A qualitative narrative study of rescue and recovery workers responding to the terrorist bombing of Oklahoma City's Murrah Building.

OBJECTIVE: Much of disaster mental health research uses quantitative methods, focusing on numerical prevalence, services, and outcomes. METHODS: Qualitative methods can provide more detailed, rich, and spontaneous insights into personal disaster experiences, yielding important insights beyond deductive methods. This large-scale qualitative narrative study examined experiences of 181 OKC bombing rescue/recovery workers. RESULTS: Thematic narrative content of the bombing experience arose from personal accounts of the bomb blast by rescue/recovery workers proceeding chronologically from initial awareness and deployment to harrowing onsite search and rescue/recovery missions to the aftermath with reflections on the bombing. CONCLUSIONS: Beyond disaster recovery/rescue worker stories published in popular media, little other substantive published knowledge on this topic is available, and therefore this research study provides a wealth of new in-depth information that can provide guidance for policy and practice for disaster response.

Characteristics and experiences of professionals providing 9/11 mental health services.

BACKGROUND: After disasters, mental health professionals might be called upon to help address the emotional consequences of the disaster among survivors and other affected groups, but the clinicians themselves could be affected. This exploratory study examined the experiences of 60 mental health professionals, most of whom provided mental health care to individuals affected by the September 11, 2001 terrorist attacks (9/11), and/or experienced 9/11 sequelae themselves. METHODS: Participants completed structured interviews 3 and/or 6 years after the disaster, with full diagnostic assessment of psychiatric disorders and questions specific to their personal and professional post-9/11 experience. RESULTS: Providing postdisaster care was somewhat stressful initially, but long-term effects were more positive than negative, with overall benefit to many personal lives. Most found their clients' 9/11 stories emotionally upsetting, yet characterized their 9/11 mental health work as positive. Work satisfaction increased by 3-fold, but this effect was transitory. One-third had postdisaster psychopathology, but most was pre-existing and therefore not a product of disaster-related stressors. CONCLUSIONS: Although most mental health professionals initially found the emotional difficulty of their work increased after 9/11, this negative effect had largely dissipated over the years. Opportunities for disaster mental health training and initial logistical support could benefit these professionals.

A prospective longitudinal study of child custody status among homeless population mothers.

Most women in homeless populations are mothers, the majority being single mothers. Retaining child custody is challenging in homeless circumstances. Prospective longitudinal studies are needed to follow the moving pieces of housing and child custody in the context carefully-assessed psychiatric and substance use disorders over time. A 2-year prospective longitudinal study of an epidemiologic sample of individuals with literal homelessness included 59 mothers. Annual assessments included structured diagnostic interviews, detailed assessment of homeless circumstances, urine drug testing, and service use documented by both self report and data from agencies serving these individuals. More than one-third of the mothers consistently lacked child custody throughout the course of the study and the proportions of mothers with child custody did not increase significantly. Nearly one-half of the mothers had a current year drug use disorder at baseline, including cocaine disorder in most. Continuing lack of child custody over time was associated with longitudinal lack of housing and use of drugs. The importance of drug use disorders in the longitudinal course of child custody points to a critical need for formal substance abuse treatment, not just initiatives to decrease drug use, in helping mothers regain and maintain custody of their children.

Learning and achievement characteristics of sheltered homeless population subgroups.

BACKGROUND: There is little systematic information about intelligence and academic achievement among sheltered homeless adults. This study adds descriptive data on intelligence and academic achievement, examines discrepancies across these concepts, and explores the associations among demographic and psychosocial characteristics in the context of intelligence categories and discrepancies. METHODS: We studied intelligence, academic achievement, and discrepancies between IQ and academic achievement among 188 individuals experiencing homelessness who were systematically recruited from a large, urban, 24-hour homeless recovery center. Participants completed structured interviews, urine drug testing, the Wechsler Abbreviated Scale of Intelligence, and the Wide Range Achievement Test, 4th edition. RESULTS: Average full-scale intelligence was low average (90) but higher than scores obtained in other studies of homeless populations. Academic achievement was lower than average (82 to 88). Performance/math deficits in the higher intelligence group indicate functional difficulties that could have contributed to homeless risk. CONCLUSIONS: The low-normal intelligence and below-average achievement scores are not extreme enough to warrant immediate attention and intervention for most individuals. Systematic screening during entry into homeless services might identify learning strengths and weaknesses, presenting modifiable factors that could be addressed in focused educational/vocational interventions.

