or two. Irrespective of an organization’s scope, there are several critical planning tasks common to all operations that should be completed as part of critical incident response plans. Step 1. Awareness and Cultural Integration The first planning task of all organizations should simply be making all employees and any affected individuals aware that the organization will now be implementing an MHRP. Ideally, this should be stated in an employee manual or AEP. The concept should be introduced and emphasized via sev- eral communication channels including verbal, signage and written policy. By engaging in such emphasis, the concept of an MHRP can become interwoven with the organization’s culture. In addition, this emphasis may help alleviate (but probably not eliminate) some of the well-documented phe- nomenon wherein some individuals are resistant to receiving mental health assistance. Step 2. Assessment of Mental Health Resource Availability In any disaster planning endeavor, it is critical to determine exactly what resources are available and which employees will be responsible for each of the necessary tasks. As previously discussed, most planning efforts focus on loss-of-life mitigation and scene preservation. As part of an MHRP, determining who will be responsible for overseeing the psychological monitoring of the plan is equally important. Ideally, a licensed mental health practitioner who is employed by the organization C H A P T E R 2 Recommendations

would be the key person; however, it is very unlikely any or- ganization would have the luxury of having such a person on staff. However, almost all organizations have access to Employee Assistance Programs (EAPs) or other mental health providers. An EAP is a program in which employees have confidential access to mental health providers to help them through psy- chologically stressful events, like chemical dependence issues and traumatic personal events. Usually, these programs are accessed when an employee needs help and is willing to make first contact. In the case of implementing an MHRP, it is rec- ommended that a mental health care provider take more of a proactive status and actually seek out employees as part of the organizational team. Federal, state or locally governed orga- nizations may be able to utilize a government-sponsored EAP (at least for the purposes of use during catastrophic events). Even if an organization does not currently have access to an EAP, it is highly recommended that the organization contracts with some mental health entity for the purposes of imple- menting an employee MHRP during critical incidents. Step 3. Embedding Mental Health Practitioners Many current mental health monitoring programs in place make use of peer-to-peer sessions, often termed “debriefings” or “defusings.” Without a doubt, sound operating practices dictate that logistical and progress briefings be made so as to ensure all personnel maintain the appropriate levels of aware- ness and situation status. However, with regard to mental health assistance, there is mounting evidence that peer-to-peer counseling sessions may be ineffective for some individuals and even harmful for others. At issue is the possibility of an employee experiencing Post Traumatic Stress (PTS). The current evidence indicates that unless an employee experienc- ing PTS is evaluated and treated by a licensed mental health provider, an untrained peer counselor could potentially exac- erbate the stress levels (albeit unintentionally) of the employee and prolong the episode. It is important to note that some employees report they greatly desire a peer-to-peer model, and believe such models have helped them in the past. However, the findings from the present study seem to belie this notion with some people and certainly demonstrate the requirement for more investigation into whether or not peer-based inter- ventions should become the preferred treatment method. In some cases, there is a stigma attached to seeking out pro- fessional mental health support from licensed providers. Given that the efficacy of peer-to-peer counseling is questionable at best, there seems to be a conundrum; how does an employer provide mental health assistance for their employees during a crisis when there is apprehension about seeking a professional and a peer may be unqualified to help? In order to overcome both obstacles, it is recommended that the employer embed licensed mental health professionals, preferably from the organization’s EAP, as part of the internal team involved in a crisis. These professionals should literally “walk the scene” with all of the employees as everyone goes about their business of dealing with the catastrophe. Using this model as a compo- nent of an MHRP has proven to be effective and accepted by most employees. Step 4. Preparations of the Mental Health Provider The embedded mental health provider should acquaint themselves with all of the available assessment and therapeu- tic techniques recognized as efficacious when treating PTS or other associated trauma. Step 5. Employee Training Program As part of the planning activities, all employees should be taught basic crisis management techniques and how to rec- ognize symptoms. While peer-to-peer counseling should be limited, knowing how to recognize some symptoms in co-workers and advising the embedded mental health team member of such signs could prove helpful. In addition, a basic description of the cause, prognosis if left untreated, and long- term care principles regarding traumatic stress should be emphasized. Step 6. Establishment of a Mutual Aid Assistance Program Some airports participate in mutual aid groups whereby in the event of a natural crisis (hurricane, flood, etc.) other airports not affected will send personnel to staff critical func- tions. Certainly, this gives the ability for the airport to function, and, often airports are a vital asset during natural disaster recovery efforts. However, there is also a mental health com- ponent to participating in a mutual aid pact. Employees who work at an airport experiencing a natural disaster are often affected by the same disaster in their personal lives. They may be caught in a dilemma between continuing to work so as to support the airport’s function or abandoning their posts so that they can deal with their own families and personal situ- ations. By participating in a mutual aid group, an organiza- tion could help enable employees to deal with their personal situations and not make a difficult, stress-inducing decision between work and family. There are two groups in existence at present. They are the Western Airports Disaster Operations Group (WESTDOG) 18

