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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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Suggested Citation:"Chapter 3 - Case Studies." National Academies of Sciences, Engineering, and Medicine. 2009. Helping Airport and Air Carrier Employees Cope with Traumatic Events. Washington, DC: The National Academies Press. doi: 10.17226/14302.
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23 1. Airports Helping Airports The following information is taken from several interviews and documentation provided by the airports involved with, or that have been the recipient of the airports mutual aid plan from the Southeast (SEADOG) and the Western United States (WESTDOG). Natural disasters in the United States were at an all-time high in 2004–2005; several hurricanes took aim at the south- eastern United States, and a group was started to provide tech- nical aid in restoring airports’ normal operations. Hurricanes struck several coastal and inland cities, and while there was warning that these storms were to make landfall, no one ever really knows what the exact amount of damage will be, or what the recovery efforts will entail. The following is an example of “airport mutual aid”; for the purpose of anonymity, “airport A” and “airport B” will replace the actual names of airports discussed in the following example: As a hurricane approached airport A in 2004, airport B offered assistance; and, as the storm made landfall, airport B’s personnel and equipment were staged well in advance to be in position to help airport A return to normal operations. Following the disaster, there were well over two dozen person- nel on site representing seven different southeastern airports in the United States. The director from airport A cited the following benefits to this “airport mutual aid”: 1. The workers that came to their aid were experienced “airport personnel” that were very familiar with the dynamics of an airport environment. 2. The process allowed contact with the outside world during a feeling of isolation. 3. The mutual aid workers made it possible for airport A’s personnel to tend to their own personal/family situations. 4. Employees of airport A could focus on getting back to nor- mal operations with the additional personnel, supplies, and equipment brought into the airport, as work may serve as a coping strategy. Following this disaster in 2004, airports in this area of the United States recognized the need for airports to come to the aid of one another, due to the uniqueness of the airport indus- try, following a natural disaster. The other airports have the needed equipment, skilled personnel, and ability to restore the operations in a time when normal operations are desired. SEADOG has been initiated since this first usage of “airport mutual aid.” The southeast portion of the United States is the target of hurricane season on an annual basis; this group (SEADOG) has been enacted several times since 2004. Each time, the logis- tics become refined, and there are lessons learned and put into practice for the next activation of the group. The group is informal in nature, and airports that participate do it on a vol- untary basis, as there is no formal structure in place. The FAA, TSA, and parts of FEMA have recognized its existence; the group also has yearly meetings to further develop the program. The western United States airports have formed a similar mutual aid group since 2007. WESTDOG was formed to offer assistance in times of natural or man-made disasters. Like other mutual aid organizations, the participation is voluntary. As part of the WESTDOG plan, there are four central ele- ments at its core: 1. Airports are critical infrastructure and play vital roles in area recovery from large scale disasters. 2. Individual airports have limited capacity and personnel to recover from catastrophic events, and will be in need of highly skilled and specialized employees that may not be able to respond to their particular airport. 3. Airport operations are highly specialized; therefore, the cre- ation of “airport centric” skills and resources is desirable. 4. This system will harmonize with existing local mutual aid agreements under the National Incident Management System (NIMS) plan. These factors lay the foundation for airports to become involved with “airport mutual aid.” There is sometimes little C H A P T E R 3 Case Studies

to no warning about a disaster, whether it be natural or man- made, and the operation of an airport is critical to the region’s recovery. Therefore, having skilled workers and reliable equip- ment and supplies staged to aid in the airports return to nor- mal operations cannot be overstated. 2. Leadership, Communication, and “Continuity of Care” The following case study is taken in part from an in-depth per- sonal interview with Hilary Fletcher, County Manager for Pitkin County Colorado as well as other data sources. Pitkin County is located in the west central part of the Rocky Mountains; the County covers 818 square miles and has a full time population of 15,000. The primary population centers are Aspen and Snowmass Village. Ms. Fletcher has been the County Manager since 2001, she has worked in various capacities for Pitkin County since 1988. She has a master’s degree in Public Administration from the University of Colorado at Denver. On March 29, 2001, about 19:01:57 mountain standard time, a Gulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado. The charter flight had departed Los Angeles International Airport (LAX) about 17:11 with 2 pilots, 1 flight attendant, and 15 passengers. The airplane crashed into sloping terrain about 2,400 feet short of the runway threshold. All of the passengers and crew members were killed, and the airplane was destroyed. The flight was being operated on an in- strument flight rules (IFR) flight plan under 14 Code of Federal Regulations (CFR) Part 135. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: the flight crew’s operation of the airplane below the minimum descent altitude without an appropriate visual reference for the runway. Con- tributing to the cause of the accident were the Federal Aviation Administration’s (FAA) unclear wording of the March 27, 2001, Notice to Airmen regarding the nighttime restriction for the VOR/DME-C approach to the airport and the FAA’s failure to communicate this restriction to the Aspen tower; the inability of the flight crew to adequately see the mountainous terrain because of the darkness and the weather conditions; and the pressure on the captain to land from the charter customer and because of the airplane’s delayed departure and the airport’s nighttime landing restriction (NTSB, n.d.). Upon occurrence of this incident, the county fire/rescue and sheriff’s departments responded accordingly. The airport is a small commercial service airport with its own fire/rescue department; they also sent employees to the scene. The climatic conditions were wintry and starting to darken while the terrain was uneven and characterized as unforgiving. This made the rescue work challenging. The first responders quickly ascer- tained that, of the 18 people on board, there were no survivors. Accordingly, the mission was refocused toward recovery. It is very clear that fire/rescue, law enforcement, and air- ports (per FAR Part 139) continually practice emergency exercises where there are survivors and the rescue of these people are practiced over and over and refined with lessons learned. It has become apparent that very few entities prac- tice the recovery phase of a fatal incident. After it is deter- mined there are no survivors the rescue and law enforcement departments release the scene to investigators. Often times office workers, road workers, human services, environmental, and risk management personnel are tasked to do recovery work, due to the size of the effort, small size of the their orga- nization, or proximity to the event. Most people do not seem to shy away from helping out, but may experience things that are not normal in the regular course of their employment. There are specific tactics of scene preservation for the agen- cies that arrive and investigate; there are certain protocols for the coroner’s office to be followed, and soon after a tragedy, the families of the victims will be arriving on scene and will try to cope with a difficult situation. When organizations practice emergency response, they attempt to include all aspects of foreseeable situations. Accordingly, it is hoped that when a traumatic event occurs, the responding agency is well-versed; however, it seems the transition from response to recovery is not always a well-rehearsed scenario. Being able to effectively communicate and lead an organi- zation during non-traumatic times is challenging, but being able to provide consistent leadership and communication are essential in guiding the organization through response, to recovery, and to regain normal operations. The following case study is a representation of exemplary leadership, which created a reliable communication network, and kept a watch- ful eye on the employees of the organization. Communication when a traumatic event occurs is much more than just generating press releases for the local media. It entails communicating with the local and national media; offering family member assistance; making transport and bur- ial arrangements; and certainly not trivial, attending to the mental health needs of the response and recovery workers. Many of the workers had not received formal training for wit- nessing fatalities that an accident could produce. As evidenced with this county, a plan was quickly developed for communi- cating within the organization, and making sure the employees received the best possible mental health follow-up care. Lessons Learned 1. Leadership The top level leader had over twenty years of progressive experience with public administration working in key posi- tions with legal, risk management, and public information. These key areas of the administration provided a solid foun- dation of knowledge areas and a network of professionals from 24

