University at Albany Center for Public Health Preparedness

Risk Communication & Psycho-Social Issues in Radiation Events

Original Satellite Broadcast: 11/08/07

Moderator: Good Morning. I’m Christine Smith. We would like to ask you to please fill out your evaluations online. Continuing education credits are available after completing the post test and your feedback is always helpful for the development of our programs. We’ll be taking your calls later in the hour. The toll-free number is 1-800-452-0662. You may also send your questions by fax or e-mail at any time during the program. The fax number is 518-426-0696, the e-mail address is on your screen. Today’s program is RAD events, Risk Communication & Psycho-Social Issues in Radiation Events. Our guest speakers are Dr. Tim Tinker, Senior Associate, Booz Allen Hamilton and Dr. Brian Flynn, Associate Director, Center for the Study or Traumatic Stress, and Adjunct Professor of Psychiatry, Department of Psychiatry at the Uniformed Services University of Health Sciences in Bethesda, Maryland. Dr. Flynn is a former rear admiral and assistant surgeon general. Thank you both for joining us today.

Dr. Tinker and Dr Flynn: Thank you.

Moderator: We appreciate you being here with us. Let’s begin with a brief summary of what we are talking about today.

Dr. Tinker: We’ll since 2004/2005 the Department of Homeland Security has been working on the National Planning Scenarios. There are 15 all-hazard scenarios, two of those scenarios have to do with radiation emergencies. Those scenarios are ranked based on a series of factors. Those factors are shown in our slide here. What we’re going to be talking about today is essentially a combination; what is the relationship between risk and crisis communications with the mental health response. I’m going to be focusing my comments primarily around the risk and crisis communications.

Moderator: And Brian?

Dr. Flynn: I’m going to be talking a little bit about why behavioral health and psychosocial issues are important and how they fit in with risk communications, and at the end share some resources for those people who would like to learn more about this.

Moderator: Tim let’s get started with you because you mentioned scenarios involving radiation, maybe you could take us through some of those.

Dr. Tinker: Sure. As I was saying, there are 15 all-hazard scenarios. Two of them have to do with radiation emergencies. The ranking of those scenarios are essentially ranked from most catastrophic to less catastrophic and there are a number of factors involved: the probability of death and injury, property damage, evacuations, and the scenario that really keeps us all up at night and for good reason the one that’s ranked number one which is the improvised nuclear device. Essentially what we’re talking about here is the detonation of a ten kilo ton nuclear device in a high density, high urban area. It is not only a frightening scenario but also a staggering scenario. If we look at our numbers here we’re talking about possibly hundreds of thousands of deaths, 3,000 square miles in terms of the overall impact. So, this certainly fits our definition of what we would describe as a low probability, but high consequence even an extremely high consequence event, and it is the potential of the outcome that’s driving our planning efforts at this time.

Moderator: So it is unthinkable but we have to think about it and figure out what we’re going to do. Now the other scenario you were talking about, is that what they call a dirty bomb?

Dr. Tinker: Dirty Bomb. That is the second scenario within the national planning scenarios. It’s ranked number 11. It’s also referred to as a radiological dispersal device. Less destructive in terms of loss of life and property, but equally frightening in terms of the level of fear that it can generate. Probably the more significant effect of the dirty bomb is really what we’re going to be talking about. The level of fear that it can generate, the disruption to everyday life, and for both of these scenarios, I think the important point is to think about the overall ripple effect because both of these scenarios, whether its the improvised nuclear device or the dirty bomb, can have very significant economic impacts in billions or hundreds of billions of dollars and the recovery time line can extend for years. So these are both very significant. We’re going to be talking about both of these scenarios a little bit more when we talk about a U.S.E.P.A. communications product that we've recently developed.

Moderator: Before we go to Brian to talk about some psycho-social impacts, Tim maybe you can talk about the specific characteristics of a radiation event in terms of what sets it apart from other events, either natural or manmade. What’s different about radiation?

Dr. Tinker: We spoke a little bit about the physical characteristics. Those physical characteristics have to do with loss of life, property damage, evacuations, but there are also a very important set of what we would describe as perceptual characteristics or perceptual indicators. We also refer to these as fear factors and some of these are showing. In terms of whether it’s a nuclear incident or a dirty bomb, we’re dealing with perceptual factors of it being invisible, unfamiliar and frightening. This is why we would describe these perceptual factors as fear factors. Now the fear factors really come from a solid base of research that’s been conducted over the last 10 to 20 years from people like Paul Slovak and Peter Salmon and others. This is a short list of those factors, there are actually well over 40 of these perceptual factors. And the reason they’re important, and the reason the perceptions are important, is they have the ability to influence not only how people may perceive a risk, how they may respond to a risk, but more importantly the acceptability or unacceptability of a risk. It’s going to be important for us as communicators, and important as mental health professionals that we understand perceptions and the role of perceptions. To answer your question more directly about what distinguishes a radiation event from others, if we come back to our perceptual factors, the perceptual characteristics, we’re talking about two events that have never happened on U.S. soil before. So in that sense, the nature of the risk is that it is new, unfamiliar, exotic, and extraordinary. It will not only result in high levels of fear but it can result in high levels of uncertainty, for all of us.

Moderator: We’ll go into that specifically in terms of RAD events a little bit later. Brian, can you tell us why behavioral health is an important element of planning overall and in responding to a disaster?

Dr Flynn: There are many of us who believe the behavioral health psycho-social consequences really are the longest term, most significant and frankly, most expensive of all the health impacts of most kinds of disasters. I don't think radiological incident is any exception. Some of the factors that contribute to why this is so significant include the fact that most disaster’s exposure is widespread and pervasive. These events exist along a spectrum of severity that last different durations of time; some short, some long. Then the type of disaster seems to make a difference. Not all disasters are created equal.

Moderator: Let’s talk about the psychological scope of a disastrous event.

