Preparing Scotland: responding to the psychosocial and mental health needs of people affected by emergencies

4 Caring for People Over Time

4.1 Preparing in advance

Health Boards have an advisory role in the development of the psychosocial resilience and wellbeing of adults and children, families, communities, schools, workplaces and other groups through public mental health programmes.

Care for People teams should identify senior mental health and social care professionals from the Health Board and local authority to give real-time advice to responders during both the emergency response and recovery phase. Advice should be available to all levels of responders and coordinated with other specialist support, e.g. Scientific and Technical Advice Cell.

Care for People teams should develop arrangements to utilise local expertise to understand specific local issues and identify the most appropriate community resources ( e.g. schools, faith groups, youth clubs, leisure facilities) to draw on in an emergency.

Care for People teams should include people who have been affected by past emergencies when developing and exercising plans, and should be aware of the support available from organisations such as Disaster Action ^[3] .

Health, social care, education and third sector services should identify in advance those people within their organisations with appropriate skills who could contribute to the psychosocial care response. Appropriate screening should be conducted for suitability.

An essential component of a comprehensive psychosocial response is providing information for people and communities that are affected. This should be consistent with the broader Care for People response and communications strategy and should:

• signpost access to additional services
• acknowledge and respect the possible range of reactions across the age range
• protect and promote social and community relationships
• involve the public and the media
• be comprehensive in its reach
• consider specific psychosocial needs of different groups of people

Further guidance on communications is available in Preparing Scotland: Warning and Informing Scotland ^[4] .

All agencies should ensure that their staff receive appropriate training in the psychosocial aspects of emergencies. This should include emergency service staff, those working in local authorities (particularly welfare and social care) and health services (particularly general practitioners). Where third sector organisations are involved in a response or care provision, consideration should be given to the benefits of joint training with statutory providers. Training should be developed in conjunction with specialists in psychosocial and mental health care and should include:

• the psychosocial and mental health effects of emergencies on people of all ages
• the principles of psychosocial care and Psychological First Aid
• awareness of possible longer-term consequences
• awareness of referral pathways for people who need more specialised care
• self-care for staff

The multi-agency training programme should include explicit arrangements for the testing and exercising of the psychosocial and mental health components of the emergency plans.

Responder agencies should agree on the types of personal information that will be collected from people who are affected by emergencies and should ensure that paper and electronic systems are compatible with respect to information sharing.

Agencies in all areas of service provision should be aware that there is clear legal power to share information in the context of emergencies and they should develop information sharing protocols (particularly about identifiable people) as part of their data-sharing partnership arrangements. Specialist advice should be sought on data protection and duties of care as they apply to different organisations ^[5] .

The following factors are associated with an increased likelihood of dysfunctional distress and risk of developing post-traumatic stress disorder:

• perception of high threat to life
• physical injury
• circumstances of low controllability and predictability
• the possibility that the emergency might recur
• an experience of disproportionate distress at the time
• experience of multiple losses (of relatives, friends or property)
• exposure to dead bodies or grotesque scenes
• a high degree of destruction of community infrastructure and social networks
• perceptions of limited social support and/or actual lack of this
• pre-existing or previous mental disorder

Agencies that deliver care should have processes in place to support staff and to recognise early signs of their distress, possible secondary traumatisation and experiences of burnout. This should be available to volunteers and interpreters involved in the response. Recommended interventions include peer support programmes.

Communications resources relating to psychosocial impacts should be integrated with the broader Care for People and Public Communications strategies coordinated by the Care for People and Public Communications Groups ^[6] . These should also dovetail with pre-existing material available from government sites and statutory sources.

Agencies should ensure there is appropriate specialist input when preparing websites concerning humanitarian, welfare, psychosocial and mental health matters, including draft or "dark site" material prepared in advance.

The content of leaflets should take account of the needs of different groups of people who might be affected by an emergency such as survivors, people who are bereaved and children. While every emergency is unique, it is likely that materials and text produced in response to other incidents can be adapted to fit the current situation.

4.2 During the first week

Mental health and social care professionals should provide specialised advice to the people responsible for managing each level of the response. The advice should emphasise that initial responses should be based on the principles of psychosocial care as exemplified by Psychological First Aid.

Responding agencies should gather information about people affected by the emergency including their contact details and personal circumstances so that follow-up support can be offered as required. Recording systems should include the facility to collect information on those people considered to be at risk, such as people who have been injured, bereaved or made homeless as a result of the emergency.

Formal screening of everyone affected should not be conducted because there are no measures of sufficient sensitivity and specificity to make this intervention beneficial. Rather, the psychosocial response should be aimed at people who have been assessed as being at risk or members of vulnerable populations.