which to build. As her career track progressed she volunteered to take on areas that exposed her to higher levels of crisis and emergency work, which allowed her to build upon her lead- ership skills. The county has now initiated recovery training with the use of the ICS program and utilizes this methodology whenever possible. This enables each key employee to practice the ICS protocols and make adjustments for their organiza- tion when necessary. It appears that preparation is vital as some people cannot be on the front lines of a crisis, while others may thrive. It is important to tally these skill sets before a trauma, rather than attempting to gain this information during a trauma. While practicing the recovery phase of an incident, a leader can put capable people into the front line positions. According to Ms. Fletcher, “it is crucial to empower differ- ent employees at different stages in the recovery phase to build employee confidence during a crisis. She describes a critical stress incident as, (1) an event with sudden unexpected and overwhelming emotional triggers; and (2) an extraordinary event that interferes with an individual’s ability to psychologi- cally cope.” 2. Communication While a tragedy is unfolding, communication becomes essential, not only with the local and national media, but more- over with an employee group. Misinformation occurs dur- ing normal operations, but during a crisis this can become magnified. The plan utilized at this airport called for all com- munications to stop in the command post once an hour in order to regroup and strategize what the next move was or how to handle the preceding hour’s problems. The strategy employed in this case study was to identify the most proficient office managers of the different departments. This tactic appeared to identify “master multi-taskers,” who can answer phones, schedule meetings, run the copier, and send emails all nearly simultaneously. While the supervisory staff is tackling individual key situations, the mid-level of- fice managers can initiate and maintain an internal commu- nication network so that all employees are given the timely and needed information to get their organizations back to “normal operations.” 3. Continuity of Care The concept of “continuity of care” was developed exclu- sively by the County Manager and Human Services depart- ment depicted in this case study. The key elements of the re- covery plan were (1) community care, (2) organizational care, and (3) employee care. The County Manager, in her 20 years of dealing with trau- matic events, came to the realization that there seemed be a lack of knowledge and training in emergency management pro- tocols for the recovery phase. In the aftermath of this aircraft incident, it is widely practiced that all organizations engage in some sort of group “defusing” or “debriefing,” referred to by most authors as a Critical Incident Stress Debriefing (CISD). The event may be either voluntary or mandatory by the organ- ization, and it usually involves a session or sessions where the incident is discussed. There are usually mental health profes- sionals and/or clergy available for employees to discuss their feelings regarding the trauma. These sessions are usually held fairly soon after the actual event. Some people feel that firefighters and law enforcement have their own internal mechanisms for dealing with tragedy and in some ways are “just wired different.” In this particular incident, 44 non-public safety workers were involved in the aviation aftermath; it took two years to officially close the incident. On the day after the crash, the County Manager and Human Services Director drafted an extensive program that they strictly followed to manage their employees through the program. It was specific and focused, because they did not want to lose any employees due to an inability to cope with what had happened or what they had witnessed. During her 20 years of public service, the County Manager had experi- enced many traumas and knew that critical events could become overwhelming. The program included the following: 1. Organizational Employee Care “Continuity of Care Plan” • The County hired a mental health care professional (MHCP) that specialized in post-traumatic stress (PTS). • The MHCP was on site for a week, roving between loca- tions and departments. • The MHCP was given the names of the 44 employees that responded/worked the accident. – The MHCP physically checked on the employees, and was available for private consult. – The MHCP rotated through departments so that all employees had access. • The MHCP led training sessions with the supervisory level so that the employees knew what post traumatic stress was and the signs their employees may exhibit. All supervisors were required to attend. – Supervisory contact with employees was daily (for two weeks), then every other day, then every third day, then once a week, then every two weeks, then once a month. – Supervisors were required to document their contact with the employees to the Human Resources Director. – Worker’s compensation was offered. • The county wrote a brochure and sent it all employees. • The county Human Resources department contacted family members, spouses, or significant others of their employees so that they would be familiar with the symp- toms of PTS, and provided them numbers to contact in 25

case they needed assistance (this system actually produced one employee referral). • Employees utilized counseling services. – The county set up an open-ended agreement (counsel- ing and financial) with the local counseling center. • The County Manager personally recognized each (44) employee that had a part in the accident recovery and each employee received three comp days, no matter their role in the efforts (this was done for the purpose of vali- dating and acknowledging employee participation). • The County Board of Commissioners was tasked with personally thanking each employee that was involved in the recovery efforts. • The recovery phase of this critical incident lasted approx- imately 1 year. 2. Community Care • Initiated contact with local counseling center for com- munity access. • Encouraged bystanders, witnesses, responders, and air traffic controllers to use the counseling center. • Responded to calls from family and friends of citizens at the scene. • The County provided the community educational infor- mation and held meetings pertaining to critical incident stress, and how to recognize symptoms of stress. The following are concluding remarks from the interview: • The area of concern seems to be the transition from response to recovery mode and dealing with the human relations impact. It is important to provide mental health recovery internally as at some point operations will return to nor- mal, but employees will have to live and work with what they have witnessed. • An organization should ensure that the lessons learned while employees are working this type of event are recorded and implemented into their emergency plan once the imme- diate event is concluded. • It is the general lack of information that makes people unsettled. • When communication doesn’t flow and an organization is in crisis, the level of stress can become extreme. • It may take a few days for the NTSB to get on scene, as well as the American Red Cross. Family members will attempt to come to the scene as soon as they can. • The Incident Command Structure (ICS) works; it should become engrained in every organization. Employees should study the ICS by taking courses and using it in everyday events just for practice so it becomes natural. • In a small community, resources may be exceeded, so mutual aid agreements should be utilized. • Emergency planning and drills should be incorporated into the recovery transition. • Managers should be aware that public safety workers are not accustomed to lengthy efforts but rather are better suited to short episodic events. • General Aviation (GA) is typically not prepared for this type of accident; the commercial air carriers have plans in place, but not GA. • The legal entity (County) should have emergency finan- cial allocations at its disposal for clean up, hiring critical workers, consultants, etc. • An organization should build strong and reliable relation- ships both internally and externally. • The incident became a National media event, due to its highly visible location (Aspen), so organizations should be ready for an intensive public focus. 3. A View from Those with Experience The following case study was taken from two interviews with aircraft incident investigators with experience over several years and many incidents. They participate in these duties as members of the Airline Pilots Association (ALPA), bring- ing their expertise in flight operations to the party system used by the National Transportation Safety Board in their incident investigation process. The discussion with these individuals is important in that they have experienced the psychological trauma of the inci- dent, as well as observed and supported those individuals who are experiencing this type of psychological trauma for the first time. While their insights may not be scientifically based, we feel it does reflect a common operational experi- ence in the activities surrounding the recovery efforts in an investigation. ALPA representatives asked to participate in an aircraft incident investigation can have varying levels of training and preparation. Individuals in this case study received training from multiple professional entities in incident investiga- tion (e.g., Air Force, university, NTSB, ALPA courses, etc.), in addition to their experiences in multiple investigations. At the time of the interview, both ALPA members were conduct- ing an incident investigation course for ALPA pilots involved in the organization’s safety program, with the expectation that these individuals potentially would be called to face an incident to investigate. Preparation The investigators noted the importance of preparation for individuals working in and around an aircraft incident scene. 26