Dr. Flynn: Ironically, and I don't think this is fully appreciated by most planners and responders, the psychosocial consequences of these kind of events are much broader than the medical consequences. The fear and distress that people experience often are many times those of actual medical casualties. In general, most disasters produce at least a four to one ratio of adverse psychological impact to medical impact and in some cases it can be in the hundreds of thousands to one. We’re dealing with a phenomenon where the psychological factors are much larger in most cases than the medical issues.

Moderator: I want to ask you about something because I think I have heard that referred to as “worried well”, and I know that’s not the right terminology. Talk about that a little bit.

Dr. Flynn: Thank you for giving me that opportunity it is something I talk about a lot. If I had my way, we would completely banish that term from our lexicon because it’s not accurate and actually I think it creates problems. People who are typically referred to as this are neither, well, nor does the term "worry well" capture the significance of what they’re experiencing. It trivializes the psychosocial responses and that purveys an attitude toward behavioral health that I think is really destructive. It helps people stay away from services they may need. In the health care setting, it can create some problems. If that attitude is communicated with victims, that is, your problems aren't really serious or aren't real, people are likely to do a couple of things we don't want them to do. They may exaggerate their symptoms so they will be taken seriously so they present in a way that makes diagnosis more difficult. Also they may go from one health care facility to the next increasing the problem of surgeon health care capacities until they find someone that takes their symptoms and concerns seriously. So I would love to see that term completely banished.

Moderator: We have to find a better way of talking about multiple unexplained physical symptoms. So we certainly do see those happening after disaster but do many people develop a psychiatric disorder?

Dr. Flynn: In terms of numbers that can be high depending on the kind of disaster, but I think one of the important messages for today is that of all the behavioral health consequences that typically is actually the smallest. The largest psychological impact is just large scale fear and distress significantly needs to be addressed and that can be experienced by most of the population, if not all of the population. Some subset of that group of people who are fearful and distressed will become so distressed that their behavior changes. It may change in positive ways or it may change in negative ways. They may smoke more, drink more, they may evacuate when we don't want them to evacuate, etc. A smaller subset of that population will go on to develop a significant identifiable diagnosable psychiatric illness, typically things like posttraumatic stress disorder or depression. It’s important to identify, diagnose and treat those disorders, but we’re not talking about that as being even the most significant numbers of people who may need attention for their psychological issues.

Moderator: How quickly, for that matter, how slowly do people get back to normal following a disaster?

Dr. Flynn: That trajectory really varies on a number of factors. If we look at the consequences of disasters as being the intersection of the forces of harm, whether it’s radiation or tornado or a flood or whatever as a factor, that and the intersection of the people who are in harm’s way, there are number of factors that really determine recovery. One is their exposure. Depending on the event, exposure can be long or short-term and for example, in an improvised explosive device, the exposure actually could be fairly short. In an earthquake, the actual exposure is measured in seconds. Or it can be long-term, like if we’re dealing with a slow leak of radiation that can exist over a long period of time. Typically, the actual exposure is shorter than the psychological impact of the loss people experience. Either the loss of loved ones, the loss of their economic sustainability, etc. Even when issues of exposure and loss are considered just change, change in family structure, family interactions, and social interactions in communities. That can go on for a long period of time. So there’s not an easy answer about how long these things go on and how long it takes people to recover, but at least we are able to identify several factors that play a role.

Moderator: Is there a difference in how people respond psychologically if a disaster is manmade versus natural?

Dr. Flynn: Yes. It’s important to think about the different kinds of disasters that may occur. Certainly emergency management, public health authorities do risk analysis. If we look at the scope of the full range of things that could happen, we have certainly natural disasters and some of those are listed on the slide. We have human generated disasters and they frequently break down in terms of intentional and non-intentional. Non-intentional are technological accidents that may happen. Intentional human-caused events include things like mass violence and terrorism. It’s important to recognize that these aren't completely mutually exclusive. There’s a large overlap between natural and human caused disasters. For example, an airplane crash may be a result of wind shear, so you have a combination of natural occurring weather phenomenon with a mechanical failure to be able to adequately respond to that. It’s important to remember that these events often overlap. But we do know that natural disasters tend to create fewer adverse psychological consequences than do technological disasters and then those kinds of incidents that are human-caused seem to create the most severe psychological problems because of their intentionality. There is something different about an event psychologically if somebody did this on purpose.

Moderator: I found a quote I think really covers it. It’s from Erickson. “People find situations involving radiation and other toxic agents a good deal more threatening than most natural hazards and even the most dangerous kind and mechanical mishap of considerable power. They say toxic hazards unnerve human beings in new and special ways.” That sounds pretty frightening. So that psychological impact is going to be much greater in a human-caused disaster.

Dr. Flynn: I think that’s exactly right and I think for the reasons that Tim talked about. There’s a lot of mystery and mythology and false information about radiation. Most of us don’t know much about that. The education and information that we get through the messages that are developed are extremely important. I think in this kind of event it’s extremely important when you have so much misinformation and mythology around the force of harm.

Moderator: So Tim now the ball’s in your court. Given the level that a radiation event will inevitably cause, what are some of the communication challenges which seem to be enormous?

Dr. Tinker: I’m glad that you mentioned the phrase “potential fear.” I think from a communications perspective it’s important for us to make a distinction between potential and perceived fear, versus real fear. Depending on how good of a job we do assessing and managing that fear it is either going to work to our benefit from a communications perspective or it can work to our detriment. Coming back to the list of challenges there are going to be many challenges. The first four to five items on our list here, evacuation and shelter, decontamination, isolation and quarantine, these are essentially the actions and behaviors we are going to want people to perform during a radiation emergency. The final two items there in terms of long-term health issues and economic impacts, those are more the outcomes, more of the consequences. If we focus on the actions and behaviors, if we think about this in terms of isolation and quarantine, decontamination, not only are these scary and frightening concepts, but it would be safe to say that probably fewer than 10% of the u.s. population has any understanding of what decontamination, isolation and quarantine mean.

Moderator: They sound scary.

