Learning From The Past and Planning For The Future
MENTAL HEALTH MOMENT August 1, 2003 "There is no worse lie than a truth misunderstood by those who hear it." - William James
Traumatic Stress, Self-Awareness, and Self-Care
Self-care It is important to remember that no matter how effective someone's coping skills may be, there are events, that can easily overwhelm those skills. This is true for each of us as individuals and each of us as members of our larger relief organization's teams. Stress reactions are common, normal reactions to any unusual and highly stressful situations.
People can experience several types of stress:
- Anticipatory stress - concerns over the future ("What if…?", "Am I ready for this?", and "Here we go!");
- Situational stress - the concerns of the moment (newness, uniqueness, and magnitude);
- Chronic stress - worry over time ("I thought this would end sooner!" and "I miss my family"); and
- Residual stress - unresolved issues from previous incidents.
The intensity of the each person's reaction to stress can be modified by several factors:
- Duration - longer exposure to any stressful event usually makes it more severe;
- Multiplicity - the more stresses there are, the greater the potential reaction;
- Situational importance - greater importance of the event means greater reaction;
- Individual's evaluation of the stress - how threatening is the situation and how prepared am I to cope with the consequences (we each have our own psychological Achilles' heel);
- Reminders that trigger vivid memories (press coverage, trials/law suits, and similar incidents); and
- Stress tolerance - general ability to tolerate plus benefits of stress inoculation.
There are three categories of reactions to traumatic stress - thoughts, feelings, and behaviors. Here are a few examples of each:
Thoughts
- Recurring dreams or nightmares about the disaster.
- Reconstructing the events surrounding the disaster in your mind, in an effort to make it come out differently.
- Difficulty concentrating or remembering things.
- Questioning your spiritual or religious beliefs.
- Repeated thoughts or memories of the disaster, or of loved ones who died in the disaster, which are hard to stop.
Feelings
- Feeling numb, withdrawn, or disconnected.
- Experiencing fear and anxiety when things remind you of the disaster, particularly sights, sounds, and smells.
- Feeling a lack of involvement or enjoyment in everyday activities.
- Feeling depressed, blue, or down much of the time
- Feeling bursts of anger, or intense irritability
- Feeling a sense of emptiness or hopelessness about the future.
Behaviors
- Being overprotective of your and your family's safety.
- Isolating youself from others.
- Becoming very alert at times and startling easily.
- Having problems getting to sleep or staying asleep.
- Avoiding activities that remind you of the disaster, avoiding places or people that bring back memories.
- Having increased conflict with family members.
- Keeping excessively busy to avoid thinking about the disaster and what has happened to you.
- Being tearful or crying for no apparent reason.
Basic Self-Care
No matter how good your coping skills or how many disasters you have worked or experienced, there will come times when some aspect of an operation breaks through your defenses and makes you vulnerable to the traumatic stress. It is clear in the research literature that there are relatively simple things that can be done to improve your resilience to stress. While this is true in any disaster, it is especially true in aviation disaster, and a higher level of self-care is required.
Shifts (stick to them) - With the exception of the first day or two, be certain that you stick to the shift assigned hours.
Breaks (take them) - A reasonable time frame is 10 - 15 minutes every two hours. More may be needed. Get away from the maelstrom for a few moments.
Diet - A healthy and balanced diet can significantly improve your ability to cope with high levels of stress. Beware of caffeine and alcohol. Both can significantly impair your ability to function. If you need caffeine to continue to function in this supercharged environment, you just aren’t getting enough sleep. Beware of too much junk food. Too much sugar can cause sugar lows in addition to the famous sugar highs.
Support - Be sure you don’t isolate yourself. Talk about things other than the operation with colleagues on your team. Talk with your family back home. Call colleagues that understand what you’re going through.
Days off - Common practice for relief operations is one day off in every seven. The high intensity and stress of aviation disasters may create a need for more frequent time off. This should be considered on a case-by-case basis and not held against any individual requesting additional time off.
But you probably knew all of that before taking this course. It seems almost too basic. Self-care and stress management cannot possibly be that simple, can they? The answer is a resounding "YES" - these basic elements are consistently found to be the most effective components of effective self-care. With that in mind, let's now go into a bit more detail.
Who is At-Risk for Stress Reactions?
When multiple and prolonged exposures to traumatic stress are present, as they are for relief workers in the aftermath of every major disaster, everyone is at risk - everyone will need to work at stress management and self-care. Some of us, however, may be at even greater risk, especially in the early stages of our involvement. Here is a list of persons to consider as being at higher risk for stronger reactions:
The young and/or the newest among us.
Those who are most caring / empathetic.
Those who are the least well defended.
Those who tend to become overly involved.
Those in the most emotionally charged settings (e.g., childcare).
Those with unresolved personal issues (e.g., rescue fantasies).