A longitudinal follow-up study of Oklahoma City bombing survivors in the first quarter century after the disaster.

BACKGROUND: This study is one of the longest postdisaster prospective longitudinal studies of disaster-related psychopathology, completed nearly a quarter century after a terrorist bombing, and the longest follow-up study ever conducted using full diagnostic assessment in highly exposed disaster survivors. METHODS: Oklahoma City bombing survivors (87% injured) were randomly selected from a state survivor registry and interviewed approximately 6 months postdisaster (N = 182; 71% participation) and again nearly 25 years later (N = 103; 72% participation). Interviews were conducted using the Diagnostic Interview Schedule (a structured interview assessing full diagnostic criteria) for panic disorder, generalized anxiety disorder, and substance use disorder at baseline and also for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) at follow-up. The Disaster Supplement assessed disaster trauma exposure and subjective experience. RESULTS: At follow-up, 37% of participants exhibited bombing-related PTSD (34% at baseline) and 36% had MDD (23% at baseline). More new cases of PTSD than MDD developed over time. Nonremission rates were 51% for bombing-related PTSD and 33% for MDD. One-third of participants reported long-term nonemployability. CONCLUSIONS: The presence of long-term medical problems among survivors parallels the persistence of psychopathology. Ongoing medical problems might have contributed to psychiatric morbidity. Because no major variables predicted remission from bombing-related PTSD and MDD, all survivors with postdisaster psychopathology likely need access to long-term evaluation and care.

Making Meaning of Surviving the Oklahoma City Bombing Seven Years Later.

Objective: No previous studies examined how survivors made meaning (i.e. interpreted the personal significance) of a disaster experience after seven years. This qualitative study follows up on a previously published analysis of 182 directly-exposed survivors of the Oklahoma City bombing, assessed after six months had elapsed for bombing-related psychopathology and meaning-making processes. The current study examines how 113 survivors (62% follow-up rate) made meaning of their bombing experience after seven years. Method: Survivors answered questions about the effects of the bombing on their beliefs and perspectives. Their responses were hand recorded by interviewers and transcribed. Content was coded into themes, allowing codes of multiple themes. Excellent interrater reliability was obtained (Cohen's kappa≥.8). Results: The survivors were 50% (57/113) male, 93% (105/113) Caucasian, 34% (38/113) college educated, and 71% (80/113) married with a mean (SD) age of 42.5 (10.6) (range = 19-69) years at the time of the bombing. Eight themes emerged and indicated that survivors matured in personal goals and character, interpersonal relationships, and philosophical thought (e.g., reconsideration of human nature and religion). More than one third of the comments included negative remarks about personal harm, especially psychological effects. Conclusions: Nearly two thirds of the material was positive in tone and consistent between six months and seven years. Negative content was entirely new relative to six-month baseline interview responses, suggesting many survivors incorporate greater reflection on negative outcomes in meaning-making processes over time. After several years, clinicians could encourage survivors to integrate positive and negative consequences as meaning. Longer-term studies are needed.

Key Attributes of a Medical Learning Community Mentor at One Medical School: The Mentee Perspective.

To assess the elements necessary to be a successful learning community (ClinCalc) mentor to medical students from the mentee's perspective. Few such studies have utilized the in-depth and richness of detail obtained in qualitative studies. This qualitative study analyzed four focus group discussions lasting 45-90 min conducted at the University of Texas Southwestern Medical School, which has an established LC, in the year 2018. The groups included 14 pre-clerkship and 8 clerkship students. Investigators evaluated transcriptions of the focus group discussions using ATLAS.ti software. Three overarching categories of discussion emerged from the group discussions: (1) Relationship Competence, (2) Teaching Competence, and (3) Ethical and Compassionate Medical Practice Competence. Relationship Competence themes included "walk with me," relationship is most important, and one-on-one. Teaching Competence themes included above and beyond, recognize and address mentor limitations, and safe and enriching environment. Ethical and Compassionate Medical Practice Competence themes included ethical decision making and compassionate care for diverse patient populations. Mentees focused on various aspects of the mentor-mentee relationship as the single most essential competence. Themes mentees discussed as important qualities of a successful mentor may denote qualities to be prioritized in faculty development and mentor recruitment. Future studies could investigate how the LC environment informs former medical students and promotes patient outcomes.