Dr. Tinker: They’re scary, they’re frightening and they’re also in many ways complex. They’re technical. And they’re abstract so the question for us, the challenge for us as communicators, as mental health professionals, is how do we make these concepts? How do we make these behaviors, these actions meaningful, relevant and most importantly doable. One of the bests ways we can do that, and we really need to start doing more of it, is a communications concept called creating contrast. Essentially what we are all familiar with: creating the before and after, the risk and the benefit, then the now and later. Giving people a sense of what the world is like before decontamination and after decontamination, before evacuation and after evacuation. Essentially giving people a sense of the benefit, the value of what we are asking them to actually do during a crisis like this.

Moderator: In order to communicate though you have to have a good environment and what do you think the communications environment is likely to be during a RAD event?

Dr. Tinker: Clearly it’s going to be an unstable information environment. In some places it could very well be an extremely chaotic type of environment. As communicators, as mental health professionals, we have to determine what’s controllable and what is uncontrollable and we have to be able to make that assessment very early, and very accurately. The type of things that we can control, from a communications perspective, we can control the content of our message, what we’re saying. We can also control our spokesperson, the messenger. We can make sure they’re properly prepared and trained and to an extent we can control the flow of information, how much information, when. Our definition here is critical because it gives us a better understanding of the operating environment. Crisis plus heightened public emotions plus limited access to facts, plus rumor, gossip, speculation, assumption and inference equal an unstable information environment. Clearly there’s going be a lot going on in this communications environment. If we were to pull out just one of these elements, say for example, rumor. How many of us even as communications professionals know and are familiar with the science of rumor? There’s an entire science around rumor. Why rumors happen. For example, we know that rumors are used by people during a crisis to try to make sense of what is going on around them. They use rumors to fill the information gaps, knowledge gaps. We also know from the science of rumor that it’s much easier to understand a rumor than even the factual new,; it is also much easier to retell a rumor. Clearly, the danger or the risk of rumor that is left unchecked, has the ability to influence, not only what people think, it can influence their actions and behaviors and more profoundly, and we've actually seen it, it can influence policy decisions in the middle of a crisis. So that said, this is just one example. There are strategies that we can use to identify rumors, control rumors, correct rumors. So we would encourage everyone to become very familiar with that type of science.

Moderator: Because it’s almost certain that rumors are going to abound. People feel victimized and if they shape the message on their own, it’s a measure of control for them. If they pass it along, they put it in a context that makes sense to them. Working with an unstable communications environment, and want to be prepared to deliver a good messages but what should we expect about how people will receive it?

Dr. Tinker: In terms of the rules, the rules are going to change dramatically for our communications. The rules are going to change for the messenger, who is our person. The rules are going to change for the message, what they are saying and rules are going to change for the means, how they’re actually going to get the message out there. One of the best examples is that spokesperson, that message that may have worked for the ribbon cutting, for the opening of a new wing of a hospital, that same spokesperson may not be the best spokesperson for a radiation emergency. And the reason being is that when we say the rules change, people in a crisis, the public, the media, a larger audience is looking for something different in our spokesperson. What they’re going to be looking for is some essential factors, some essential characteristics such as being able to express empathy and caring and compassion. Having a sense of honesty and openness, dedication and commitment.

Moderator: All these things determine whether or not this messenger is going to be trusted.

Dr. Tinker: Absolutely.

Moderator: If the messenger isn’t trusted then the advice the messenger gives is not going to be followed.

Dr Tinker: The main thing is extremely important: we know in the event of a nuclear device that we could lose all of our electronic capabilities. So it’s going to be important that we look at non-traditional, more grass roots types of communications strategies such as working through our community-based organizations. Working through our faith-based organizations because we know in the event of a nuclear type of event, those old school types of media such as television, radio, even our new media around mobile communications and all the online communications could be severely affected.

Moderator: Take us through how people tend to behave in a crisis in terms of how that affects their ability to receive clear guidance.

Dr. Tinker: Well, before we can talk about behavior we also need to step back and take a closer look at what is actually happening to a person at that time. There are a lot of things that can lead up to that behavior. People are seeing different things, hearing different things. They’re feeling different things. Our messages are going to have to be able to work at a number of different levels. Our messages are going to have to be able to really capture at a visual level what people are seeing. At an auditory level, what people are hearing, and at a kinesthetic level what people are feeling. So in crafting our messages, it is important that we have a combination of all three of those. The seeing, the feeling and the hearing because ultimately it’s the combination of that-- of those three that lead to the actual behavior or the doing. They end up influencing and motivating the actions and decisions that people will take.

Moderator: I wanted to ask Brian if you could just touch on perception versus reality in a crisis, particularly a RAD event.

Dr. Flynn: This is an important factor. There are many similarities between behavioral health, public health, and physical medicine, but there’s also a significant difference. That difference is in behavioral health perception trumps reality. If people fear that they’ve been exposed, if the believe they’ve been exposed, it can and will trigger an adverse psychological reaction, irrespective of whether actual exposure took place or not. Probably the best example that gets used in the context of radiation is an incident in Gaoiania, Brazil where an abandoned radiological device had Cesium 137 in it. When all was said and done after the exposure, after that was released from that machine, there were 250 people who had radiation exposure. But the point I want to make is not those that were exposed but those that were not exposed. 125,000 people sought screening. This is that large fear and distress issue. People worried about whether they were exposed. They believed they had been exposed. So you have in that case a 500 to 1 ratio more than the 4 to 1 we talked about at the beginning of this broadcast. The other fascinating and disturbing part of this was that the first 60,000 who were screened, 5,000 people started showing signs of nausea, diarrhea, rashes, signs that were consistent with acute radiation illness. So it’s a fairly rare phenomenon and technically called mass psychogenic illness. It is a situation and gives us an opportunity why this ‘worried well’ term doesn’t work. People were more than worried and they certainly weren’t well when they were experiencing this level of symptoms.

Moderator: Brian I have heard similar stories of a lot of people becoming ill when they smell a strange odor. It has happened in some schools. I think it goes back to the whole idea of radiological or toxic threat being particularly unnerving.

Dr. Flynn: That’s right. Also a reminder – I think we need to begin to think about fear as a contagious disease. Fear is as contagious as many other exposures that we have. If we think about fear as a contagion, we can look at it differently and not as a mental health issue, but as an infectious disease issue.