Psychological First Aid should be initiated by first responders and carried forward by all relevant staff subsequently engaged in the response. Specific formal interventions, such as single session debriefing, should not be provided.

During the first week social care and mental health professionals should provide supervision and support for Psychological First Aid providers. They should also plan their responses to people's emerging mental health needs, including the care and treatment of people who develop disorders.

Responders should be aware of the broad spectrum of ways in which people may react psychosocially to an emergency. They should be able to deliver Psychological First Aid and should know how to make referrals for the very small minority of individuals who may need specialised mental health intervention at this stage.

People whose pre-existing mental health problems are exacerbated in the days after an emergency should be referred for specialised mental health intervention.

People should be neither encouraged nor discouraged from giving detailed accounts of their experiences but should be given the opportunity to talk if and when they wish to do so.

Support should be delivered in an empathic and open manner. It should be practical and pragmatic and should provide people with information about possible reactions, how they can help themselves, and where and when to access further help if necessary. Written leaflets should be pitched at a reading age of approximately nine years of age and should be translated for people whose first language is not English.

Responders should be trained to recognise and respond to the needs of children affected by emergencies, whether or not they work with children normally. Reuniting children with a parent or other familiar/trusted adult should be a priority. Responders should begin from the assumption that parents (and carers) are the best placed to support their children and should empower them to do so. Professionals should not work directly with children without the consent of a parent or guardian. They should do so only if there is no familiar and trusted adult who is able to provide the necessary care, for example if the parents' own reactions to the emergency overwhelm their ability to provide effective parenting.

People affected by the emergency may wish to meet with others who have been similarly affected. Practical advice and sensitive support should be offered to facilitate the formation of groups and networks that are able to increase opportunities for self-help and to develop and sustain psychosocial resilience and independence ^[7] .

While promoting mutual support among the people who are affected, responders should have processes for screening people who may pose as professional helpers to protect those affected from incompetent or exploitative behaviour. This should not prevent informal support from relatives and friends.

All telephone information lines should include provision to direct people to appropriate psychosocial support. They should be staffed by trained personnel who can provide information and support consistent with the approach of Psychological First Aid and integrated with the broader Care for People and Public Communications strategies.

Pre-prepared websites should be adjusted to the specific circumstances of the emergency and made available online..

The Care for People team should work closely with the Public Communications Group to provide psychosocial advice.

Funerals, memorial services, acts of remembrance and cultural rituals should be planned in conjunction with the people who have been affected.

The managers of rescuers, responders and other staff working with people who are affected by the emergency should be aware of the risk to staff of secondary traumatisation or burnout. Special attention should be paid to staff who are directly affected by the emergency including, for example, staff living and/or working in the affected communities. Support, based on the principles of Psychological First Aid and peer support should be provided for staff who are affected.

4.3 During the first month

Psychosocial and mental health plans and responses should be reviewed and regularly updated based on the specific circumstances of the particular emergency and the emerging needs of the people and staff who are affected. This includes interventions begun earlier in the emergency response that may need to continue or change and psychosocial components of the communications strategy.

Mental health and social care (and, where appropriate, education) professionals should continue to provide advice during the recovery phase and should be involved in reviewing and developing the broader Care for People strategy.

Local Health Board(s) should work with partner agencies and lead on delivering primary mental health care and augmented primary mental health services for people who develop mental disorders as a consequence of emergencies. This may include involving mental health clinicians in a "one-stop shop" model of service provision.

People who have psychosocial problems that do not resolve after adequate humanitarian aid, welfare services and social support from their families and communities should be identified. These adults and children should be formally assessed in terms of their need for health and/or social care services. Assessment should consider people's emotional, social, physical and psychological needs and should take place before any specific intervention is offered.

Appropriately skilled staff from the mental health care services should work with and offer supervision and advice to staff in primary care to develop their knowledge, skills and resilience.

People who develop acute mental health problems in the first weeks after an emergency ( e.g. psychotic symptoms or suicidal thoughts) or whose pre-existing mental health problems are exacerbated should be referred for specialist mental health intervention.

The percentage of people affected by an emergency who are likely to develop high levels of distress during the first month after an emergency is low, but they should be identified so that services can maintain contact with them.

Mental health assessments should be undertaken by staff who are skilled and experienced in working with specific populations ( e.g. children and adolescents, elderly people). If treatment is considered appropriate, it should aim to promote a sense of safety, calm, self- and community-efficacy, connectedness and hope, as core features before more specialised interventions begin.

In order to identify those at risk of secondary traumatisation or burnout, there should be continued monitoring of staff in responder organisations and other staff working with those affected by the emergency. Special attention should be given to non-professional responders and to those staff living and/or working in the affected communities. Mental health care services should be provided to those who are assessed as requiring them.