Perspectives of Survivors of the Oklahoma City Bombing with and without PTSD 17 Months Postdisaster: A Qualitative Study.

This study compared perspectives of highly trauma-exposed Oklahoma City bombing survivors (N=141) with and without PTSD. Survivors' responses to questions about the effects of the bombing on their perspectives were hand-recorded and transcribed, six themes identified, and interrater reliability established. Both diagnostic groups (with and without PTSD) expressed greater appreciation for life, greater concern with human vulnerability and mortality, and positive changes in religion/spirituality as consequences of the bombing. Survivors with PTSD also expressed negative religious/spiritual changes and substantive gains in self-confidence. Results indicate that disaster survivors may experience profound changes in their perspectives with ramifications for their mental health.

A Qualitative Longitudinal Study of Workplace Issues, Authorities and Media, and Relationships Recounted by Oklahoma City Bombing Survivors After Nearly a Quarter Century.

OBJECTIVE: The aim of the study is to examine the long-term course of disaster-related experience among survivors of a terrorist bombing and the long-term recollection of initial workplace effects across nearly a quarter century. METHODS: From an initial randomly selected sample of highly trauma-exposed survivors of the 1995 Oklahoma City bombing, 103 participated in qualitative open-ended interviews about their bombing experience approximately 23 years after disaster. RESULTS: The survivors described their bombing experience clearly with extensive detail and expression of persistent strong emotion. Their discussions reflected findings from earlier assessments and also continued over the course of the next decades to complete their stories of the course of their occupational and interpersonal postdisaster journeys. CONCLUSIONS: Long-term psychosocial ramifications in these survivors' lives continue to warrant psychosocial interventions, such as occupational and interpersonal counseling.

Making Meaning of Disaster Experience in Highly Trauma-exposed Survivors of the Oklahoma City Bombing.

Survivors of disasters can be expected to form meaningful perspectives on their experiences that shape their trajectories of recovery; thus, these perspectives are important to study. If humans are naturally compelled to create meaning from traumatic experiences, the creation of meaning should be evident in survivors' discussion of the effects of the disaster in their lives. Therefore, the purpose of this study of highly trauma-exposed disaster survivors was to identify meaningful aspects or outcomes of their disaster experiences in their perspectives. This study examined a random sample (N=182) of survivors of the Oklahoma City bombing six months after the disaster using open-ended questions. Text responses (N=650) were compiled, themes identified by multiple coders, responses coded into the themes, interrater reliability established, and the themes were then interpreted. Six themes were identified and grouped into three general categories: personal aspirations (reprioritizing life and altruism and self-improvement), connection with others (a freestanding category/theme), and making meaning (appreciation for life, religion and spirituality, and contemplating life, death, and humanity), which contained the majority of the responses. The findings from this study affirm the human need to make meaning from the experience of a traumatic disaster and suggest the potential relevance to survivors' recovery of therapies based on the creation of meaning and the promotion of positive growth.

Episodic Memories Among Irritable Bowel Syndrome (IBS) Patients: An Important Aspect of the IBS Symptom Experience.

Objective: Some IBS patients possess detailed memories of the events surrounding their bowel symptom onset ("episodic memories"). In this exploratory study we sought to: (1) examine memory relationship with gastrointestinal (GI) symptom severity, extraintestinal symptoms, and mood; (2) qualitatively explore memory valence and content in IBS patients with or without episodic memories. Methods: Referral IBS patients n = 29; age 47.0± 2.2 years, 79.3% female) enrolled in this cross-sectional, mixed methods research study. Participants completed validated specific memory instruments [Autobiographical Memory Test (AMT), Sentence Completion for Events from the Past Test (SCEPT)] and relevant questionnaires [IBS symptoms 10-cm visual analog scale); SF-36 Health-related quality of life (HRQOL); Perley-Guze and PHQ-15/12: somatization; Beck Depression/Anxiety Inventories). Qualitative analysis examined the content and valence of general memories. Results: 14/29 (48.3%) of IBS subjects endorsed episodic memories of IBS symptom onset, often GI infections/enteritis (35.7%). Recall of the exact year (69%) and month (60%) of symptom onset were common. Episodic memories were associated with greater IBS symptom severity/bother, higher anxiety/depression, and poorer HRQOL. Though AMT and SCEPT memory specificity were not different based on episodic memories, overgeneralization to negatively-valenced cues in the AMT was associated with more severe IBS in those without episodic memory. Qualitative analysis revealed no observable differences in topic focus of IBS patients with and without episodic memories. Conclusions: IBS patients often endorse episodic memories associated with symptom onset, and this recall seems to associate with more severe symptoms. Overgeneralization responses to negative stimuli may lead to worse bowel symptoms in those without episodic memories. IBS memory specificity may associate with qualitative differences in processing psychosocial experiences and might be important to IBS pathophysiology.