Moderator: What can we do in our communication to counter that fear, at least well enough so that people can make good decisions about risk reduction actions?

Dr. Flynn: Whether it’s the first few minutes, first few hours, the first days of a crisis like this, our goal is going to be the same. Out goal is to be consistent. It’s going to be important for all of our audiences to be able to hear, understand, remember and do and not do. That said, we are going to repeat, repeat, repeat our key messages. There’s the old axiom in commercial marketing that a person has to be exposed to a message at least seven times. In a crisis we learn in magnitude by three. So lets multiple that by three, we can expect that our audiences are going to have to hear a consistent and clear message 15, 20 times. Our messages are going to have to be framed as the only three things you need to remember right now are “A,” “B” and “C.” Let me repeat. Do “A,” “B” and “C.” It all comes down to doing these three things. We are going to have to be clear, concise and brief in our communications. Of course our communications are going to change as the crisis unfolds, as the situation changes. In the first hours what we can expect from people and what they will expect from us is very clear guidance around health and safety. How I can protect myself, how I can protect my family. As we get further into a crisis, we have to look back over the last couple of years. We’re probably going to start seeing some wrinkles, some missteps in the response process and it is at that point we have to move. We don’t leave it behind but we’re going to have to enlarge our message base, expand that platform to start addressing issues around trust. Can I trust you? Can I trust your organization? We’re going to have to speak to benefit. What’s the benefit to me, my family if we follow your advice? Giving people a sense of choice and voice and an increased knowledge base.

Moderator: I wanted to ask Brian, Tim mentioned audiences plural. So what different audiences should we direct these risk messages to?

Dr. Flynn: I think there are a number of audiences. Let me identify just a few. I think there’s a trap that we sometimes fall into in communication and that is just thinking communication with the general public or segments of that. I think that’s important. But we also need to think about communication to leaders. If we can get leaders to say that right things, give the right messages, to behave in ways that really promote calming, socially appropriate behavior, we’ve gone a long way. Workers of all kinds should be the recipients of our messages. Workers, responders in general, utility workers, etc. Also because this is a public health broadcast, we need to be concerned about health care workers in these kinds of situations and the special needs and stresses that they may have. We also sometimes forget that organizations can be recipients of our messages. We can be very helpful to organizations and helping them understand what happens to their workers. So not only do we have messages that speak to the individual and their families but messages that can speak to the organizations in which people work.

Moderator: You made a pretty clear distinction between the general public and responders. How do behavioral and mental health interventions differ between general public and first responders?

Dr. Flynn: There are enormous similarities and enormous differences in both those categories. If we look at workers, for example, we have the fear of health impact. Am I going to get sick? Am I going to die because of the work that I do? There are enormous stress-related issues about working in personal protective equipment. In fact, there’s been very interesting research that show otherwise very capable people, some percentage of folks just cannot work in PPE because of the stress-related kinds of issues. Even those that can, it’s hot, uncomfortable, cumbersome, and sometimes claustrophobic. There are stressors that come just within that kind of environment. Overworked. Never enough people to go around in these situation. Degradation of performance. Everybody wants to do a good job. Because of a lot of different factors, people wont be able to do the quality of work that they used to or that they aspire to. That’s a stressor. Then there is certainly enormous issues dealing with large scale illness and death and handling bodies. If you look at the general public, primary victims, a number of those concerns are the same. There is the health impact. Am I going to be sick? Am I sick? What’s going to happen to me? The status of loved ones is a huge concern. In most kinds of events, if they’re short-term acute events, we’re separated from the people we love most in this world and that separation is a huge stressor. If we’re at work and our children are at school and separated from those we love, it’s a huge stressor. Inadequate information, as Tim talked about so well is a huge stressor. Getting conflicting information, incomplete information and then issues of grief, bereavement, those kinds of massive losses that may attend some of the events are enormous stressors for individuals also. Then there are issues of social stigma. We saw that here in New York State with love canal. People who are from an area where there has been some kind of toxic exposure or radiation are often stigmatized and they’re ostracized from the communities in which they may relocate.

Moderator: I think we saw it in SARS. People were reluctant to go to Chinese restaurants, I believe we also saw in the Guiana event, persons from that region of Brazil, they traveled elsewhere, their license plates gave them away as being from that part of the country and they were actually ostracized. How does stigma make the situation even worse?

Dr Flynn: You have on top of all the other stresses, including illness, you have social isolation. One of the things that we know about the psychology of disaster response is that the availability and solidness of social support is a major factor in recovery. People who have better support systems tend to do better than people who don’t.

Moderator: So what’s helpful in terms of messaging in a crisis? What interventions might we be able to help prompt?

Dr. Flynn: Well, there’s some interesting research coming out or summary of research that really takes a look at the empirical evidence about what is helpful in the early to mid stages of an event. Contrary to some of our other more traditional interventions, is kind of a less is more kind of approach that we may not want to do intense psychological interventions, but we may want to do things that respond to and react to five things that are being identified in the literature, as things that really do work in reducing psychological distress. These include providing a sense of safety for people. Calming people. Providing and encouraging a sense of self and community efficacy; that we can do things that can help us out of this awful situation. Connectedness. Again, that issue of social support is so important, and a sense of hope. So it’s important that our early interventions try to exist and try to identify and be geared toward as many of those five elements as we can.

Moderator: So Tim, how do you make this happen in terms of messaging? How do you get these interventions under way in terms of sending the right message?

Dr Tinker: Well there is a number of tools that we can use. These tools have been tested. They’ve been implemented but our advice, our observation, our own experience says the tool is only as good as the person using them, using the tool. If we were to use an analogy of a master carpenter or a skillful surgeon, the reason that they got to that expertise is that they have been using those tools. They have been practicing those tools and as a conscientious communicator, whether a radiation emergency or some other crisis, we’re always going to be doing what we like to call, anticipation, preparation and practice. Anticipating our scenario, anticipating questions from our stakeholders and even anticipating what we spoke about earlier, rumors, misconceptions, possible controversies and based on that understanding, preparing our messages, preparing our spokesperson and then practicing these skill sets. So there’s a lot of things that we can be doing in anticipations of a crisis.

