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Virtual Reality Helps CDC Staff Deployed for Outbreak Response Prepare for Stress

Published: May 14, 2009

David Benedek, M.D., from the Center for the Study of Traumatic Stress
Richard Klomp, an Office of Health and Safety behavioral scientist, adjusts Lorine Spencer's, Ph.D., virtual reality equipment which immersed her in a remote village setting as part of a pilot deployment training at CDC.

Recently, about 20 CDC professionals visited a remote African village to aid in an outbreak investigation. While family members of dying patients wailed in the background and body bags were stacked outside the field medical center, the CDC staff set about to orient themselves to the sites, sounds and smells of this new place. They did so without leaving the CDC Atlanta Roybal Campus.

Putting themselves at some risk, CDC professionals for decades have been willing to go anywhere to help control disease outbreaks, collect health knowledge, and improve response strategies. While the ranks of those from CDC who actually went to potentially risky sites was once an elite few, today, more and more CDC staff are being asked and volunteering to be deployed during public emergencies in the Untied States and globally.

Psychological First Aid

Psychological first aid (PFA) includes five core principles: safety, calming, connectedness, self-efficacy, and hope and optimism.

The actions taken when administering PFA include the following:
  • Contact and engagement with members of the team
  • Physical and psychological safety assessments
  • Calming and stabilizing distressed persons
  • Gathering information about issues or concern
  • Offering practical assistance
  • Making connections
  • Helping others cope
  • Linking troubled people with collaborative services

In addition, the numbers and types of professions represented on a CDC response team have changed. In the past, CDC’s Office of Health and Safety focused its concerns on protecting deployed staff’s physical safety. Today, in addition to their physical safety, OHS recognizes the mental stressors of deployment and has developed a program to watch out for the mental well being of staff during and after deployment.

Rick Klomp, a behavioral scientist with the OHS Workforce and Responder Resiliency Team, piloted a 4-day training to develop Deployment Safety and Resiliency Team (DSRT) members. The training included a resiliency component (e.g., Psychological First Aid, Stress Management and Coping, Peer Support, Assessment and Proper Referral Protocols) and a safety component (e.g., customized versions of Disaster Site Worker training and Collateral Duty for Federal Workers). In addition, pairs of participants went through a one-hour virtual-reality training session.

To develop this 4-day curriculum, Klomp worked closely with colleagues at the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences (USUHS); professionals at Virtually Better, Incorporated; and, OHS safety officers.

The Start: A Tsunami of Stress

After CDC’s deployments in response to the tsunami in 2004 Klomp and Dori Reissman, M.D., a psychiatrist and senior medical advisor with NIOSH, began to look at the wide variety of stressors CDC emergency responders encountered.

“We realized more could and should be done to help those brave, dedicated and highly-skilled folks,” explained Klomp.

They began providing pre-deployment briefing information and training about physiological, cognitive, emotional and behavioral signs of stress. “We really emphasized the importance of self care to folks who were getting ready to go out the door,” remembers Klomp. “We provided those same services during the Marburg Hemorrhagic Fever outbreak and Hurricane Katrina.”

eff Sypolt, a safety and occupational health specialist
David Benedek, M.D., from the Center for the Study of Traumatic Stress, lectures on peer support during the CDC Deployment Safety and Resiliency Team member training.

"It occurred to us that we were chipping away at potential problems on the front end and back end of deployments, but we weren't really providing any mental health or safety assistance to individuals while they were deployed,” said Klomp.

This has changed with a new training program. The main element of the 4-day pilot training project is the "Deployment Safety and Resiliency Team" (DSRT) member concept. “In this approach, we carefully select and train non-mental health professionals to deploy with CDC teams. These individuals have a specific mandate to assess and address the physical and emotional health, safety and resiliency of their team members in the field,” Klomp said. “Essentially they should function like a medic in a military unit, only they don't just focus on physical health.”

During the pilot training, David Benedek, M.D., Lieutenant Colonel, from USUHS’s Center for the Study of Traumatic Stress, taught basic concepts of psychological first aid and how to build resiliency among colleagues through peer support. “The concept for DSRT is not to provide mental therapy, but knowledgeable peer support. You don’t have to be a therapist to be a DSRT. The point is to be more vigilant in the deployment setting,” he said.

Maestro Evans, a health education specialist with NCHHSTP who piloted the DSRT training, said, “My impression of the role of the DSRT is to assist the deployed team leader in maintaining the safety, health and well-being of those deployed. The most significant thing from the training that I will use is constant triage of the mental well-being on the deployment team and to provide an outlet for continuous support.”