Comparison of violence risk screening experiences of emergency department clinicians.

OBJECTIVE: Individuals commonly present to the emergency department (ED) for care after violence and many are also at risk for subsequent self or other-directed violence. Screening for violence risk represents an important part of ED care, but is challenging to implement effectively. Feedback from ED providers is needed to characterize differences across provider types in order to facilitate implementation of enhanced screening practices. METHODS: This qualitative focus group study examined the experiences of 6 psychiatric social workers, 16 emergency medicine physicians, and 15 psychiatric providers in conducting violence risk screening to elicit ideas about solutions and barriers. RESULTS: Eight themes emerged: Approach to Patient Assessment, High-Yield Clinical Data in Risk Assessment, Suicide Risk Screen, ED Clinician Resources, Analysis of Professional Risk, Affective Response of Clinician, ED Role and Scope, and Clinical Management. All clinician types discussed the themes from their professional perspectives and generated important knowledge of violence risk screening practices. CONCLUSIONS: The findings affirm the importance of interdisciplinary cooperation in addressing violence risk in the ED and emphasize the need for ongoing clinical education and feedback as well as the importance of optimizing efficiency.

A systematic mental health assessment of first-year students at a historically Black college.

BACKGROUND: A systematic diagnostic mental health assessment was conducted with first-year students at Paul Quinn College, a small historically Black college/university (HBCU) in Dallas, Texas. METHODS: A sample of 128 students was assessed with the Mini-International Neuropsychiatric Interview for DSM-5 and the Childhood Trauma Questionnaire. RESULTS: Nearly one-third of students were diagnosed with a current psychiatric disorder, most commonly substance use disorders (17%) and major depressive disorder (9%). Despite these findings, few students had ever received psychiatric treatment, and considering their substantial trauma histories, few developed posttraumatic stress disorder, reflecting protective factors in the HBCU. CONCLUSIONS: The prevalence of psychiatric disorders in this HBCU study is consistent with findings of studies conducted at predominately White institutions. However, the relatively low access to treatment of these HBCU students suggests relevant mental health care disparities in this population. Further research is needed to develop interventions designed to help connect HBCU students to mental health care.

A prospective longitudinal study of tobacco use and tobacco use disorder in a homeless population.

BACKGROUND: Little is known about smoking habits and disorders among homeless populations. Previous research has not generally differentiated tobacco use from tobacco use disorders in this population. Known associations of tobacco use and morbidity and mortality in general populations may also apply to homeless populations. METHODS: A 2-year longitudinal prospective study of 255 homeless individuals examined tobacco use and tobacco use disorders in association with other psychiatric disorders and service use and homeless outcomes. RESULTS: The majority of the sample used tobacco daily and had a tobacco use disorder, characteristics that changed little over the 2-year follow-up period. Tobacco use disorder was associated with greater substance, medical, and psychiatric service use during the 2 follow-up years. However, tobacco use was not associated with change in housing status over the 2-year follow-up period. Cessation of tobacco use was associated with cessation of alcohol use. CONCLUSIONS: Smoking is a major health issue for homeless populations. This study found that smoking status was unassociated with the achievement of stable housing. In addition, homeless people who smoke were found to be more likely to use health care services, indicating a potential source of intervention for smoking cessation.

Disasters, Diagnosis, and Distress: Multiple Perspectives, Populations, and Methodologies.

Disaster mental health is a consequential topic in today's world in which disasters are increasing in both numbers and magnitude and inflicting deep psychological wounds across wide populations [...].

Deconstructing childhood conduct and adult antisocial criteria for the diagnosis of antisocial personality disorder.