The work is very unique, with many specialists and agencies quickly converging on the scene. Individuals uncertain of their role and responsibilities are likely to become hesitant and over- whelmed with the traumatic scene. The investigators cited sev- eral examples where training recovery personnel prior to the event would not only assist them in accomplishing their tasks, but to support healthy adaptation to the stress associated with this work. The NTSB investigators felt that recovery personnel need a sense of duty, knowing they are part of a team to prevent this tragedy from happening again. The destructive nature of an aircraft disaster can incapacitate workers and lead to personalizing the trauma and feeling a sense of helplessness. “It’s a disturbing sight to see the consequence of errors or malfunctions. People identify with that . . .” One investigator quickly admitted that some aspects of the recovery process (e.g., recovery of human remains) were emotionally more difficult for others than for himself. He states he has learned to tolerate this particular duty by acknowledging “evidence comes in many forms and this is just one of them.” Both inves- tigators felt recovery teams in the field had to focus on their purpose to collect and preserve evidence, with the goal of iden- tifying the cause of the disaster. Preparation of the recovery team should include knowl- edge of the NTSB incident investigation process, the design of team structures, and policies to allow an individual to work within the system to accomplish their goals. Both investigators interviewed noted training was important to keep individ- uals working the scene to be better able to maintain focus on their specific jobs and not disengage or become overwhelmed during periods when they were idle. The investigators related incidents where individuals who were not well-trained or would become overwhelmed at the incident scene, and that focusing on their specific job was one attempt to make the event less personal. Another point made in the interviews was that an individ- ual who is prepared to face difficult images of a disaster scene can avoid what they consider triggers to their stress. Some sights, smells, and/or situations can remind or create memo- ries among the observers. This may be difficult or impossible to predict, but some investigators are familiar with common smells or sights at disaster scenes. These may trigger memories of feelings from prior incidents. This was a common theme with both individuals interviewed. One investigator said that body part recovery was not an issue for him as long as he viewed the material as evidence, but that one trigger point in the field for him is looking at the victims’ personal effects, this causes stressful reactions and unpleasant memories. It is apparent that trigger points for stress reactions may be difficult to identify proactively. Another story related was an incident investigator who had no apparent triggers but later found that children’s clothing on the incident scene would trigger stress reactions. This trig- ger point developed following the birth of his first child. It is apparent that ALPA’s preparation also included plan- ning the mental health support for surviving airline crew mem- bers they are representing, family of injured or deceased crew, and the investigators themselves. ALPA’s CIRP was developed to address and decrease crewmembers’ psychological stresses during and following an investigation. This program is dis- cussed in more detail in the following section. Connectedness Both interviewees noted that connectedness with others involved in the investigation or at home were important fac- tors in maintaining their personal mental health. In their observations of others involved in incident investigations, they observed outcomes that ranged from significant impair- ments and withdrawal from aviation to resilient individuals who returned to work, apparently without problems. Both investigators interviewed noted a variety of coping mechanisms were used (alcohol use, withdrawal, humor, and focusing on the job at hand) and often shared within the groups. Investigations of major disasters are known for long hours of continuous operations with associated fatigue. The investigators noted that recovery team members would often look after each other and suggest breaks for individuals they detected needed a reprieve. While some group members would resist the suggestions early in group formation, with increas- ing camaraderie, team members would respect the sugges- tions more. The development of a team that watched after each other was deemed an important development. One investigator noted the intention of a group leader was similar to military operations—to form a cohesive group and to promote each person looking out for the welfare of the other members. This would apply to operational as well as mental health support. This is also the basis by which the CIRP provides an individual to monitor ALPA team members for signs of psychological stress during and after the investiga- tion process. The CIRP member is assigned support duties and remains onsite with the ALPA team during the investigation to provide support and referral for professional mental health support services. The CIRP is multi-faceted, but its central premise is to address the needs of crew members involved in incidents or ALPA members on investigation teams. Peers, imbedded with the investigation team, are trained to identify stress-induced problems that would need referral to appropriate health care professionals. Both ALPA members interviewed strongly supported using peers as initial contacts, citing greater accept- ance of the situation as they are “talking with someone who went through this already.” 27

One ALPA member noted that teams working with cock- pit voice recordings would request a pilot who knew the inci- dent pilot, in order to assist with voice recognition and oper- ational questions. This work was done in Washington, D.C., removed from the incident site and other ALPA support personnel. Listening to the voices of colleagues during the incident is considered to have a high potential for personal reactions and psychological trauma. In response, ALPA now dispatches mental health support personnel (CIRP) to accom- pany pilots involved in this type of work. When discussing situations in which individuals did not receive needed help, the ALPA investigators strongly felt a professional mental health support program would have been of assistance, if available onsite. Other Issues These investigators acknowledged they are often told of incidents with immediate orders for departure to the scene. Although the travel time, organizing an arrival to the scene, and verifying that the site has been secured creates a hectic schedule, they note they don’t have time to prepare for the investigation psychologically. One investigator recalled a phone call notifying him of an incident that was in progress at the time of the call. A pilot was riding a tug to the aircraft crash and fire within minutes of the impact to notify ALPA investigators of the incident. Crash/fire/rescue, security, med- ical personnel, and airport workers may also find they have little time to prepare for the trauma of the incident scene. Important Points These investigators believe that some individuals working in this field are susceptible to psychological trauma as a result of their experiences. It does not appear to be predictable to the investigators as to who is at risk. It is also noted that suscepti- bly can change according to the circumstances of the incident or issues surrounding the individual. Preparation through training and simulation are consid- ered valuable not only for work effectiveness but as a coping mechanism. Simulation of the chaos and pressure in some incident investigations are difficult to replicate in the train- ing setting and make the experience of incident investigation a learning experience in itself. Triggers that remind or create unpleasant memories or stress reactions are important to recognize, as avoidance appears to be possible for some individuals. Foreknowledge of this topic is considered worthy of discussion in a training program. Camaraderie can create teams who monitor each other’s performance and ability to cope with the situation, providing support when needed. Coping mechanisms, and especially methods that are counterproductive, should be discussed with incident investigators during training programs. ALPA’s CIRP has strong support from the two members who are familiar with the program. Both feel peers designated as mental health support team members are an effective mea- sure when used onsite, in real time, and are known to the team during the experience. 4. Innovative EAP Builds Employee Resilience The following information was taken from an in-depth inter- view with an organization that regularly works with traumatic events. This organization has outsourced their EAP. Employee retention is a very important aspect in any com- pany, but when the personnel are a highly trained, specialized group of individuals doing very specialized tasks, it becomes critical that the employees are retained and are given the opportunity to build their resilience. Most organizations have EAPs in place; they are normally stand alone outside resources that are not within reach during the normal course of business. Efforts are usually needed for an employee to access the needed resources, and in some cases there are time gaps in receiving the benefits. Another divisive issue is that some employees feel there is a negative stigma attached when reaching out to one’s EAP and therefore some employees do not ask for the help that is needed. The organization that this case study depicts has deviated from the standard EAP process and has chosen to integrate their EAP contractor into their employee relations from initial training events up to and including regular field work. The EAP contractor will venture out to the organization head- quarters, as well as, in field visits and specialized site visits while the employees are actually working a disaster. This integration allows the employees to form personal relationships with the EAP contractor and accordingly, this person may also play a peer role to the employee. This is espe- cially unique, in the fact that, some people like to talk about particularly disturbing events with someone who has actu- ally been to an event of such magnitude. The importance of this integration is the psychological first aid that can be given and received on-scene. A licensed mental health worker can assist the employee, and the employee has had the opportu- nity to establish rapport and a trusting relationship with the EAP provider. Essentially, the EAP has been inextricably woven into the protocols of the organization, and there is organizational-wide acceptance of the mental health provider, thus wiping away any stigma that may be negatively attached to the situation. An employee working a traumatic event has the benefit of work- ing alongside the EAP contractor, and the contractor is able to assess the employee on site. The EAP contractor becomes a 28