Moderator: Brian, you talked about five early interventions, starting with promoting a sense of safety and going to giving people hope. So how do you actually get these going in the various stages of a response to an emergency?

Dr. Flynn: One of the things that I would suggest is that people who are developing messages and delivering messages use something like a template that I developed for this presentation and that is a template that recognizes and identifies these five characteristics and thinks about how it might play out in the preparedness stage, when an event is going on and recovery. Think about how and if the messages that are developed really do address any or all of these five. Certainly our hope would be they don’t make them any worse, but I think in addition to all of the other things that messages are intended to do, we can use these messages as an intervention to really help calm people. So whether it’s this diagram or something similar that people would like to use, I would suggest that you think about for example, do the messages that we’re crafting in the pre-event period really promote a sense of calmness in people or do they not? Certainly hopefully they don’t exacerbate it, in the pre-event period are the message that we’re giving things that really do enhance a sense of safety and security? So I’m just suggesting that some of these issues in addition to all of the other purposes of messages, we really can’t have a behavioral health intervention if our messages really tend to promote these five factors.

Moderator: So what do you think communicators are missing in terms of psychosocial factors, that we miss entirely or don’t pay enough attention to?

Dr Flynn: There are a few. One that we might talk about today, certainly it is my sense that most of what risk communicators try to do is get their message out to people. One of the things that I think is missing in a lot of our efforts is kind of what do people want to know at different stages and that may be different than what we’re trying to get them to do or get them to know about. So I think that really being sensitive to what people want to know and what their primary concerns are at different stages, are things we need to add to our constellation of issues on risk communication.

Moderator: So we need think about, or actually we need to hear what people are saying so that we can address their concerns.

Dr Flynn: Exactly.

Moderator: It is not decide, announce, defend- that whole paternalistic model that I will confess, public health at times has been very fond of.

Dr. Flynn: You make an extraordinary point. It has been repeated early on in public health and behavioral health, that we need to plan with people not for people.

Moderator: We’ll be ready to take your calls in just a few minutes. The toll free number is 800-452-0662. Send you fax to 518-426-0696 or by email to the address on the screen. I want to get back to that conversation. You’ve brought along some really interesting flow charts that I would be delighted if you could take us through.

Dr. Flynn: I would be glad to. They aren’t as complicated as they look. The next three diagrams that you’re going to see really try to address this issue about what are the factors that determine how people behave and respond to these kinds of events and the importance of appropriate messaging in that. If you look at the first diagram, across the top you see the concerns that people have and this is in the immediate impact stage and a couple of take-home messages here. One is that people in that early stage don’t want to know a lot of things. They want to know primarily three things. First, am I ok? My wife is always accusing me, it’s really all about me. Second, what about the people that I love? Then, third, what do I do? They will express those concerns partly through the lens or filter or whatever metaphor you want to use of their personal characteristic. The extent to which they perceive themselves as being vulnerable to the risk. Are they impaired, are they resilient? What’s been their life experience with stress and traumatic events? Then you get to the message issues. Those are the same through all three of these. Really, factors that determine whether messages will be found. Credibility of the message, of the messenger, of the cultural appropriateness and the combination of all of those will be a major determinant in the outcome; how people behave. So, one of the points that I would like to make throughout this is people have different concerns at different stages. But also the importance of the behavioral connectedness of the messages, because people want to know what to do. Our messages need to make sure that we give people the right kinds of instructions, directions, recommendations that will lead to outcomes that are positive and not negative.

Moderator: And of course this is what you call the immediate onset period only and disasters and events tend to go on. So take us through primary impact because those concerns, that list just gets longer.

Dr. Flynn: Longer and more complicated. Those kind of issues include not only the issues of am I okay, but things like guilt, anger, social justice, who got treatment before other people, those kinds of issues. The concerns become much more complex and comprehensive. The personal characteristics become a bit more extensive because at this point people may have become ill or may have had loved ones die, etc. The message elements stay the same but than some of outcomes again, become a little more complicated and the consistency through this is that behavioral connectedness of our message. In every one of these phases, people want to know: what should I do?

Moderator: So no we’re in the recovery period. Do we still have to worry about all these factors?

Dr. Flynn: Even more. In the recovery period, that list of concerns gets longer. The list of what people have experienced, their own personal characteristics get longer. Again, there may be more deaths, there may be economic challenges and business close down or the economy fails. Those kinds of personal characteristics will influence what people hear, or how they respond to that and how they behave. Then the long-term outcome, this is where you see litigation, those kinds of things. Things we weren’t worried in the immediate Impact area. I believe strongly is we address these properly, adequately and consistently over these times, recognizing that people want and are concerned about different things, then we actually can reduce inappropriate litigation. We can increase confidence in leadership, those kinds of things. Again, the common characteristic in this is the behavioral connectedness. People still even in the recovery period, need to know what to do, even if it’s what do I do to prevent this from happening again. People want to have a sense of involvement, a sense of purpose, a sense of meaning, the things that they tangibly can do to help keep themselves, their loved ones and their communities out of harm’s way.

Moderator: They may be angry and not even know why, or the anger may be directed inappropriately. Perhaps, Tim, as people who are delivering the message as sort of the kill the messenger scenario, what can we do in terms of having effective tools to use to prepare for a radiation event?

Dr. Tinker: We’ll fortunately there’s a wealth of information in tools that have not only been developed but have been tested over the last ten to twenty years for crisis like this. But unlike other communications tools, the tools that we are going to be talking about really focus on helping us prepare and respond to those challenges that we talked about earlier and those challenges have to do with what actually happened to people during a crisis. They have difficulty processing information. They become less trusting. They tend to think more negatively, and coming back to the perception issue, their perceptions may vary remarkably from reality. We have a number of tools at our disposal.

Moderator: Some of these are in template forms. They really are just good techniques and they are easy once you learn them. Talk about what we can do.

