# Presentation: 523748

## UNDERSTANDING AND INTEGRATING PSYCHOSOCIAL FACTORS TO ENHANSE COMMUNICATION DURING A CRISIS

*Emergency Public Information Subcommittee*
*May 5, 2008*
*Reston, VA*
**RADM Brian W. Flynn, Ed.D.****Assistant Surgeon General (USPHS, Ret.)****Adjunct Professor Of Psychiatry****Associate Director**** Center for the Study of Traumatic Stress ****Dept of Psychiatry**

## 
   In a disaster, 
   the size of the
   psychological
   “footprint” 
   greatly 
   exceeds the
   size of the
   medical
   “footprint.”

**   ****In a disaster,**
**   ****the size of the**
-    **psychological**
**   “****footprint”**
-    **greatly**
-    **exceeds the**
**   ****size of the**
**  ** **medical**
**   “****footprint.”**

**psychological **
**“****footprint”**

**medical **
**“****footprint”**

*Source:  Shultz JM, et al., Behavioral Health Awareness Training*
* **for Terrorism and Disasters, Miami FL, DEEP Center, 2003*

- Psychosocial Consequences in Disasters

## Psychosocial Consequences in Disasters

- Psychosocial Consequences in Disasters

**Fear and Distress **
**Response**

**Impact of Disaster Event**

**Behavior**
**Change**

**Psychiatric**
**Illness**

*Source:  Butler AS, Panzer AM, Goldfrank LR, Institute of Medicine Committee on*
* **Responding to the Psychological Consequences of Terrorism Board of on Neuroscience *
*and Behavioral Health.   Preparing for the psychological consequences of terrorism: *
*A public health approach.  Washington, D.C.: National Academies Press, 2003.*

## Defining the Scope of Behavioral Health Factors...

- Psychiatric disorders
- Substance abuse
- Fear driven behavior
- Fear driven decision making
- MUPS/MIPS
- Family/social function
- School behavior/ performance

- Workplace behavior/performance
- Risk taking
- Hypervigilance
- Distractibility
- Vulnerability/resiliency

## Quote:

**“****I understand and empathize with your concerns**
**about mental health in an overwhelming public health emergency. **
** **
**However, the issues I have to deal with, and the decisions I have to make, in the first twenty-four hours are life and death issues.  **
**The mental health concerns, while important,**
**do not rise to that level of importance.”**
*Source:  Public Health Official, CDC conference, January 2004*

## The behavioral choices people make to stay in place, evacuate, seek/not seek medical care, search forloved ones,etc. are veryreal life anddeathdecisions.

## Today’s Presentation:

- Communication beyond the written and spoken word
- The role of confirmatory bias in communication
- Engaging consumers
- Focusing on what people want to know in addition to what we want them to know
- Prevention
- Optimizing the relationship
- 	between behavioral health
- 	and risk  communication

## New Ideas?

- “Without a great deal of forethought, prolonged training,
- and the development of systematic performances, drills, and tests of all participants, no community can prepare itself to provide those additional health services that will be essential for civilians subject to disasters.  When the average community prepares itself for disasters, the effort of each citizen and every profession must be fitted into a coordinated system.  Whoever guides each part of the whole must have a clear concept of the working of all the other parts.”

*Source:*  William Wilson (Col. MC, USA)
- U.S. Armed Forces Medical J., Vol 1, No.4
**April  1950**

## “Better than any medication we know, information treats anxiety in a crisis.”					Source: Saathoff, 2002

## IMPORTANCE OF COMMUNICATION IN

- FEAR AND DISTRESS

- BEHAVIOR CHANGE

- POSITIVE/
- ADAPTIVE

- NEGATIVE/
- MALADAPTIVE

**IMPORTANCE OF COMMUNICATION IN**
**RESPONSE TO THREAT**

***COMMUNICATIONS!***

***COMMUNICATIONS!***

***COMMUNICATIONS!***

***COMMUNICATIONS!***

- ?

## Linking Behavioral/Public Health Roles And Expertise In Communicating Risk

- Behavioral
- Health
- Perspectives

- Enhance/
- Inform
- Risk
- Communication

- Consumer Oriented Approaches

- Consumer/
- Community Oriented Approaches

- Results:
- 1.  More effective individual/
-   community intervention
- More efficient/effective
-     organizational function
- Promote appreciation for
- respective skills/
- contributions

## Communication Takes Many Forms.Communication Through...

- Written and spoken word
- Behavior
- Symbols and rituals
- Images

## I.Communication Beyond The Written And Spoken Word

## Communication Through Behavior

**What does the behavior tell us about the risk of the event?**

**What does the behavior tell us about the leader?**

## For Example, What Behaviors Impact The Messages In Pan Flu?

- What behaviors reinforce the message?
- What behaviors undermine the message?
- Whose behavior impacts the message?
- Leadership
- Provider
- Consumer