quasi-peer as well as a credentialed mental health professional. The organization is confident with the level of mental health assistance their employee is receiving as it is simply more than psychological first-aid administered by a lay person. Employees appear to benefit from this plan for many rea- sons. The EAP contractor is involved in training scenarios, management briefings, and on scene work. The EAP con- tractor is seamlessly involved in the employees work expe- rience, and as such, the value lies in the EAP contractor being able to “check-in” with employees during the course of work, after hours, and in an office setting if necessary. An appointment two weeks down the road in a professional set- ting is often-times unneeded, due to the mental health aid that was given in the field, when requested, or when it is most appropriate. The EAP information is also housed on an internal web- page for the organization’s employees. If the employee accessed the intranet, then EAP information for a variety of issues is easily accessed. The EAP has become embedded in the orga- nization, which may make it more cost-effective, in that the organization is able to retain its highly trained workforce in face of traumatic events. A less than obvious benefit of having an external EAP is the issue of confidentiality. This organization feels that having an outside vendor allows the employee increased anonymity with accessing mental health support. There is a built-in barrier between the management and the provider as well. The EAP contractor is also able to help an employee’s fam- ily and encourage self-care for the employees. It is hoped that this creates an atmosphere of employee resiliency where the employee knows the stigma of mental health support has been erased. Accessing the EAP is encouraged and supported by the entire organization. Using this model of assistance, the organization hopes to demonstrate that each person in the organization is valued by allowing and encouraging each employee to build their own resiliency; then the work of the entire group is less burdensome. 5. Home Grown Resilience The following case study is taken from an in-depth interview with an airport manager with fifteen years experience, twelve of those at the executive level of a small general aviation airport in the Midwest. The airport manager is the only full-time airport employee located on the field and has been involved in three fatal incidents over the past 12 years. This case illustrates the per- sonal, group, and organizational resilience that this individual has been able to cultivate as a result of experiencing traumatic aviation events. The airport in this case is a small non-Part 139 general aviation airport facility that is city-owned and operated. The airport manager is the only full-time employee on the field. There is no FAA requirement for emergency preparedness, but over the years, the airport manager has fully developed an emergency plan for the airport, and has, in cooperation with the city-operated fire department, held a full-scale disaster scenario. Upon the second fatal general aviation airplane crash, this airport director had a desire to become more cohesive with the responders within the jurisdiction, the airport manager approached the city fire chief, and the chief agreed that this individual would greatly benefit from firefighting and res- cue training. The airport manger began training with the fire department and is now a fully certified member of the city fire department, in addition to being the airport manager. Over the past few years, the airport manager has been responding to the same calls as the fire department and build- ing camaraderie and trust with the fire department employees. The airport manager has responded to house fires, automo- bile incidents, and fatalities. This extensive training and the response to traumatic events has enabled the airport manager to become personally resilient in the face of traumatic events. While building this trust and connectedness with the city fire department, the airport manager decided to build a training scenario for the airport and the fire department which involved a supposed aircraft incident (as required for a FAR Part 139 commercial service airport) and with the approval of the fire chief, ran the incident at the airport. This exercise enabled the fire fighters to become familiar with response activities sur- rounding aviation and the need for site preservation for the NTSB or FAA. The airport manager has been able to determine the direc- tion of personal needs in order to build internal strength and resilience while affiliating with a group and receive group resilience, all the while under the guise of organizational resilience from the city. Being a singular employee at the air- port can be a daunting, yet exciting proposition. However, when traumatic events occur, people need to have a support network and a feeling of connectedness. By seeking additional training from the fire department, this airport manager began building resilience on an indi- vidual level. With the advanced training, this manager then began to build trusting and cohesive relationships within the fire department, exemplifying group resilience. In the end, by bringing together the fire department and the airport, this indicates organizational resilience. Hobfoll, et al. (2007) identifies five essential elements of trauma intervention that an organization can offer in order to enhance an employee’s resilience (1) safety, (2) calming, (3) self- and communal efficacy, (4) connectedness, and (5) hope. This airport manager was able to bring together these five elements by understanding what objectives needed to be met in order to satisfy a personal need. The airport manager determined at the second aircraft fatality that there 29

was an internal need to be more prepared and connect with the fire department. The airport manager connected with the fire chief and began training with the fire department, thus building self- and com- munal efficacy. This provided an atmosphere of connectedness, and after working with the fire fighters on non-airport fire department calls, the manager found peaceful resolutions and an ability to cope with the after effects of a traumatic event. All of these elements combined provide a safe and calm atmo- sphere in the midst of chaos. Lessons Learned 1. Determine who will handle the media for the airport during the event. The airport manager was on scene as an official, but also as a city fire fighter. This made the response activity go quite smoothly; however, upon return to the office the media, and others barraged the terminal and phone lines for informa- tion. Who is to give out fatal information? When building scenarios and training events for traumatic events, make con- tact with the department or person that will handle the media and notifications on behalf of the airport. If the airport is small (1 employee) then someone from the local jurisdiction may be delegated to handle this duty. 2. Determine who will handle victims’ assistance activities. Victims’ families may want to visit the area and be brought to the site of the incident to aid in their grief process. While this is an important step for families it is not a comfortable position to put the airport sponsor in. At the point of initial investigation, the airport has no idea of the NTSB outcome and there may be liability, so careful planning should ensue. There should be a determination of what neutral party in the response effort should handle the victims’ family members. If the scene is on the airport property, then accommodations for access will need to be considered. Make direct contact with the American Red Cross for your region. 3. Be cognizant of anniversary dates and memorial requests. It is not uncommon for family members to want to visit the site of the incident in the preceding years on the anniver- sary of the event. This will trigger phone calls and emotions surfacing, or reliving the event for the airport worker. Also, there have been several airports around the country that have been asked to put a permanent marker or memorial on the incident site. This, too, will cause emotions to resurface sur- rounding the trauma. Careful consideration and planning will need to be taken to have the appropriate resources in place to deal with requests of the family and possible mental health implications for employees. 6. Example Mental Health Recovery Plan This Mental Health Planning Document was retrieved from The State of New York’s Office of Mental Health. It provides a comprehensive review of the planning and resources needed to develop a mental health response guide. While it is not an “airport-specific” plan it illustrates many different facets to consider while developing an organizations individual plan. It is available at http://www.omh.state.ny.us/omhweb/countyguide/. The New York State County Disaster Mental Health Planning and Response Guide: A Guide for County Directors of Mental Health and Community Services The County Disaster Mental Health Planning and Response Guide provides specific information and resources to assist the county Director of Community Services (DCS) in the development of a comprehensive county mental health dis- aster plan. The Guide follows the disaster management con- tinuum and takes into consideration the important aspects of Planning and Preparedness, Mitigation, Response, Recovery, and Evaluation. It is recommended that the DCS review the community’s plan routinely so new information in the field of disaster men- tal health may be integrated into the plan in a timely manner. Key contact information for vendors, volunteers, employees, and others should be reviewed every 6 months and the plan updated accordingly. 1. General Overview 1.1 Planning/Preparedness • Convene a county Disaster Mental Health Advisory Committee. • Review the county’s Emergency Management Disaster Plan. • 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 county disaster mental health response and recovery plan. • Develop county disaster mental health response teams. • Establish county MOU with community partners. • Participate in county disaster drills and exercises. 30