4.4 During the first three months

Psychosocial and mental health interventions should continue to be reviewed and updated according to specialist advice and current circumstances.

Where support groups and networks have been established, there should be liaison and consultation with these regarding the delivery of services and planning for future support.

If emergency-specific services have been established to meet the psychosocial and mental health needs of the affected populations, care should be taken to ensure the services remain available to all those affected and are integrated with other community, social and mental health services.

Evidence-based interventions should be made available for adults and children who have developed post-traumatic disorders. Guidance on this is available from the National Institute for Health and Clinical Excellence ^[8] and NHS Education for Scotland's Guide to delivering evidence-based psychological therapies in Scotland (The Matrix) ^[9] .

Professional practitioners should offer formal assessments to people who have psychosocial problems that continue or develop a month or more after an emergency. Assessment should consider people's emotional, social, physical and psychological needs and should take place before any specific intervention is offered.

Support and information should be made available to the families and friends of people who develop mental disorders with a view to maintaining and enhancing available psychosocial support, while bearing in mind confidentiality and the wishes of the people who have been affected. These are especially important where children and young people are involved.

General information about possible reactions to traumatic events should be made available to schools in the affected communities and to employers (and in particular to occupational health providers) whose staff may have been affected by the emergency.

Where emergencies have involved extensive damage to homes, property or businesses, there may be delays in the resolution of insurance claims or other pressures. In these circumstances people should be offered support by appropriate agencies in keeping with the principles of Psychological First Aid.

4.5 Beyond three months

Psychosocial and mental health interventions should continue to be reviewed and updated according to specialist advice and current circumstances.

Mental health and social care specialists should continue to provide advice to responder organisations until recovery phase responses have been completed.

Professional practitioners should offer formal assessments to people who have psychosocial problems that continue or develop three months or more after an emergency. Assessment should take place before any specific intervention is offered.

Evidence-based interventions should be made available to people who have developed mental disorders as a result of the emergency. Identified staff in specialist mental health care services should be made available to work with and offer supervision and advice to staff in primary and secondary care.

Work, rehabilitation and play opportunities should be provided to enable people who require them to re-adapt to the routines of everyday life.

It is not uncommon for legal proceedings relating to emergencies to take place several years after the event. These proceedings and their findings, together with any associated media interest, may be a source of further distress for those affected by the emergency and for the wider community. The Care for People team (or its successor) should work with relevant Public Communications Group members to ensure psychosocial advice is provided at such times.

People involved in legal proceedings relating to the emergency should be offered support by appropriate agencies ( e.g. Victim Support, Inquest, Criminal Injuries Compensation Authority) ^[10] .

If emergency-specific services have been established to meet people's psychosocial and mental health needs, then they should remain available to everyone who is affected for as long as a need persists.

There should be careful planning before closing any emergency-specific services to avoid giving the message that there is a time limit on the provision of support. The possibility of a phased closure or progressively integrating with other community, social and mental health services should be considered. The nature and circumstances of the particular emergency should determine whether these are appropriate measures.

Local authorities and Health Boards should consider how resources will be made available in the longer-term recovery period to facilitate additional follow-up support, which may extend for several years.

Memorial services, acts of remembrance and cultural rituals marking the anniversaries of the emergency should be planned in conjunction with the people who have been affected. They may want to do this independently or as a group. Some people may require additional support at this time.

An evaluation of the psychosocial and mental health response should be conducted based on consultation with those involved, and any lessons identified should be followed up.

When people have been affected by emergencies there is a likelihood that professionals ( e.g. from academia, medical departments etc) may wish to conduct research. Any such requests should be fully and properly considered, and it is recommended that Regional Resilience Partnerships identify a 'Lead for Research' through which any requests may be directed, and whom may coordinate information gathering, research and evaluation programmes. In this context the Lead for Research may best sit with the individual that has, or would be the identified chair of STAC. The Lead for Research should work in consultation with the Caldicott Guardians ^[11] and other staff who are responsible for information stewardship in the involved agencies.

The guidance has been developed from a wide range of Scottish, UK and international sources of expertise. These sources include work led by the Department of Health for the North Atlantic Treaty Organisation ( NATO) Joint Medical Committee and work conducted by the European Network for Traumatic Stress ( TENTS) programme. In 2009 the authors of the NATO guidance and the TENTS guidelines combined the common principles and recommendations of both sets of guidance in a single document, Guidance for Responding to the Psychosocial and Mental Health Needs of People Affected by Disasters or Major Incidents. This document has formed the basis of the Scottish Government guidance.