and the South East Airports Disaster Operations Group (SEADOG). Contact with WESTDOG can be made through the Dallas-Ft. Worth International Airport (DFW) and con- tact with SEADOG can be done through Pensacola Interna- tional Airport (PNS), Savannah/Hilton Head International Airport (SAV), or the Gulfport-Biloxi International Airport (GPT). Presently there are no known mutual aid programs between air carriers, and it is unlikely one could emerge due to competitive issues, operational complexities, and regulatory oversight. However, intra-company mutual aid pacts should be considered between stations. Step 7. Assimilating the MHRP into Critical Incident Response Training or Airport Emergency Plan The final step in the pre-planning phase is to fully integrate MHRP concepts into any disaster/incident training under- taken by the organization. In the event of full-scale disaster simulations, the MHRP should also be simulated, practiced, and evaluated so as to equip an organization with the neces- sary knowledge prior to an actual catastrophic event. As an example of such training, an organization could designate some employees to play a role of an overstressed employee by having that person exhibit certain symptoms that should be recognized by peers and evaluated by the embedded mental health provider. Figure 2 outlines each of the steps for the planning phase of a MHRP. Mental Health Recovery Planning and Development A comprehensive guide to planning the mental health re- sponse was developed by the state of New York and includes a thorough review of a range of possibilities to consider. Each entity should explore the following areas while developing their individual plan. 19 Step 1. Awareness and Integration Step 4. Mental Health Provider Preparations Step 3. Embed Mental Health Step 7. Training Assimilation Step 5. Employee Training Step 6. Establish Mutual Aid Step 2. Mental Health EAP Available Contract Mental Health Provider Figure 2. MHRP planning steps.

1. Planning/Preparedness • Convene a Disaster Mental Health Advisory Committee. • Review the AEP. • Review the disaster mental health plan of your local American Red Cross and other disaster mental health response agencies in your community. • Develop a comprehensive airport disaster mental health response and recovery plan. • Develop Airport/Community disaster mental health response teams. • Establish a Memorandum of Understandings (MOU) with community partners. • Participate in Community/Regional disaster drills and exercises. 2. Mitigation • Identify high risk areas and populations within the air- port work groups and its contiguous borders. • Develop disaster-related educational brochures (i.e., psychological impact of disasters and how to seek help, recover, etc.) and distribute to high risk areas and populations. 3. Response • Activate response protocols for airport disaster mental health teams. • Coordinate resource deployment and service provision with other community-based disaster mental health teams. • Assess mental health needs of the affected airport and community. • Initiate early phase supportive interventions. • Identify high risk populations and implement the appro- priate early phase interventions. • Distribute public mental health educational materials. • Collaborate with local government around risk commu- nication. • Re-assess and evaluate mental health needs of the affected community. 4. Recovery • Assess and evaluate the intermediate and long-term men- tal health needs of the airport community. • Identify community/regional resources to provide inter- mediate and long-term mental health and substance abuse treatment. • Train mental health/health practitioners in long-term mental health and substance abuse treatment inter- ventions. • Implement supportive interventions for airport Disaster Mental Health teams and other disaster personnel. 5. Evaluation • Conduct periodic disaster drills and tabletop exercises, as in compliance with FAA regulations, and participate in other community/regional/state drills. • Following a disaster or a drill or exercise, convene an “after action” committee to review preparedness, miti- gation, response, and recovery issues and activities and make necessary updates and changes. This list of planning elements has been adapted from the New York State County Disaster Mental Health Planning and Response Guide. The full plan can be viewed as a part of the case studies listed in this Guidebook. Five Essential Intervention Principles A number of researchers, professionals, and national and international organizations have articulated some recommen- dations and guidelines for managing trauma in the aftermath of disasters [Blythe and Slawinski (2004); Alexander (2005); Bisson, Brayne, Ochberg, & Everly (2007); Bisson & Cohen (2006); International Society of Traumatic Stress Studies Resources (2006); and The World Health Organization IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2006)]. Hobfoll, S.E. et al. (2007) represents some recent work done by a group of international experts from a variety of disciplines relevant to disaster mental health. This group was formed to address the needs of individuals traumatized by disasters in lieu of the lack of controlled studies in this area in order to articulate some “evidence informed” recommendations. The project resulted in the identification of five essential elements (Figure 3) of mental health interventions performed in the aftermath of disasters. These principles state that pro- moting (1) a sense of safety, (2) calming, (3) a sense of self- and community efficacy, (4) connectedness, and (5) hope are all important. 20 Figure 3. Five essential intervention principles (Hobfoll et. al, 2007).