1.2 Mitigation • Identify high risk areas and populations within the county 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. 1.3 Response • Activate response protocols for County disaster mental health teams. • Coordinate resource deployment and service provi- sion with other community-based disaster mental health teams. • Assess mental health needs of the affected 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 county government about risk communication. • Re-assess and evaluate mental health needs of the affected community. 1.4 Recovery • Assess and evaluate the intermediate and long-term men- tal health needs of the affected community. • Identify community resources to provide intermedi- ate 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 DMH teams and other disaster personnel 1.5 Evaluation • Conduct periodic disaster drills and tabletop exercises. • 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. 2. Planning and Preparedness 2.1 Convene a Disaster Mental Health Advisory Committee The involvement of and collaboration with a wide variety of public and private agencies and organizations is strongly encouraged. Planners may find it useful to sort the planning process into “topic” specific task groups or subcommittees addressing such areas as legal issues, recruitment and train- ing issues, operational and deployment protocols, “special incidents” planning, etc. A vibrant and comprehensive men- tal health disaster plan is highly correlated with the collabora- tion and diversity of participants involved in its development. Effort should be made to invite participants from multidisci- plinary backgrounds and experiences. Representatives from the following list of public and private agencies and organi- zations might be invited to serve on the overall advisory com- mittee or its topic specific task groups: 2.1.1 County/City Stakeholders • Office of Emergency Preparedness. • Department of Health/Public Health. • Office of the Medical Examiner. • Department of Health and Human Services. • Department of Human Resources Management. • Department of Information Technology. • Department of Legal Affairs/Risk Management. • Law Enforcement, Fire, and Emergency Medical Services. • Business Community. • School Districts/Universities/Colleges. • Correctional Facilities. • Airport Administration Officials. 2.1.2 Regional/State/Federal Stakeholders • New York State Office of Mental Health (Field Office). • New York State Department of Health (Regional Office). • Regional Resource Center/Hospital Bioterrorism Pre- paredness Program. • New York State Office of Alcohol and Substance Abuse Services (Regional Office). • New York State Office of Mental Retardation/Develop- mental Disabilities (Regional Office). • New York State Emergency Management Office (Regional Office). • New York State Office of Mental Health Psychiatric Centers. • U.S. Department of Corrections (Federal Prisons). • U.S. Veterans Affairs. • U.S. Military Installations. 2.1.3 Other Public/Private Agencies and Organizations • American Red Cross. • Salvation Army. • Academic Medical Centers. • Community Hospitals and Healthcare Facilities. • Mental Health Associations. • Home Health Agencies. • Tribal Nations. • Nuclear Power Facilities. • Faith Organizations. • Transportation Companies (rail, bus, air). • Private Schools/Universities/Colleges. • Business and Industrial Community. • Veterinary Associations. 31

• Special populations (those agencies or advocates repre- senting children, elders, individuals with emotional and physical challenges, various ethnic/cultural populations such as Hispanic, African American, Asian, Mennonite, deaf/hard of hearing, etc.). • Private Residential Care Facilities. 2.2 Review Your County Disaster Plan The county’s mental health disaster plan is one compo- nent of each county’s overall community-wide disaster plan. To obtain a copy of the County Disaster Plan, contact the County Emergency Manager or Director of Emergency Pre- paredness. Each county plan should include a general overview of the authority of the County Department of Mental Health during the event of a disaster. In reviewing the county’s dis- aster plan, pay particular attention to the following issues in a county: • Potential disaster hazards and risks. • Disaster history. • Special plans (or Annexes) which identify specific roles, responsibilities, or procedures the County will engage in related to the type of disaster. For example, many coun- ties have elected to develop special plans in the event of the following: – Aviation or other transportation accidents. – Weapons of Mass Destruction incidents. – Radiological/Nuclear incidents. – Hazardous Materials (HazMat) incidents. – Public health emergencies (such as SARS, Influenza, and other communicable diseases). • Review data on the geographical and population demo- graphics of the county as well as data on the risk groups below. The DCS may also want to collaborate with the county’s Geographic Information Systems (GIS) group to map out specific risk groups: – Rural vs. urban communities. – Individuals living in flood plains. – Individuals living on earthquake fault lines. – Children, elderly, deaf/hard of hearing. – Schools, colleges, and universities. – Ethnic/cultural populations. – Religious communities. – Group homes or assisted living facilities (mental health, substance abuse treatment, MR/DD). – Nuclear power and other energy facilities. – Business and industry, especially those which may be high risk targets for acts of terrorism. – Disaster/emergency relief personnel. 2.3 Review Disaster Plans for Local Disaster Response Agencies A county’s local chapter of the American Red Cross is responsible for meeting the short-term or immediate dis- aster related needs of a community during times of disaster. A community may also have other organizations that have disaster-related service missions. Identify such agencies and request and review copies of their respective disaster plans. Identify opportunities to collaborate and reduce redundancies in service provision, where appropriate. 2.4 Develop a Comprehensive Mental Health Disaster Plan Preparing for, responding to, and recovering from disaster is predicated on a comprehensive disaster mental health plan. Development of this plan should include representatives from across professional disciplines as well as those from the pub- lic and private sectors. Once the plan is completed, it should be shared with and reviewed by a wide audience, especially those who have direct responsibility for carrying out specific tasks and roles identified in the plan. Listed below are key elements of a mental health disaster plan. Further informa- tion regarding these key elements may be found in the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Mental Health All-Hazards Guidance Document, 2003 [see Comprehensive Literature Review, Appendix A]. 2.4.1 Mental Health Disaster Plan-Key Elements • Statement of Purpose – A statement of the general purpose of the plan and how it is intended to be used. • General Assumptions – This information should include an overview of the responsibilities of the County Department of Mental Health, highest probability scenarios, as well as special considerations having significant impact on planning, including vulnerable populations, special facilities, etc. • Concept of Operation – Include the County DCS’s approach to an emergency situation: jurisdictional responsibilities; sequence of action before, during and following an event; requests for aid, etc. This section is intended to be relatively brief, providing only the most general overview, pri- marily for readers of the plan who will not need the level of detail contained in the remainder of the plan. • Citation of legal authorities and reference documents – Reference the specific legal authorities that enable the County Department of Mental Health to fulfill the elements of the plan or to maintain existing services. In the event the County Department of Mental Health mobilizes and deploys paid staff and volunteers to pro- vide disaster mental health services on behalf of the County, reference should be made in the plan as to what legal authority authorizes such deployment and how employee or volunteer liability will be covered in the event of a disaster-related accident or injury. 32