## Communication Through Symbols & Rituals

## Understanding Symbols And Rituals

- Symbols and rituals help when the written and spoken word fails us
- They have both idiosyncratic and shared meaning

## Understanding Symbols And Rituals

- They promote a shared experience
- They can help unite occupational, cultural, religious, and generational groups
- They can help heal divisions

## Understanding Symbols & Rituals

- We can learn much from:
- The faith community
- The military

***More important linkages***
***For both BH & PH...***

## The Purpose Of Remembrance Events And Sites

- Provide comfort to survivors and families of the dead
- Recall and honor the suffering and recovery of those who   survived

## The Purpose Of Remembrance Events And Sites

- Provide a time and/or place specific to event to focus/honor/reflect

## Important Balances/Tensions

- Emphasize those who helped
- Local
- Distant

## Oklahoma City Bombing-- A Case Example

## Communication Through Images

- Images Are Like Projective Tests
*Behavioral Health Professionals Can Help Public Health Risk Communicators Appreciate The Projective Nature/Power Of Images*

## What Do The Communicators Communicate Through Their Behavior?

## “I never want to see this image published again!  You have no idea what this does to the family of this child every time they see it.  It re-traumatizes them!”

- “I never want to see this image published again!  You have no idea what this does to the family of this child every time they see it.  It re-traumatizes them!”
*-Oklahoma City Psychologist*

- “This picture has probably been more responsible for bringing donated funds into this community to help the survivors than any other single image.”
- -AP reporter

- Rumor Control: This firefighter did not commit suicide.
- Rumor Message: Responders are at huge psychological risk

## In Pan Flu...Who Are The Responder/Rescuers?

## What assumptions are made about the event by the image?

**What assumptions are made about the event by the image?**

**What assumptions are made about the people by the image?**

**How do our existing beliefs effect how we interpret the image?**

**Could there be a helpful risk communication message here about use of PPE and self-care?**

## What assumptions are made about the event by the image?

**What assumptions are made about the event by the image?**

**What assumptions are made about the person by the image?**

**How do our existing beliefs effect how we interpret the image?**

## What Will Be The Defining Images During Pan Flu Recovery?

**How Do Images/Messages Interact?**

## What Will Happen To Our Cherished Symbols When Avian Flu Strikes?

## II.The Role Of Confirmatory Bias In Communication

- An example of where behavioral health/science expertise can be helpful

## Definition:

**We tend to **_**perceive and accept**_** input that is **
**consistent with and reinforces our biases.**
**We tend to **_**ignore**_** input that is not consistent **
**with or challenges our biases.**
**We tend to **_**interpret**_** input in ways that**
**confirm our biases.**

## Understanding the Power Of Confirmatory Bias

**Bias**

**Experience**
**Observation**
**Message**

**Bias**
**Confirmed**

## Modifying Bias

**Bias**

**Experience**
**Observation**
**Message**

**Bias**
**Refuted**

**Bias Modified/**
**Reduced/Replaced**

## Biases confirmed?

**Potential biases:**
**Negative racial stereotypes?**
**Class stereotypes?**
**Gender stereotypes?**

**What is the message/observation?**
**Looting?**
**Surviving?**
**Evacuation?**
**Situation out of control?**

**Biases confirmed?**
**Refuted?**

## Biases confirmed?

**Racial stereotypes?**
**Beliefs about police?**
**Gender stereotypes?**

**What is the message/observation?**
**Image of police?**
**Situation in control?**

**Biases confirmed?**
**Refuted?**

## III.Engaging Consumers

## COMMUNITY INVOLVEMENT

- Remember *“Redefining Readiness”...*

## Why Including Consumers Is Important...

- Failure to include the public in planning.  Results in...
- Inaccurate assumption about human behavior
- Reduced compliance, trust, confidence
- Lacking understanding of factors influencing comfort with and confidence in planning (*Redefining Readiness*, NY Academy of Medicine)
- We can learn from MH consumers/advocates: ***“With us not for us.”***

## “...the American public has had little or no role in helping government and private organizations develop terrorism plans...”(Redefining Readiness, NY Academy of Medicine, p.59)

## Working Group on Civic Engagement in Health Emergency Planning – Overview

**Problem – ****Does “volunteerism” plus “stockpiled basements” equal “public preparedness”? **
**Process – ****What scholarly research and practical experience suggest**
**Principal Findings**
- Extreme events compel citizen action & judgment; can’t boil down the public’s role in disasters to a simple checklist
- Civic infrastructure yields remedies at all stages of disasters, and it ought to be involved in planning & execution
- Effective leaders engage community partners in advance of an event, not just hone their mass media skills

*Source: Monica Shoch-Spana, Ph.D.,*
*Center for Biosecurity, UPMC. *
*Presented at IOM December 19-20, 2007*

## Think About Organizations As Message Recipients Also...

- Look at our messages through the lens of their connotative meaning/group behavior, etc.