BACKGROUND: Antisocial personality disorder (ASPD) is a serious psychiatric disorder that can be incapacitating and costly to individuals and society. The ASPD diagnosis has 2 main components, childhood conduct problems and adult antisocial behaviors, with specific age requirements. The nosological effects of these criteria on population subgroups defined by these aspects of the criteria have not been fully explored. METHODS: Data for ASPD were analyzed for 3,498 individuals in the St Louis, Missouri, site of the Epidemiologic Catchment Area study of general population psychiatric disorders collected in the early 1980s using structured diagnostic interviews for DSM-III criteria. Effects of the criteria on population subgroups defined by various combinations of the criteria were examined. RESULTS: Earlier-onset conduct disorder was more severe than later-onset childhood conduct disorder, with more total childhood and adult symptoms and negative psychosocial adult outcomes (substance use disorders, criminality, and homelessness). Three subgroups with adult antisocial behaviors (differentiated by no conduct disorder, later-onset conduct disorder, and earlier-onset conduct disorder meeting ASPD criteria) were similar in numbers of adult antisocial symptoms, but the ASPD subgroup had more negative psychosocial adult outcomes. CONCLUSIONS: These findings provide evidence for and against reconsideration of the 15-year age-of-onset requirement for conduct symptoms in ASPD criteria.

Groundhog Day: research without old data and old references.

BACKGROUND: The use of older data and references is becoming increasingly disfavored for publication. A myopic focus on newer research risks losing sight of important research questions already addressed by now-invisible older studies. This creates a 'Groundhog Day' effect as illustrated by the 1993 movie of this name in which the protagonist has to relive the same day (Groundhog Day) over and over and over within a world with no memory of it. This article examines the consequences of the recent preference for newer data and references in current publication practices and is intended to stimulate new consideration of the utility of selected older data and references for the advancement of scientific knowledge. METHODS: Examples from the literature are used to exemplify the value of older data and older references. To illustrate the recency of references published in original medical research articles in a selected sample of recent academic medical journals, original research articles were examined in recent issues in selected psychiatry, medicine, and surgery journals. RESULTS: The literature examined reflected this article's initial assertion that journals are emphasizing the publication of research with newer data and more recent references. CONCLUSIONS: The current valuation of newer data above older data fails to appreciate the fact that new data eventually become old, and that old data were once new. The bias demonstrated in arbitrary policies pertaining to older data and older references can be addressed by instituting comparable treatment of older and newer data and references.

Employee Job Satisfaction and Performance in Association With Workplace Responses to the 9/11 Attacks on New York City's World Trade Center.

OBJECTIVE: Research is needed on disaster-affected workplaces, particularly on employee job satisfaction and performance, to inform workplace responses promoting employee postdisaster adjustment and wellbeing. METHODS: Quantitative and qualitative data were collected from a volunteer sample of 255 employees of eight workplaces affected by the 9/11 attacks on New York City's World Trade Center nearly 3 years post disaster. RESULTS: The effects of 9/11 on both job satisfaction and job performance were more negative than positive, especially for the Ground Zero employees. Effects on job satisfaction and job performance were generally congruent. Workplace responses focused on individual needs were perceived as positive and those focused on workplace needs as negative. CONCLUSIONS: Workplace responses focused on business improvement intended to improve workplace performance may not have the desired effect and may reduce employee job satisfaction and performance.

Objective and Subjective Perspectives on Implementation of a Violence Risk Screening Program in an Emergency Department.

OBJECTIVE: The objective of this study was to use quantitative and qualitative data to gather information about emergency medicine and psychiatric provider perspectives regarding the evolution of a violence risk screening process including the simultaneous implementation of a universal suicide screening program. METHODS: A retrospective review of violence risk screening data for 496 patient encounters over a 2-year period and across 4 phases of implementation and improvement was completed. Four focus groups were conducted with emergency medicine and psychiatric providers using nondirective facilitation methods to gather data regarding provider perspectives about violence and suicide risk screening. The focus groups were recorded, transcribed, and analyzed for thematic content. RESULTS: Four of the 6 violence risk screening items were most strongly associated with high-risk stratification across all phases. There were no changes in proportions of positive responses for 3 of the items. The proportion of positive responses for the other items changed significantly after expert feedback and clarification of item wording. Only 3% of the focus group passages included discussion of the universal suicide screening program. CONCLUSIONS: The providers indicated that they believed the violence risk screening and suicide screening procedures helped improve clinical thoroughness and documentation. Ongoing feedback between providers and program developers was beneficial. The implementation of the universal suicide screening process was relatively seamless for these providers.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.