Dr. Tinker: They help us really respond directly to those challenges. People having difficulty processing information. People being less trusting. Some of the techniques there’s well over 40 templates techniques. These are the five that we believe are just at a minimum, the core of these templates. Let me very quickly walk through each of these 27, 9, 3. This comes back to the challenge about people having difficulty processing information. One of the other templates is the rule of three. We know in high stress events people can typically only process about three key messages, and when we think about the average media sound bite, that’s 27 words, 9 seconds and 3 key messages. In a crisis, making sure that we kind of stay with our three messages. C.C.O. Compassion, conviction, and optimism. This is probably one of the most powerful templates it goes as far back as World War II. Winston Churchill used it and most recently, Rudolph Giuliani, during 9/11. Both of these people used this consistently in terms of making sure that they prefaced their statements and their news conferences by starting off with a statement of empathy and caring and compassion. Why is that important? Because the risk communications research and experience has shown that if we start off with information without acknowledging that we’re in a crisis, that this is a tragedy, people immediately tune out and this also brings us back to this delicate balance between the informational, intellectual rational side of what goes on in a person in a crisis and the emotional empathetic side.

Moderator: That’s that Will Roger’s quote “They don’t care what you know until they know that you care”. Some leaders I think are a little reluctant to use this. Hopefully they are empathetic. The stiff upper lip idea, I guess.

Dr. Tinker: Yeah. It really – we have to have that balance because once again, the research shows that people are resistant to hearing, to listening, to doing what we want them to do until I see your humanity. Until you can bring that element in. AGL minus 4. Average grade level minus 4. A very important point. Comes back to the challenge about how people process information and at what level they process information. We know during times of crisis in high stress events we can automatically subtract four grade levels. The average grade level in the U.S. today is between 10 to 12 years of education which suggests that our messages, our communications, need to be somewhere at the sixth to eighth grade level. An average 12-year-old should be able to understand not only what we are saying but what we are asking them to actually do. In high stress events people tend to remember what they hear first and last which says that our most important messages need to be in the first position and third position. If we have a soft message it is probably going into that second position. One negative equals three positives. Coming back to the challenge about people tending to think more negatively. In we do have to respond or deliver a negative message, let’s make sure that we balance, counterbalance, even offset that negative with a least three positive messages. A fourth positive message will actually allow us to overtake that negative.

Moderator: Just so that our viewers don’t think we’re giving them a lot of alphabet soup here, I know that this works. Our guest on last months broadcast talked about rural evacuation research and he spoke about research that found when people are advised not to evacuate, they disregard that advice. Whereas, if it is posed positively, sheltered and placed, they’re much more likely to pay attention to it. It seems like just semantics but it’s not.

Dr. Tinker: You’re right, and coming back to the earlier point about complex, difficult abstract types of concepts especially in the forms of behaviors and actions, it becomes critically important.

Moderator: You had something called message maps on the screen, what are the techniques we can use for developing a message map?

Dr. Tinker: This is one of the best tools. We’ve been using it in our work with public health agencies, in a number of different sectors. I have to give credit to Dr. Vincent Cavello, he is really the person that came up with the concept. The message map that we’re looking at here is developed in response to a dirty bomb scenario. Just to quickly walk through this, it’s organized in three layers of three. At the very top layer we have our topic or issue area, for this one it is a radiation message map. The second layer is what we describe as our key message, or the overarching messages and the overarching messages are the messages that we want to make sure we are consistently delivering to our audiences. Then, the third layer is what we term our supporting facts or proof points. The supporting facts allows us to drill down a little bit deeper. If we’re probed by the media, or probed by the public, we have an added layer of detail and information. One of the most important points though, in terms of developing our message maps, crafting the content for our message maps is that we are using all of the templates that we spoke about. The 27, 9, 3, the AGL minus 4, and in doing that, what we ultimately produce are messages that are informative, that are precise, that are visual and that are even personal.

Moderator: In a radiation event, without a doubt, there’s going to be a lot of technical information, highly technical information that’s got to be presented so that people understand it. How can we help them to do that?

Dr. Tinker: You’re right. How do we make information memorable, meaningful, and relevant? The folks that are really the experts on this are the folks that have been working within the whole consumer marketing field, their ultimate communications goal is to get an individual and group to use, to reuse and to refer their product or service. Well we need to be thinking in a similar way. We need to really reframe our – come at this with a different approach of helping people to not only understand and remember what we’re telling them but refer the information, refer the guidance to their friends and their families. There’s any number of ways that we can do this; shown on the slides the use of visuals, supporting factual information, creditable third parties and so on. There are other ways we can do this; through the effective use of graphics, examples, analogies, testimonials, stories. There is nothing more powerful than hearing the story, the eyewitness account of somebody.

Moderator: You have to be careful with risk comparisons though don’t you?

Dr Tinker: Absolutely, because that is where we get more into the quantitative side of things and that brings us back to the communication side of the ledger where we are getting more technical and complex. We want to keep things simple, clear, and concise. Really the power of the visual. If we were just to take the visual for example, we know based on the risk and crisis communications research that a good strong visual can help increase retention of information by over – somewhere between 40 and 50%. It can also help increase consensus. It we’re having to do problem-solving in a group, it can increase agreement and consistency by 20% and help us communicate our ideas by as much as 40%. So yes, enhancements, anyway we can support, strengthen, reinforce our messages, we should take full advantage of those opportunities.

Moderator: I actually had an opportunity to see how dramatically a visual can improve comprehension. I participated in a number of nuclear power plan exercises and it’s very helpful when you see what the containment actually is and the different layers between ourselves and potential exposure. In terms – you said making a comparison that people can understand. The nuclear power plant operators are always talking about – this was all a drill it wasn’t really happening – a leak of contaminates into the containment building. Just hearing that, it was frightening. Then I asked him how much water are we talking about? I was told just about as much that would fit in a teacup. You can understand why that would make people feel a little better then this idea of a flood of radiation, and yet I think in terms of technology we sometimes get too enamored of it and we hide behind it. That’s good advice you just gave. What are the major challenges we need to do now to improve our preparedness for a RAD event?