*Example—*
- CDC Pandemic Flu Website
**Business Pandemic Influenza Planning Checklist**
*“**1.5 Communicate to and educate your employees”*
- 		--http://www.pandemicflu.gov/plan/workplaceplanning/businesschecklist.html

- This quote implies a certain type of organizational culture.  Perhaps one not best ready to survive a pandemic.  Perhaps  organizations where leadership communicates “with” employees and overtly recognizes that employees can also educate leaders stand a better chance of weathering a pandemic.  Do we in behavioral health have something to contribute to this discussion?

## IV.Focusing On What People Want To Know In Addition To What We Want Them To Know

## Those We Love...

**Those We Love...**

**Parent **
**at**
** ****Work**

**Child **
**at **
**School**

**Elderly Parent-**
**Home/**
**Assisted Living**

**Social Supports**

## AM I OK?

**The Basic Questions...**

**AM I OK?**
**WHAT ABOUT THOSE I LOVE?**
**WHAT SHOULD I DO?**

## Concerns

_**Concerns**_
- Am I OK?
- What about
-   those I love?
- What should
-  I do?

_**Personal **_
_**Characteristics**_
- Perceived risk
-   vulnerability
- Resilience
- Impairment
- Experience
- Med/Psych risk
-   factors

_**Messages**_
- Credibility of
-   message
- Credibility of
-   messenger
- Cultural
-   appropriateness
-   of message
- Delivery
-   mechanisms
- Behavioral
-   connectedness

_**Outcomes**_
- +/- Distress
- Pos/neg behavioral
-   adaptation

**CONCERNS**

**Personal **
**Characteristics**

**Messages**

**OUTCOMES**

**IMPORTANT FACTORS/PROCESSES DURING THE ****IMMEDIATE ONSET ****PERIOD**

## Concerns

_**Concerns**_
- Health risk
- Availability of
-   health services
- Guilt
- Anger
- Soc. justice
- Fear of future
- Grief
- Bereavement
- Soc./community
-   change
- Economic loss
- Crisis of faith
- What should I do?

_**Personal **_
_**Characteristics**_
- Hlth. status
- Resilience
- Impairment
- Experience
- Soc. support
- Med/Psy risk
-   factors
- Remaining
-   resources
- Spiritual/faith
-   context

_**Messages**_
- Credibility of
-   message
- Credibility of
-   messenger
- Cultural
-   appropriateness
-   of message
- Delivery
-   mechanisms
- Behavioral
-   connectedness

_**Outcomes**_
- +/- Pos/neg     behavioral
- adaptation
- +/- Trust
- +/- Social change

**CONCERNS**

**Personal **
**Characteristics**

**Messages**

**OUTCOMES**

**IMPORTANT FACTORS/PROCESSES DURING THE ****PRIMARY IMPACT ****PERIOD**

## Concerns

_**Concerns**_
- Hlth. status
- Guilt
- Survivor guilt
- Anger
- Soc. justice
- Fear of future
- Grief
- Bereavement
- Soc./community
-   Change
- Economic loss
- Crisis of faith
- What Should I do?

_**Personal **_
_**Characteristics**_
- Hlth. status
- Resilience
- Impairment
- Experience
- Soc. support
- Med/Psy risk
-   factors
- Remaining
-   resources
- Spiritual/faith
-   context

_**Messages**_
- Credibility of
-   message
- Credibility of
-   messenger
- Cultural
-   appropriateness
-   of message
- Delivery
-   mechanisms
- Behavioral
-   connectedness

_**Outcomes**_
- +/- Understanding
- +/- Trust
- Social change
- +/- Anger/revenge
- +/- Litigation
- Pos/neg behavioral
-   adaptation

**CONCERNS**

**Personal **
**Characteristics**

**Messages**

**OUTCOMES**

**IMPORTANT FACTORS/PROCESSES DURING THE ****RECOVERY**** PERIOD**

## Guide For Interventions

- A major new article is about to come out:
***Five Essential Elements of Immediate and Mid-Term ***
***Mass Trauma Intervention: Empirical Evidence***
*(Psychiatry, in press)*
- Authors: Steven Hobfoll plus 19 others
- Very diverse/credible authors

_***The Five Elements:***_
- Provide a sense of safety
- Calming
- Sense of self- and community efficacy
- Connectedness
- Hope

## Suggested Matrix For Considering Messaging Strategies

**Suggested Matrix For Considering **_**Messaging**_** Strategies**

|  | Preparedness | During Event/
Early Aftermath | Recovery Period |
| --- | --- | --- | --- |
| Provide sense of safety |  |  |  |
| Calming |  |  |  |
| Self & Community efficacy |  |  |  |
| Connectedness |  |  |  |
| Hope |  |  |  |