• Organization and Assignment of Responsibilities – Identify tasks (within the County Department of Men- tal Health, other County Departments, outside agen- cies) to be performed and positions and organizations responsible for carrying out these tasks. – Identify who is responsible for modifying and updat- ing the disaster mental health plan and how often. – Identify the level of integration of preparedness and coordination of operations with other important com- ponents of local government (i.e., health/public health departments, substance abuse agencies, criminal jus- tice agencies, mental retardation/developmental dis- abilities agencies, etc.). • Administration, Logistics, Legal Issues – Policies and procedures regarding releasing personnel home, holding personnel in place, recalling essen- tial personnel, and facilities evacuation (for County Department of Mental Health personnel and facilities). – Procedures for record keeping of program activities, expenditures and obligations, human resource utiliza- tion and situational reports. – Procedures for the management of both pre-identified and spontaneous volunteers. – Procedures for feeding, sheltering, transporting, and supervising personnel. – Procedures for the repair/replacement of essential equipment (radios, computers, cell phones). – Arrange for personnel to have identification badges and address and resolve potential access issues with law enforcement or other related agencies. – Address issues of licensing, personal, professional and organization liability, patient records management, informed consent, confidentiality, emergency evalua- tion or commitment laws, and duty to report laws. • Communications – Procedures and methods for notifying county men- tal health personnel, facilities, services providers, and appropriate others. – Alternative plans in the event of failed communication capability. – Identify the availability of technical consultation. • Public Information – Identify policies and responsibilities for dissemination of public mental health information. – Identify external populations that may need special warning and procedures for implementing such warn- ings (i.e., deaf and hard of hearing populations). – Describe the relationship with the county Public Infor- mation Officer. – Identify the availability of public information material (fact sheets, guides, multiple languages, access to services, etc.). – Identify a process for distributing educational and other materials to mental health service sites. – Identify experts and resources outside the County Department of Mental Health that may be utilized as consultants or advisors during times of disaster. • Evacuation – Develop evacuation procedures for county mental health offices and facilities. – Identify alternate sites and facilities. • Collaboration with Other Agencies – Coordinate with American Red Cross Disaster Mental Health Services. – Coordinate with community hospitals, mental health centers and other mental health service providers. • Resource Management – Identify how the County Department of Mental Health will find, obtain, allocate, and distribute necessary resources (i.e., personnel, transportation, communi- cations equipment, mutual aid, management of spon- taneous volunteers, etc.). • Special Response Plans – Develop special response plans for high risk events or incidents in which the County Department of Men- tal Health or its facilities has special jurisdiction or responsibility (i.e., aviation disasters, nuclear power facility accidents, weapons of mass destruction events). • Continuity of Operations – Describe how the County Department of Mental Health will maintain or re-establish vital functions (those services mandated by State or county regu- lations) of the department during the first 72 hours following an event that seriously compromises or dis- rupts normal operations. – Identify and address procedures for restoring vital records and data management within 72 hours. – Procedures for the identification of essential person- nel, staff notification, staff and family support, and staff transportation. – Identify alternate locations for essential operations. – Identify alternate sites for vital records (e.g., dupli- cate copies of the disaster plan, personnel rosters, etc., should be located off site should existing sites be destroyed or are inaccessible). • Other Planning Considerations – Identify a plan to prepare and support County Depart- ment of Mental Health personnel during and follow- ing deployment (i.e., physical health, mental health, family support). – Ensure the County Department of Mental Health’s role in disaster training, drills and exercises. – Collaborate with county’s GIS department to map high risk geographical areas and populations. 33

– Develop a list of federal, state and local mental health and substance abuse treatment facilities, contact names, and telephone numbers (including alternate modes of contact). 2.5 Develop Disaster Mental Health Response Teams A county disaster mental health response team provides a significant resource to the community. Following a dis- aster, the majority of those affected will experience a range of reactions that can be both stressful and impact personal functioning. Disaster mental health response teams provide important supportive mental health interventions that may mitigate both the acute and long-term psychological conse- quences of disaster. Consideration must be given to the key issues listed below in the development of a county disaster mental health response team: • Risk Management: If utilizing volunteers, address pro- fessional liability issues such as malpractice, work- place injury, etc. If utilizing County Department of Mental Health personnel, address how employees will be compensated for time worked as well as limitations on employee number of work hours/days. • Selection Criteria: Team members should meet minimum educational standards as well as possess documented experience in providing disaster mental health or other trauma-related support services. • Application and Review Process: Team members should complete an application highlighting his/her education and clinical experience. Requiring letters of reference is highly encouraged. A thorough review process should be conducted and include the identification of any crim- inal or legal history as well as a review of the member’s professional license for any professional misconduct or sanctions. • Recruitment: Teams should be representative of the community in which they are deployed. Teams should be comprised of members from various cultural/ethnic backgrounds, represent a range of academic mental health disciplines, and possess rich clinical and practical experience. Below is a list of potential recruitment sites: – Local public/private mental health and substance abuse treatment facilities. – Community-based private practitioners. – Professional associations—State/local branches (i.e., American Psychiatric Association, American Psycho- logical Association, American Counselors Association, National Association of Social Workers, American Psychiatric Nurses Association). • Training: The skills required by disaster mental health response team members are not typically offered through traditional clinical graduate mental health programs. A rigorous training protocol highlighting the necessary intervention skills and response protocols should be pro- vided for disaster mental health workers prior to join- ing the team. Team members should be provided with ongoing training and education to maintain and enhance their disaster mental health response skills as well as to keep abreast of changes in the field. The following train- ings are recommended and encouraged: – Disaster Mental Health: A Critical Response curricu- lum (UR/NYS OMH/DOH) – Disaster Mental Health Services curriculum (American Red Cross) – Risk Communication (NYS DOH) – Incident Command System (FEMA) – Other Supplemental Training  First Aid, CPR, Disaster Health Services, Disaster Casework (American Red Cross).  Training to enhance skills in crisis intervention, grief counseling, death notification, mass casualty/ fatality, and special populations – Training spontaneous volunteers in disaster mental health or in mental health interventions with special populations may need to be offered during the disas- ter relief operation so that spontaneous volunteers may be utilized to augment insufficient or depleted human resources. • Position Descriptions: All team members should be pro- vided with a position description clearly outlining their roles and responsibilities on the response team. Descrip- tions should be developed for the following positions: – County Mental Health Director – Response Team Coordinator – Response Team Leader – Response Team Member – Other positions as determined. • Credentialing: Team members should be credentialed prior to joining the team. This involves verifying the professional license of the individual and the clinical training necessary to work with those impacted by dis- aster. Once verified, team members should be provided with identification badges. A process for routinely veri- fying and credentialing volunteers, especially sponta- neous volunteers, should also be developed. It is advis- able not to deploy spontaneous volunteers unless their educational and clinical backgrounds can be verified. • Tracking: Monitoring the availability of team resources is imperative to effective disaster response. Methods should be developed for tracking the recruitment and training of team members. Tracking should also include a mechanism for identifying members who may volun- teer with more than one response team in an effort to reduce redundancies in available disaster mental health response resources across agencies. It is important to 34

clarify deployment priorities and expectations for those members who do volunteer with multiple relief agencies. • Mobilization and Deployment Process: The county mental disaster health plan should include a compre- hensive mobilization and deployment process so men- tal health interventions may be offered “to the right people at the right time.” These processes should ensure that team members are deployed to safe environments and their activities monitored from a risk management perspective. Spontaneous or “self” deployment should be discouraged. It is highly recommended that team members be deployed to a separate, off-site volunteer processing center prior to deployment to their work assignments. 2.6 Establish Memorandum of Understanding with Community Partners A Memorandum of Understanding (MOU) should be devel- oped between the County Department of Mental Health and any agency or vendor identified in the plan that provides disaster mental health services or human and/or material resources to carry out the activities of the plan. These MOUs should clearly articulate the roles and responsibilities of the partner agencies and the mechanisms and procedures for car- rying out such duties. MOUs should be reviewed and cleared by the County’s legal and risk management department. 2.7 Participate in County Disaster Drills and Exercises Counties are often required to hold community wide drills or exercises on a yearly or biyearly basis as required by the State Emergency Management Office. Other county or com- munity agencies may also be required to hold similar drills and exercises (i.e., County airport, nuclear power facilities, hospitals, etc.). The County Department of Mental Health should take the opportunity to participate in these drills and exercises with the goal of evaluating the operational aspects of their plan in addition to building relationships with com- munity and county partners. 3. Mitigation 3.1 Identify High Risk Areas and Populations The County Department of Mental Health must work in collaboration with the County Office of Emergency Prepared- ness to identify potential high risk disaster areas or popula- tions within the county or its contiguous borders. These areas should be mapped and routinely reviewed by disaster mental health team members. Individuals from these high risk areas and populations can face significant psychological stressors in the aftermath of disaster. Efforts should be made to reach out to high risk groups and areas and provide pre-disaster education which has been found to be successful in potentially mitigating acute and long-term psychological consequences of disaster. Disaster mental health research, though limited, sug- gests the following populations may be at heightened risk for developing significant stress reactions or psychiatric illness following disaster: • Children • Female gender, especially married women • Adults in their middle years, especially parents, pregnant mothers • Frail elders, especially those with physical health complications • Ethnic minorities • Individuals with pre-existing psychiatric or substance abuse disorders • First responders, especially law enforcement, fire- fighters, emergency services with insufficient training and experience. • Poverty, lower socioeconomic status (SES). 3.2 Develop Disaster-Related Informational and Educational Brochures Providing information to individuals about disaster pre- paredness and the anticipated psychological consequences fol- lowing disaster may be an important preventative approach to mitigating such reactions. Informational brochures address- ing personal, family and work life disaster planning, common post-disaster stress reactions and community resources avail- able to meet the disaster related-needs of those impacted by disaster are important areas to highlight prior to disaster. These materials should be available in multiple languages specific to the population-based needs of your County. 3.3 Develop Operational Protocols to Manage Spontaneous Volunteers Disaster history and experience suggests that a significant number of individuals will spontaneously present as volunteers following large scale disasters. Establishing protocols to screen, train, and deploy these spontaneous volunteers is critical to the disaster mental health operation. Counties must also address risk and liability issues inherent in volunteer management. 4. Response 4.1 Activate Response Protocols for Disaster Mental Health Team(s) An effective response protocol is predicated on the clear and concise descriptions of the roles and responsibilities of those involved in the response. It is highly advised that the County’s disaster plan incorporate a process by which the County DCS is notified and advised of local disaster events. This communication allows for the timely assessment and provision of immediate mental health interventions that can potentially mitigate acute, intermediate and long-term stress reactions in the community. The mental health disaster plan should include response protocols for a limited-team versus a full-team deployment. Team members should be advised 35