Dr. Tinker: Well there are very significant challenges. Especially from a communications perspective. As we get further and further away from 9/11, it’s going to become increasingly difficult to keep people engaged, to keep their attention. I think already we’re seeing low attention, low involvement, a low sense of urgency around these types of issues. So I think it’s going to be important. A lot of good planning has been done. I think as communicators we’re going to have to step back, take a fresh new look, a different look and I think part of that is really asking ourselves, putting ourselves in the shoes of the consumer, putting ourselves in the shoe of the audience and asking ourselves what it is that we’re asking people to actually do. In order to do that, our communications, our planning, our training, all of it is has to come back to the topics that we have been talking about. Adding value, addressing emotions, addressing perceptions and answering a very fundamental question about the issue of that the value must outweigh the costs. Some of the fundamental questions that we’re not only hearing but we need to ask ourselves if you got out into any small town – for example, why should I care about this? Why should I care about radiation emergencies now? Over the last couple of years you’ve been asking me to care about pandemic flu and the year before that, you asked me to care about small pox and anthrax and Bioterrorism. So at some point in out training, in our planning we’re going to have to answer fundamental questions about why should I care. If I do care, what’s that benefit to me if I follow your advice? If I take those actions is it actually going to reduce my risk, is it going to protect my family? Will it actually eliminate the risk? Even one that we’re hearing quite frequently, maybe the consequences of doing nothing. When we’re doing town hall meetings or focus group meetings – what is the cost of doing nothing? These are some of the fundamental issues that we’re going to have to bring this back, reframe the issue, reframe our communication strategy to where we are. I think we’re done a good job over the last several years on the informational side but reframing the communications that are approached to strategy, to bring it back to values. What is it that people really care about? How can we link it and bridge it— make it relevant to their everyday lives? I am not sure we have really answered that question.

Moderator: Brian, what about the psychosocial interventions? What different types of interventions might we think of?

Dr. Flynn: Typically the default setting for most people when they think about those kinds of interventions are individual and collective psychosocial kinds of interventions; counseling, therapy, etc. That’s important, but one of the things that I would like to stress today, it that is only one piece of a much larger responsibility and opportunity that we have that includes generalized and specialized information. Information is a psychological intervention for folks and that’s why we’re talking about this today. Planning and preparedness does make a difference. We need to make sure that in our health planning, in our overall emergency planning we do consider the psychological behavioral health factors in that. Consultation with leadership is extraordinarily important. As I mentioned earlier, if we can have access influence on leadership behavior, we can really help reduce stress and adverse psychological effects. Certainly training and education as we’re doing here today is an important key factor.

Moderator: Tim, obviously we need to have resources if we’re going to plan. Are there any good resources for planning for radiation events and to communicate effectively through them?

Dr. Tinker: One of the newest and very good resource over the last year, we’re been working with the U.S.E.P.A. to develop a pocket guide. The content of this pocket guide is exclusively around communicating radiation risks. The audience for the pocket guide are not only communicators but we have physicists, the subject matter expert, even the policy person. Any person that may find themselves in a situation where they’re going to have to communicate about radiation emergencies. The content of the guide really focuses on the relationship that we’ve been talking about over the last hour. The relationship between the messenger, the message and the means and provide some very useful tips and techniques. Also as a part of the project, not only developing the guide, but we’re in the process of developing a one-day training course to where people can receive training on the content and the skill set that is in the guide. If anyone is interested in obtaining a copy of the guide as well as learning more about the training opportunities, that are welcome to contact me.

Moderator: Quickly, what are some of the scenarios that the guide covers.

Dr. Tinker: There are three major scenarios. We spoke about those earlier in the broadcast. There’s the improvised nuclear device, the dirty bomb and then there are also other scenarios such as the transportation incident and the industrial incident. For each of these scenarios in the pocket guide, we describe what happened, when it happened, what to expect, not only in terms of the operational response but also in terms of the communications response. What specific actions that we need to take and what are the messages that we need to be delivering. The messages that people need to be hearing and acting upon during that crisis.

Moderator: I’m told we have a caller on the line from Oklahoma. Go ahead caller.

Caller: Good Morning, thank you for taking my call. Thank you for your message of preparedness and planning and that’s very important for the individual as well as the business. My question involves the joint information center and if could you address the role that the joint information center has in disseminating the message during a crisis.

Dr. Tinker: That is a great question. It actually speaks to the role of the important, the purpose of partnership communications and more importantly it’s not only a physical location, it is essentially a response mode that allows us to speak with a common language, speak with a common voice and also have a common purpose. Over the last several years in the context of exercises and drills. I think what we have learned is that communications has been a weak link in that overall operational response. We know that that jig is the hub. The nucleus for not only coordinating that communications response but coming back to some of the key elements we’ve been talking about, making sure we have consistency across our messenger, across our message and across the means.

Moderator: I understand this is a two-part question and our caller has a question for you, Brian. Go ahead, caller. Apparently we lost the caller. It had to do with the psychosocial impact of an event. Are there plans for mental health professionals to become more aware of their role?

Dr. Flynn: Yes. There are activities involved in that and almost every state now has some kind of state sponsored crisis team that’s being developed and has special preparation for this. Candidly, most mental health professionals are not trained in this kind of activity, nor in terms of temperament suited for this for everybody. So it’s important that we identify the folks who are good as this, provide them specialized training and make sure that there is a framework under which they can operate. One of the things we don’t want to have happen is just spontaneous volunteers responding to these kinds of issues where we really have no idea what the person’s background is, what their motivation is and the extent to which they really do know or don’t know the specialty concerns and issues of disaster behavior health.

Moderator: We want to take some more calls now. The toll free number is 800-452-0662. You can send your written questions by fax to 518-426-0696 or email them to the address on the screen. We actually did get a fax question asking you folks about the need to periodically reassess the impact of messages. How do you undertake that?