In addition to these highly-specialized training tracks, each of which lasted two days, Klomp wanted to do something to give DSRT participants a sense of how confusing, stressing, challenging and rewarding it can be when they are deployed.

“I had been to a conference about four years ago at which an extremely interesting presentation had been made on the use of virtual reality (VR) training to clinically treat soldiers who had returned from Iraq and were plagued by symptoms of Post-Traumatic Stress Disorder.” Klomp noted, “As a mental health clinician, I was intrigued by this treatment modality, but I wondered to myself, why can't we use this kind of technology prophylactically--to prevent the onset of these debilitating symptoms, not just to treat them?”

Jasen Kunz and Ellen Wan dn
Jasen Kunz, a safety instructor for the deployment training, helps emerging leader Ellen Wan don personal protective equipment.

Identifying Stress Responses

To the extent one will have a positive outcome following a traumatic exposure will depend in part on the person’s resilience, ability to bounce back, and the type of experience and the ability to mediate the event. Stressors may lead to adaptive or maladaptive responses.

Adaptive Stress Responses
  • Behavioral: altruism, exercising, spending time with family and friends, dealing with problems
  • Emotional: feeling in control of events, feeling hopeful, feeling calm, feeling empowered by personal resolve
  • Physical: increased performance, regaining normal equilibrium once stress stops
  • Cognitive: confident, heightened awareness, increased concentration
Maladaptive Stress Responses
  • Behavioral cues: extreme disorientation, high risk behavior, excessive drug, alcohol, or prescription drug use, separation anxiety, isolation or withdrawal, acute anxiety, maladaptive coping
  • Emotional: acute stress reactions, anxious/fearful, acute grief reactions, despair, hopeless, sadness, feelings of guilt or shame, irritability or anger, emotional numbness or disconnectedness
  • Physical: headaches, worsening health condition, stomachaches, fatigue, exhaustion, sleep difficulties, chronic agitation, difficulty eating
  • Cognitive: difficulty concentration, difficulty remembering, distressing dreams or nightmares, difficulty making decisions, preoccupation with death or destruction, intrusive thoughts or images

The Training: Psychological First Aid

In the VR training environment, participants received an in-briefing from their designated team leader who tasked them with specific assignments. These assignments reinforced principles they already had been taught in the resiliency and safety portions of the DSRT training. They encountered local people who spoke a language they could not understand and they were exposed to fairly austere living conditions. Stress was added to the mix by assigning them multiple tasks they had to remember while distracted by unusual sights and sounds.

Wearing headphones and virtual reality goggles, participants were fully immersed in the environment. To add another level of reality for the senses, jars that contained smells one might find in a remote village such as diesel, barnyard and urine were opened and wafted near the trainees as they worked to complete their tasks.

“We built in three different levels of difficulty so inexperienced, partly-experienced, and seasoned ‘deployees’ could participate at a level appropriate to their skills and expertise” Klomp explained.

“I really enjoyed the virtual experience,” remarked Lorine Spencer, Ph.D., R.N., Office of Strategy and Innovation and DSRT trainee. “I think including this in the training as well as offering it to those individuals being deployed would be beneficial in helping them be more prepared and potentially increase their resiliency while deployed.”

DSRT Put in Play for H1N1

Currently CDC has more than 100 professionals deployed internationally and throughout the states in response to the H1N1 flu outbreak. "So far, a couple of individuals who have completed the four-day DSRT training have reported that they have been able to apply portions of what they learned in class and in the VR environment to better respond to actual situations they have encountered as they have been deployed to work in the Emergency Operations Center as part of CDC's response to the H1N1 influenza outbreak of 2009," Klomp said.

“I have tried to incorporate the training while being deployed to the EOC [CDC’s Emergency Operation Center] for H1N1 by stressing the importance of people taking time off and using PFA techniques to reduce stress,” said Michele Hoover, a public health advisor. “As a whole the messages from the training are being incorporated into the broader messages from EOC leads - this is a marathon not a sprint, recognizing the efforts and hard work of the staff. I found that giving someone a smile can really help improve a work environment.”

Karon Abe, a health scientist with CCHP, learned “to recognize the signs of distress in team members and to be the person to help find a way to make it better. The role of the DSRT is an evolving one and will depend a lot on the experience of the person. The whole training was very useful and an important component to add to any deployment team.”

Where to Seek Help

National Suicide Prevention Lifeline: 1 800 273-8255
Substance Abuse and Mental Health Services Administration mental health services locator

USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO

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