as to the nature of the event, where they will report for their briefing and work assignment, and other issues that poten- tially impact their safety and security. To maintain resource and scene management mental health response teams should be deployed according to the circum- stances of the incident, availability of service sites, and num- ber of victims involved. Many times, the “sense of immediacy to respond” and the response chaos inherent in disaster results in mass deployment. Care should be taken to provide service across the disaster response and recovery timeline and only once the need is assessed, verified and logistical arrangements have been addressed. Staggering team member deployment will also prevent exhausting your resource pool prematurely. Prior to service site deployment, team members should be provided with appropriate identification and oriented to what is known about the event at that point in time. Specific infor- mation regarding victim demographics, safety and security issues, the service delivery plan, and other pertinent details of the incident or response should be provided. Team mem- bers should also be advised and provided with the names of their administrative (work site) and technical (clinical) super- visors and clear expectations and protocols regarding the use of such supervisors. Expectations regarding telephone con- tact and periodic updates with county disaster mental health administrative leaders should also be addressed. 4.2 Coordination with Other Community Disaster Mental Health Teams As mentioned earlier in the planning and preparedness sec- tion, efforts should be made to identify other disaster mental health teams or resources located in your county. Further effort should be made to coordinate response to avoid duplication of services, or more importantly, disruption or absence of such service. At times, disaster mental health teams from outside the community may self deploy or be requested to augment local county teams. In these situations, coordination and clar- ification of roles and responsibilities is also important to address and resolve. 4.3 Assess the Mental Health Needs of the Impacted Population Information concerning the psychological impact the dis- aster has had on a community and the potential long-term effects should be gathered as expeditiously as possible. In col- laboration with emergency response officials, selected team members may be deployed to gather information from com- munity representatives regarding the impact the disaster has had on “at-risk” populations previously identified. 4.4 Initiate Early Phase Supportive Interventions In the initial aftermath of a disaster individuals will be pri- marily focused on addressing their immediate disaster-related needs such as receiving first aid for injuries suffered in the dis- aster, locating lost or missing family members, obtaining food, water, and clothing and seeking shelter. While not all disaster victims will require extensive mental health intervention, some individuals, based upon the circumstances of the disaster as well as their own individual characteristics (see page 10), may require more focused mental health support. Early phase sup- portive interventions usually involve providing basic comfort care while assessing the individuals for stress reactions that might signal future psychological complications. Pre-disaster training for response team members should include orien- tation and skill development in approved disaster mental health interventions as those indicated below. Interventions that exceed the provision of basic supportive care may in fact be harmful. Early Phase Supportive Interventions • Psychological First Aid • Crisis Intervention • Bereavement Counseling 4.5 Identify High Risk Populations and Implement Appropriate Early Phase Interventions While the majority of individuals impacted by disaster are likely to experience some stress reactions, many of these re- actions are usually transitory and typically resolve within a short period of time. There are, however, some disaster sur- vivors who will go on to develop more significant psychiatric complications. Previous disaster research has suggested cer- tain disaster characteristics or those of certain individuals could place someone more at risk for developing severe stress reactions (see page 10). Efforts should be made to identify high risk populations and provide them with supportive in- terventions that could mitigate long-term psychological con- sequences. Reach out to individuals who may represent such risk groups and work collaboratively to address these issues. 4.6 Distribute Public Mental Health Educational Materials Research suggests that mental health resiliency following disaster may be enhanced through the provision of educa- tional materials that describe the common stress reactions and the methods and services available to respond to such re- actions. Efforts should be made to release this information as soon as possible after disaster strikes. These educational ma- terials may need to be translated into languages other than English depending upon the needs of your County and be re- leased repeatedly over a period of time following disaster. 4.7 Collaborate with County Government in Risk Communication In the event of a disaster, local county government must provide periodic information and updates regarding the county’s disaster response and recovery plan. The content 36

of such information should be reviewed by disaster mental health risk communications experts in an effort to mitigate any adverse psychological reactions by the community. The County DCS or other disaster mental health expert should be consulted when preparing these disaster bulletins or updates. Mental health consultants in these roles should be provided with the appropriate Risk Communications training prior to disaster. 4.8 Implement Supportive Interventions for Disaster Mental Health Teams Meeting the mental health needs of a community follow- ing disaster can be considerably stressful to those mental health professionals providing such aid. It is highly suggested that protocols and resources be developed and offered to meet the mental health needs of disaster mental health teams and others administering care to disaster survivors. Resources and ideas for providing mental health support to mental health professionals can be found in the Comprehensive Literature Review, Appendix A of this guide. 5. Recovery 5.1 Evaluate the Intermediate and Long-Term Mental Health Needs of the Community Disaster mental health research suggests that while most of a disaster-impacted community will experience a range of stress reactions, these reactions are usually mild and transitory. It has also been found that a minority of individuals may develop more moderate to severe psychological reactions that over time, if untreated, may develop into such psychiatric disorders as Acute Stress Disorder, Major Depression, Post- Traumatic Stress Disorder, or Generalized Anxiety Disorder. Pre-disaster substance abuse and dependence disorders were also found to be exacerbated by disaster. With this in mind it is highly recommended that counties use systematic screen- ing approaches to prioritize the delivery of more intensive mental health services. Outreach efforts must be implemented in the impacted community in a timely fashion so that a better understanding of the long-term mental health needs can be evaluated. 5.2 Identify Community Resources to Provide Mental Health and Substance Abuse Services As indicated earlier in the Planning and Preparedness sec- tion, a county mental health disaster plan should include a listing of local mental health and substance abuse treatment facilities and individual providers willing to treat disaster sur- vivors. Providers should possess the requisite education and training experience to evaluate and assess the range of inter- mediate and long-term psychological symptoms and psychi- atric and substance abuse disorders in survivors resulting from disaster. Depending on the size and scope of the disas- ter, financial assistance to provide intermediate and long- term mental health treatment may be available. County men- tal health officials should utilize their regional and state office of mental health representatives to explore such options. 5.3 Train Mental Health Professionals in Intermediate and Long-Term Mental Health Treatment Interventions In the event of a large scale disaster, the County Department of Mental Health must project the long-term mental health implications on the community. Training opportunities in intermediate and long-term mental health interventions will be required. Below is a list of mental health treatment modalities commonly used for those individuals suffering significant post-disaster psychological consequences. These modalities have varying levels of scientific evidence support- ing their efficacy. Intermediate/Long-Term Treatment Approaches • Cognitive-behavioral therapy • Phase-oriented treatment • Brief dynamic therapy • Psychopharmacology/pharmacotherapy Efforts should be made to train mental health professionals in these treatment approaches prior to or shortly after disaster strikes the community. 5.4 Implement Supportive Interventions for DMH Teams and Other Disaster Personnel As mentioned previously, providing mental health sup- port to disaster survivors, in and of itself can be stressful. Because mental health professionals are not immune to stress reactions in the context of their work, it is highly suggested that ongoing support services are offered to mental health response team members and other disaster relief workers, especially in the long-term recovery phase of disaster. Spe- cial care should be taken to administer only those support- ive interventions that are recognized as efficacious by the disaster mental health field. 6. Evaluation 6.1 Conduct Periodic Disaster Drills and Tabletop Exercises Reviewing and evaluating the county’s mental health disas- ter plan can ensure an effective response that meets or exceeds the mental health needs of a community. A successful plan will include an evaluation component where specific protocols and processes are reviewed, tested, and evaluated for their efficacy and result. State and County emergency management practices often include periodic drills and exercises. It is highly suggested that components of the disaster mental health plan be included in these drills and exercises. Such drills might include a periodic call down of mental health team members to evaluate availability and response times; tabletop exercises which evaluate the Department’s ability to coordinate and 37