Dr. Tinker: Well, there’s a number of ways we can do that. We can use qualitative methods as well as quantitative methods. The more important point about the assessment is what are the types of questions that we are wanting to try to answer and how are we going to use that information. From the qualitative side, we can use in-depth interviews, we can use focus groups to not only test the effectiveness of our message but how that message may need to change. As we said earlier, one size does not fit all in terms of our messaging and communication strategy. We need to have a message set that is appropriate before the crisis, during the crisis and after the crisis and I know that Brian was recently involved in a very special messaging type of conference around recovery issues and that was a very unique, unusual effort. He may want to say more about that.

Moderator: Our viewer also wanted to know about how do you talk about what’s not known. That uncertainty factor has a huge psychosocial impact and yet you don’t know what’s going on. You’ve got to communicate something. Perhaps you can comment on that.

Dr. Flynn: Well, I’ll take a first crack at it. I think the first thing to do is be honest. That’s certainly consistent both in behavioral health and risk communication. Be candid about what we know and what we don’t know. There are parts of crisis and risk communication that Tim knows more about than I do. When you don’t know something, you need to reassure people that if you don’t know it, you will learn as much as you can and communicate back with them. I think the unknown is a given in these kinds of situation. All messages really need to incorporate what we already do know about how we can calm people, how do we make them not be vulnerable to rumors and false information and part of that is having credible messages and people who are willing and able to acknowledge what they don’t know but are able to get back to people when they do know.

Dr. Tinker: The only thing I would add to that, Brian is right, but probably the best way to talk about the unknown is speak about what we do know because in the early hours of a crisis when we’re starting the investigation, data isn’t available. It’s going to be important for us to acknowledge, be honest, up front about what we do know. We also know based on the risk communication research, that in a crisis what people ultimately come to rely on is our response, is the process. So it’s going to be important in the first few hours to establish ourselves as the go-to resource for information to where we can say this is what we know, this is what we don’t know but this is what we will know based on the process. We have a process in place. What we expect to know say in the next 24, 48 hours is A, B and C.

Moderator: One of the templates you didn’t show us, but I think it’s an important one, is the I.D.K, the I don’t know. There’s a caveat to that. If you should know, make sure you know it, prepare for those questions. Is that important?

Dr. Tinker: Invariably there are going to be situations there are going to be questions that fit into the category of I don’t know. There’s absolutely nothing wrong with that. The thing we do want to avoid when we do have a question, it really almost begs for the response of a no comment, let’s avoid that. There are other ways of saying we don’t know. Based on the best available information, we expect in the next few hours to have a better sense of what’s happening there. But there is a template that if we are in the position to where we don’t know, let’s say why we don’t know, as we already spoken about before, if we’re in the early hours of a crisis, it’s important to acknowledge that. It’s also important based on the I.D.K. to follow up with saying even though I don’t have the answer, I can get you more information. I’ll be happy to follow up with you. I may not be the right source, or the right resource, but I can point you to the person that may have that information and then attach a fixed time to that. I’ll follow up with you in the next 8 hours or the next 24 hours. But the old caveat is don’t promise anything that you can’t deliver. If you’re going to tell a person you’re going to get back with them in 8 hours, let’s do that. It comes back to our trust and credibility and its also a process issue. Once again, it’s going to come back to process, the execution of our communications process. Ultimately, that’s what people come to rely on.

Moderator: I wanted to ask Brian, how long are we talking about in terms on recovery time for psychosocial planning after a RAD event? I guess it depends on the scope of the event.

Dr. Flynn: It really is the scope and the nature of it. Again, if it’s a small event with a few casualties, not major deaths or injuries, it’s a shorter time. If it’s a situation that is intentional, results in large scale destruction and death and, you know, bodies that can’t be identified, those kinds of things, and the cascading economic effect, we’re talking about something that is much longer in that situation. So I think it’s important for us to understand the factors that are involved in here and understand that there is a tremendous range of duration. Also within families and individuals, there may be differences. Individuals may recover more rapidly than some other individuals. Some communities I think by virtue of certain characteristics of that community; good leadership may recover more rapidly. There are a number of factors and a hard question to make a generalization about.

Moderator: I think we should probably tell folks how they can contact you if they need more information so Tim, how do people contact you?

Dr. Tinker: You can reach me at my number shown on the screen. 703-902-4519 or my e-mail address tink_timothy@bah.com. They are more than welcome to contact me. I can assist them in getting a copy of the guide book and finding out more about the training.

Moderator: Brian, how do people get a hold of you?

Dr. Flynn: My contact information is on the screen also. My e-mail is brianwflynn@aol.com. My phone number is 410-987-6482.

Moderator: We don’t have a great deal of time left, but it does occur to me with an energy crunch there’s more and more talk about nuclear power plants and psychosocially, how to we plan for this and how do we communicate to people that there might be a need for this?

Dr. Flynn: Well, I think I’ll start with that. I think as a thought about the same thing, it seems to me that one of the first things we need to do it have accurate information about what we know about today’s technology and today’s risks. One of the things at least I perceive is that people tend to make their cases on both sides of the extreme in that situation. Either it is absolutely dangerous or it is absolutely safe and I suspect reality is somewhere in the middle. I think as we begin to talk realistically about levels of risk, then people can make better informed decisions about whether this is something they want or don’t want in their community. I think we need to be careful not to be drawn to the two ends of the spectrum.

Moderator: Tim, maybe you could just share some web site information there’s a lot of resources out there. Tell our viewers where they should refer for more additional information.

Dr. Tinker: Well there’s as we spoke about the new pocket guide out of U.S.E.P.A., available both in hard copy as well as electronic version. There are other great resources through C.D.C. and U.D.E.P.A.

Moderator: I just wanted to mention if you e-mailed a question and you haven’t heard it post here, we will be getting back to you with an answer. We do want to thank you so much for joining us today. We would like of course to ask that you please submit your online evaluation. Your feedback is very helpful in planning future programs and continuing education credits are available after your complete the post-test. This program will be available online within a week or so. Please check our web site for details. I’m Christine Smith, see you next time on the University at Albany Center for Public Health Preparedness, Grand Round Series. Thank you very much, this was wonderful and we really appreciate it.