## V.Prevention

## Preventing The Disaster...

**Death & Physical Trauma**

**Psychological Trauma**
**(4-500:1 Larger **
**Than Medical)**

**Social/Community Disruption**

**Public Health Effects**

**Adverse Economic Impact**

**DISASTER**

## Levee Design/Community Planning...

**Levee Design/Community Planning...**

## Mine Safety...

**Mine Safety...**

## Liquid Natural Gas (LNG) Tankers 

**Liquid Natural Gas (LNG) Tankers **
**Close To People...**

## East Africa Embassy Bombings:

**East Africa Embassy Bombings:**
**Same Time/Same Bomb**

**	****Nairobi:**
-   Many deaths
-   Many injuries
-   Many          psychological
- 		casualties

## The Difference?  Architecture!

**East Africa Embassy Bombings:**
**Same Time/Same Bomb**

**Dar Es Salaam:**
- Few deaths
- Few injuries
- Minimal psychological casualties

**The Difference?  Architecture!**

## Preventing/Reducing Exposure

**We Must Learn More About How**
** ****To Get People Out Of Harm’s**** ****Way**

## Do We Know Enough About Why People Do Not Evacuate?

- Don’t receive warnings?
- Physically unable?
- Logistics?

## Do We Know Enough About Why People Do Not Evacuate?

- Historical distrust of authorities?
- Commitment (possessions, animals, family)?
- Denial?

**Different Reasons Call **
**For Different Strategies!**

## VI.Optimizing The Relationship Between Behavioral Health AndRisk  Communication

## Who Are We Talking About?

- Behavioral health agency risk communicators, disaster specialists, special populations specialists
- Risk communicators in:
- 1. Other government administration agencies
- 2. Government operations organizations
- 3. Private/private not for profit organizations
- 4. Others

## Understanding Each Other...Do Your Homework

- Professional culture
- Organizational culture
- Organizational scope and boundaries
- View as a cross cultural opportunity/ challenge

## Initiating The Relationship

- After doing homework, take the initiative.  Before event is best, during is good, after is just OK
- Choose timing (events, successes, failures, etc.)
- Be clear on both your contribution and limits
- Build on personal relationships
- Use trusted/respected broker
- Send the best first
- Come with something specific to offer

## Anticipate Challenges/Barriers

- Funding
- Work load
- History—organizational
- Political influences
- Stigma about behavioral health
- Inaccurate understanding of behavioral health

## Prepare To Highlight Benefits

- Help RCs do their jobs faster, better
- Prevent/reduce problems/errors
- Promote consistent messaging
- Enhance message/communication effectiveness
- Pre-event education/orientation to BH factors and value added

## Think About What Risk Communication Can Add to Behavioral Health

- Many of the same as on prior slide
- New/better mechanisms to deliver BH interventions
- Opportunity to reduce stigma
- Opportunity to develop organizational allies
- Apply skills in a different context
- Promote community mental health
- Learn skills (e.g., communication, clarity of message, presentation skills, etc.)

## Building Trust/Confidence

- Be competent
- Don’t over-promise
- Follow customer service principles
- Be flexible
- Respect boundaries
- Build relationships based on utility, not funding
- Trust builds personally before organizationally

## General Behavioral Health Contributions...

- Content
- Context
- Human resources
- Stress identification and intervention

## Options For Specific BH Roles...

- Joint planning/preparedness
- Pre-event training/education
- Review/preparation of talking points
- Review/preparation of releases
- Ready experts
- Coaching of risk communicators
- Identification and help with stress related issues for RC personnel
- Recipient of RC consultation

## Special Communications Issues:

- How people absorb information?
- Developmental stage
- Trauma history
- Cognitive abilities
- Stress level
- Cultural context
- Through what pathways do people receive information?
- How do people gauge the credibility of the source and legitimacy of the content?
- What do they _***do***_ on the basis of the information?

## Why Is Integrating Behavioral Health And Risk Communication So Critical?

**Why Is Integrating Behavioral Health And Risk Communication So Critical?**

## Combining Behavioral Health and Risk Communication...

- Enhances understanding of how people receive and process information and how this translates into behavior
- Promotes trust and credibility
- Optimizes desired behavior and reduces undesired behavior
- Helps assure that resources are preserved and appropriately used
- Reduces the size of the footprint of adverse psychological consequenses

## The Bottom Line Message:

**Understanding and Integrating Risk Communication And Behavioral Health Are Central To Sound Preparedness And Response**

## 		   Contact Information:

**BRIAN W. FLYNN, ED.D.**
**P.O. Box 1205**
**Severna Park, MD 21146**
**Phone: 410-987-4682**
**Email: Brianwflynn@aol.com**