deploy multiple internal and external agencies providing mental health resources; and special drills which might involve establishing a community family assistance center following a mass casualty incident or Point of Dispensing clinic typi- cally used in responding to public health emergencies. 6.2 Convene an “After Action” Committee Following the Implementation of the Mental Health Disaster Plan In the event that the Disaster Mental Health Plan is acti- vated, arrangements should be made as soon as possible to review the results of the activation. Special attention should be given to specific response and recovery activities associated with the plan. Opportunities to identify and revise specific planning, preparedness and mitigation efforts should also be addressed. 7. References and Resources 7.1 Planning Tools and Technical Resources CDC Public Health Emergency Response Guide for State, Local, and Tribal Public Health Directors, 2004 Department of Health and Human Services, Centers for Dis- ease Control and Prevention http://www.bt.cdc.gov/planning/pdf/cdcresponseguide.pdf Community Guidelines for Developing a Spontaneous Volunteer Plan Illinois Terrorism Task Force Committee on Volunteers and Donations http://www.state.il.us/iema/spontvol.PDF Disaster Technical Assistance Center U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services http://www.mentalhealth.samhsa.gov/dtac/ Early Intervention for Trauma in Adults: A Framework for First Aid and Secondary Prevention Litz, B.T. and Gray, M.J., In “Early Intervention for Trauma and Traumatic Loss.” Edited by Brett T. Litz. The Guilford Press, 2004. Pp 87–111 Mental Health All-Hazards Guidance Document, 2003 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services http://media.shs.net/ken/pdf/SMA03-3829/All-HazGuide.pdf Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence National Institute of Mental Health (2002) http://www.nimh.nih.gov/publicat/massviolence.pdf National Center for Post Traumatic Stress Disorder http://www.ncptsd.org National Institute of Mental Health http://www.nimh.gov National Memorial Institute for the Prevention of Terrorism http://www.mipt.org New York State Education Department, Office of the Professions, Online Verification http://www.op.nysed.gov/opsearches.htm New York Office of Alcoholism and Substance Abuse Services http://www.oasas.state.ny.us/www/home.cfm State Mental Health Authorities’ Response to Terrorism, 2004 National Association of State Mental Health Directors http://www.nasmhpd.org/general_files/publications/med_ directors_pubs/Med%20Dir%20Terrorism%20Rpt%20-% 20final.pdf 7.2 Risk Communication Communicating in a Crisis: Risk Communication Guidelines for Public Officials U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), 2002 http://www.riskcommunication.samhsa.gov/index.htm 7.3 Disaster-Related Agencies and Programs American Red Cross http://www.redcross.org Department of Homeland Security http://www.dhs.gov Federal Emergency Management Agency (FEMA) http://www.fema.gov National Voluntary Organizations Active in Disaster (VOAD) http://www.nvoad.org New York State Emergency Management Office (SEMO) http://www.nysemo.state.ny.us/ Project Liberty New York State Office of Mental Health (OMH) http://www.projectliberty.state.ny.us/ 7.4 Special Populations American Academy of Child & Adolescent Psychiatry http://www.aacap.org/publications/factsfam/disaster.htm U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. http://www.mentalhealth.samhsa.gov/publications/allpubs/ SMA03-3828/default.asp Disaster Mental Health: Crisis Counseling Programs for the Rural Community (1999) U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. 38

http://www.mentalhealth.org/publications/allpubs/sma99- 3378/default.asp Psychosocial Issues for Older Adults in Disasters (1999) U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. http://media.shs.net/ken/pdf/SMA99-3323/99-821.pdf Responding to the Needs of People with Serious and Persis- tent Mental Illness in Times of Major Disaster (1996) U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. http://www.mentalhealth.org/publications/allpubs/SMA96- 3077/default.asp Tips for Talking About Traumatic Events U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. http://www.mentalhealth.samhsa.gov/cmhs/TraumaticEvents/ tips.asp The National Child Traumatic Stress Network http://www.nctsnet.org/ 7.5 Intervention Resources Early Intervention for Trauma in Adults: A Framework for First Aid and Secondary Prevention Litz, B.T. and Gray, M.J., In “Early Intervention for Trauma and Traumatic Loss.” Edited by Brett T. Litz. The Guilford Press, 2004. Pp 87–111 Grief Counseling Resource Guide New York State Office of Mental Health http://www.omh.state.ny.us/omhweb/grief/ Mental Health Intervention for Disaster National Center for Post-Traumatic Stress Disorders (NCPTSD) http://www.ncptsd.org/facts/disasters/fs_treatment_disaster. html 7.6 Training Resources Disaster Mental Health: A Critical Response University of Rochester Center for Disaster Medicine and Emergency Preparedness http://www.centerfordisastermedicine.org Field Manual for Mental Health and Human Service Workers in Major Disasters U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (2000) http://www.mentalhealth.samhsa.gov/publications/allpubs/ ADM90-537/Default.asp Mental Health Response to Mass Violence and Terrorism: A Training Manual U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services http://www.samhsa.gov National Disaster Mental Health Training Program National Center for Post Traumatic Stress Disorder (NCPTSD) http://www.ncptsd.org/about/training/ndmh_training.html Triumph Over Tragedy: A Community Response to Manag- ing Trauma in Times of Disaster and Terrorism Edited by Evans, G.D., Wiens, B.A., The National Rural Behav- ioral Health Center, 2004. http://www.nrbhc.org/news_detail.asp?ID=11 39

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TRB’s Airport Cooperative Research Program (ACRP) Report 22: Helping Airport and Air Carrier Employees Cope with Traumatic Events provides insight and practical guidance to address the difficult emotional and psychological implications in response and exposure to traumatic events. These traumatic events can be the result of human-made accidents, acts of terrorism, or natural disasters that have occurred at, in the vicinity of, or resulting from the operation of an air carrier at an airport.

An ACRP Impacts on Practice related to ACRP Report 22 was produced in 2011.

Information on buying a recording of a webinar produced in 2010 on this report is available online.

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