This following checklist contains the five essential interven- tion principles that Hobfoll et al. (2007) introduced and are further explained for the emergency planner to consider: 1. Promote a sense of SAFETY. • Negative post-trauma reactions persist under conditions of ongoing threats. • Introducing a sense of safety reduces survival reactions over time. • The perception of safety is also important. • There are a number of cognitive interventions for decreas- ing exaggerated perceptions of dangerousness. 2. Promote a sense of CALMNESS. • Prolonged states of emotional arousal can cause: – Sleep, concentration, and decision-making dys- function; – Unrealistic perception of dangerousness; and – Avoidance. • Major criticism of psychological debriefing: – Increases arousal at a time when restoring a sense of calming in important. 3. Promote a sense of SELF-EFFICACY. • Self-efficacy: having a sense or belief that your actions are likely to lead to a positive or desired outcome “I can do this.” – Individual and – Collective/group→organizational. • Following trauma, people are at risk of losing sense of competency to handle problems they face. • Important to feel one can cope competently with the spe- cific trauma-related events/tasks. – Normalize emotions and – Solve problems. 4. Promote CONNECTEDNESS. • Social support facilitates information sharing, problem solving, normalization, and emotional support. 5. Instill HOPE. • Trauma results in shattered world view, catastrophizing→ “all is lost” situation. • Instill a sense that outside sources will act benevolently. • Interventions to decrease exaggeration of personal re- sponsibility for causing event. • Decrease catastrophizing. • Normalize reactions. • Stress that most people recover on their own. • Emphasize strengths of individuals and organization. Response to Actions to Assist Psychological Recovery Psychological trauma results from the exposures people experience before, during, and after incidents occur. Iden- tifying individuals at risk for psychological trauma may be challenging, as the context and nature of the exposure may not be evident. For example, providing information though radio contact with an aircraft prior to the crash may not give the individual the visual picture most people associate with a traumatic event, but the individual may experience symp- toms that need support. If you are imminently involved with a disaster, a helpful initial process identified in the Hobfoll article, described earlier in this chapter, may be of assistance in your initial response to victims, recovery and rescue workers, or others who may be at risk. Actions to consider during emergency operations include the following: 1. Identify individuals at risk and their organizational super- vision. While disaster victims and airport personnel directly involved in rescue operations are the immediate concern, also consider personnel from maintenance, security, dispatch, gate agents, baggage handlers, and air traffic controllers to list a few. Remember small organizations (e.g., contract maintenance or security) within large airports may be forgotten and may not have support or policies to assist them. 2. Identify resources for mental health support. Organizations that provide mental health support should be contacted as they may have specific guidance and/or per- sonnel to support your operation, depending on the nature and the scope of operations. These organizations may be within organizations (e.g., Employee Assistance Programs), contract groups or through mutual aid (Fire department or affiliated airports). Development of a MHRP will list sup- port groups (Red Cross for victims/families, etc.) 3. Assess the needs of the affected community. Identify the conditions and exposures of the teams working in the rescue, recovery, and investigation of the disaster. Unique issues may need physical support that as- sists coping, such as temperature management, lighting, or personal needs (food, communication with family, etc.). Consider the challenges faced by individuals tasked with jobs outside their training and experience, such as mainte- nance personnel tasked with cleaning a fatal accident scene. 4. Initiate early supportive measures. Prepare crews who will work with the recovery effort whenever possible, as this will help them focus their efforts and minimize uncertainty. Pairing crew members with someone experienced in the operations appears to be help- ful, as well as providing individuals to offer mental health support on site to workers as needed. Do not expect NTSB, FAA, or other groups to provide mental health support for your staff. While their assistance during operations does help your team members, the men- tal health support embedded in their organizations is not intended to support individuals external to their group. 21

5. Identify high risk groups and individuals for additional support. The ultimate goal of a team would be to self-monitor the individuals, supporting and relieving colleagues as needed. This was identified as a key element by a num- ber of well-developed recovery and investigation teams. Education and support are needed to prevent additional trauma and provide additional supportive measures, such as time off, counseling, etc. 6. Continue to monitor personnel and effectively commu- nicate. Listen, and provide answers, to individuals involved in the recovery operations, as uncertainty was found to be a significant factor in aggravating stressful work. Make lists to keep concerns from being forgotten. 7. Assess the intermediate and long term needs. 8. Evaluate the effectiveness of the plan after each training session and disaster. This list is but a shell of the plan needed to support an organization, but as with operational disaster action plans, it must be tailored to the specific needs and resources of the organization. Excellent examples of Mental Health Disaster Recovery Plans are available to review and use as a template to develop your individual plan. Please see the New York State County Disaster Mental Health Planning and Response Guide: A Guide for County Directors of Mental Health and Community Services attached as a case study to this guidebook and available at http:/www.omh. state.ny.us/omhweb/countyguide/. Lastly, there is “no one size fits all” approach, there- fore careful consideration of your employee’s percep- tions and mental health regarding the incident, and the organization structure, culture, and communication net- work is critical in framing your response to the traumatic event and realizing the best possible course of action for all involved. 22