April 15, 2023 marks the 10th anniversary of the Boston Marathon bombing. On the day of the bombing, 281 injured patients were brought to Boston hospitals to treat physical trauma. At Mass General Hospital, emergency medical teams were rapidly mobilized to care for the victims of the marathon bombing, many of them with life-threatening injuries. At the same time, a mental health disaster response was also mobilized — within hospitals and in the community.
In a paper published in Lancet Psychiatry, Katherine Koh, MD MSc, a psychiatrist at MGH and member of the Street Team at the Boston Health Care for the Homeless Program, and her colleagues outline the key features of the mental health disaster response after the bombing. What we have learned from that experience has informed our response to other disasters, including the COVID-19 pandemic.
Hospital-Level Initiatives
At the hospital level, at least three distinct types of organizational responses took place:
Multidisciplinary teams, including staff from emergency medicine, psychiatry, chaplaincy, and patient-family services, were established to help patients cope with the events.
Some institutions pursued a systematic strategy of screening patients for assessing mental health needs related to the event.
Third, hospitals initiated programs specifically to educate and support clinicians, for example offering training sessions for psychiatrists and other mental health clinicians on best practices for providing care to acutely traumatized individuals. Other hospitals also created support groups for medical staff affected by the bombing.
Community-Level Initiatives
Community-level initiatives were also established.
First, support centers were created or activated by community organizations in the weeks after the bombing to provide information on resources and mental health counseling to community members. Additionally, a longer-term Family Assistance Center was set up for months to provide support services to bombing victims and their families. The most common request for service was a mental health referral, more so than support with financial services, legal assistance, or benefit information.
Second, initiatives offering services directly to people in need were mobilized. Support groups for individuals affected by the bombing were provided by various community organizations. Several community sites offered free in-home and community-based counseling. Stay Strong Boston was created to provide individuals with access to a mental health self-assessment tool, information on coping, and information on how to access mental health services. Multiple hotlines were made available to support members of the community.
What Did We Learn from the Boston Marathon Bombing?
Koh recommends that at the healthcare level, mental health disaster preparedness should be taught systematically. Training programs for allied health professionals should include education about the mental health response to disasters. She also recommends that all hospitals prepare a psychological response team that could be rapidly mobilized and available to provide mental health care to both patients and staff after a disaster.
At the community level, a coordinated response should utilize and build on the framework of existing community agencies and programs. The evidence-informed approach known as Psychological First Aid (PFA) is recognized as a guiding principle informing the care of individuals in the immediate aftermath of a disaster. Its basic principles include establishing connection and engagement with community members, ensuring their safety and comfort, and providing information to help cope with the psychological impact of disasters.
As an adjunct to these efforts, the media can be a powerful force in promoting or preventing healing. The media can disseminate messages that include ways to obtain help, educate about the stages of grief, and provide information about common symptoms after disasters. However, the endless cycles of reporting on the event and the inclusion of graphic images and details may lead to over-exposure and may lead to a wider circle of traumatization or re-traumatization.
Mental Health Disaster Response to the COVID Pandemic
The response to the Boston marathon bombing showed that a well-coordinated response at the hospital and community level can be quickly mobilized and offers a roadmap for managing not only the physical, but also the mental, trauma that occurs after a disaster.
While most mass casualty events are natural disasters, mass shootings and terrorist attacks, in 2020 we encountered a new type of mass casualty event in the form of the COVID-19 pandemic. Although there were important differences between the pandemic and the Boston Marathon bombing, the lessons learned after the marathon bombing helped to structure our mental health response in the setting of the pandemic.
In order to decrease the load on local hospitals, the Boston Hope Field Hospital, a 1000-bed facility, was launched to care for COVID-19-postive patients with milder illness. Half of the beds were reserved for the homeless population. In that setting, Koh and her colleagues created and implemented a mental health disaster response employing the principles of psychological first aid.
What Koh and her team demonstrated is that effective mental health disaster response can be applied in a field hospital setting. Although PFA is often applied on the individual level to survivors, these principles can be applied at the systems level to organize a population-wide response for homeless individuals in a disaster setting. In addition, mental health providers who have experience working in acute settings can support community medical teams through their experience in trauma-informed care, supportive psychotherapy, and crisis de-escalation. These interventions can be implemented quickly and without needing large staffing, financial, or administrative burdens, particularly when telehealth is used to capitalize on existing outpatient relations with mental health professionals.
As we move forward, Koh emphasizes that the development of emergency preparedness systems in cities must include provisions for a mental health response to a disaster. This is imperative in order to minimize both short-term and long-term sequelae of traumatic events. Future disaster planning must include mental health preparedness as a central component of disaster response and must expand to include planning that creatively cares for vulnerable populations. Yet the field of mental health disaster preparedness remains underdeveloped. The success of the emergency response to the Boston bombing has been measured in terms of morbidity and mortality outcomes; however, the effect of the mental health response has received scant attention and its effectiveness has not been systematically assessed.
Read More
Dotson S, Ciarocco S, Koh KA. Disaster psychiatry and homelessness: creating a mental health COVID-19 response. Lancet Psychiatry. 2020 Dec;7(12):1006-1008.
Koh KA, Raviola G, Stoddard FJ. Psychiatry and Crisis Communication During COVID-19: A View From the Trenches. Psychiatr Serv, May 2021; 72(5):615.
von Keudell A, Koh KA, Shah SB, Harris MB, Smith M, Rodriguez EK, Dyer G. Mental health after the Boston marathon bombing. Lancet Psychiatry. 2016 Sep;3(9):802-4.
Katherine Koh, MD, MSc is a practicing psychiatrist at Mass General Hospital, a member of the Street Team at the Boston Health Care for the Homeless Program and an Assistant Professor in Psychiatry at Harvard Medical School. As a member of the street team at BHCHP, she focuses her clinical care on homeless patients who live on the street through a combination of street outreach, clinic sessions, and home visits for patients recently or unstably housed. She also maintains a general outpatient practice at MGH and conducts research on the health of homeless populations. Her primary interest is improving systems of mental health care for homeless patients.