Those who have recently experienced other loss(es) and are grieving.
Those who are least trained, supervised, and/or supported.
Those who do not practice good self-care and stress management.
The trauma specialists, especially those who may think they are immune.
We will all have some reactions to the stressful situations we face during our assignments and this is perfectly normal. In fact, we all tend to be "changed" by the uniqueness and the intensity of our experiences in mass-casualty assignments, but we need not be "damaged" by these experiences.
How Do Serious Stress Reactions Come About?
If only there was one simple answer to that question. Then, perhaps we could fully inoculate everyone to the stress and protect relief workers as they serve others. Unfortunately, there is not always a pure, cause and effect relationship between exposure to traumatic situations and development of long-term problems. Most people now realize that one easily definable traumatic event can result in development of stress reaction (and possibly lead to development of PTSD). For relief workers, though, there are multiple exposures to traumatic material that has been experienced by others.
Hearing the stories and feeling the pain of others can easily make us secondary victims. As we are working very hard at serving others, we often do not realize how much exposure we have had. That is because our exposure it is often more insidious process, slowly building over time. A good way to think about it is that it is similar to secondhand smoke - it very often hard to measure and it is even harder to predict what effect it may have on us in the future.
What is it that Determines our Susceptibility to Traumatic Stress?
Several factors play a role in determining how each of us manages stress.
- Prior trauma experiences and stress inoculation;
- Gradation of exposure;
- Identification with the victim - reactions like "that could have been my child" and "survival guilt";
- Our own physical and psychological health status; and
- Other "routine" stresses - work, family, etc.
Self-Awareness
How well do we know ourselves? Coming up with an honest answer to that question is a good way to begin exploring whether or not to tackle the added stress that mass-casualty relief assignments brings to out lives. We must work to develop an understanding of our vulnerabilities and we have to be careful with our expectations.
Relief workers are similar to police, fire, and rescue workers in personality type. Some of the common traits that we share can lead directly us into internal conflict.
- We like to be in control (and have things under control).
- We are generally perfectionists.
- We are action-oriented people.
- We have a high need for stimulation and excitement (easily bored).
- We often want/need immediate solutions/gratification.
- We tend to freely accept challenges and take risks.
- We are strong willed, highly motivated, and dedicated workers.
These same qualities that allow us to do a good job - the very things that others so value in us - are the qualities that can also land us in unwanted roles as secondary victims of the traumatic event.
How should we try to avoid these problems? We can begin by learning what it is that pushes our buttons and triggers our personal reactions to trauma. Most factors involve associations and similarities to our lives. These can be triggered by sights, sounds, and smells (e.g., children who are the same age as our children/grandchildren). Other triggers may be recent life events (still resolving death of a family member or friend) and reflections on our own fears/mortality (that could have been…). These situations should not be mistakenly viewed as opportunities to escape stresses/issues at home or to resolve prior life events.
We need to be able to recognize and "manage" our anticipatory reactions. Many experience a strange (and sudden), heightened awareness of everything that can go wrong in life (a loss of innocence). There can be over-identification with the victims and/or the survivors (everything starts to seem personal). There can also be a sense of déjà vu as people have "Here we go again?" reactions whenever similar cues are present.
We also need to able to accept the problems presented by our own frustrated desires and the frequent desire for closure. There can be a sense of helplessness and lack of control over traumatic events. Working with people for short periods of time as they begin the process of grieving, we seldom have a chance to see very much progress and it is too early to gauge outcomes.
We must avoid the natural tendency to beat up on own egos when things are not running a smoothly (perfectly?) as we would like. This is especially true when things actually go wrong. It is easy to become incapacitated by guilt, self-pity, fears of next time, and/or trouble letting-go.
We must also keep in mind that mass-casualty relief work is not for everyone. For some volunteers, even routine disaster assignments are too stressful and mass-casualty events are anything but routine. The process of taking care of oneself can begin even prior to acceptance of these difficult assignments, during the recruitment call. Think seriously about whether or not you need this amount of stress in your life right now (or if you ever need it).
If you are already grieving another loss or if you have recently been on another mass-casualty operation (or any rough assignment), put your own health first and say "NO" this time. If you have more general doubts about your ability to handle this kind of work, avoid it altogether and stick with other, less-stressful assignments.
Strategies for Improving Coping While On-the-Job
Carefully consider how these issues fit into you personal and organizational stress management plans:
- Pre-briefing is essential. Convey the magnitude and the gory details - convince workers about the need for treating the big ones a bit differently than their day-to-day tasks.
- Tasks-at-hand should be the immediate and central focus. Break up the work and start to do the little jobs well. At first, the big picture may just be too overwhelming.
- Stress management is critical, with careful monitoring by DMHS Personnel. Begin with the basics - work from Maslow's lowest level needs on up.
- Routines and rest periods must be established and maintained. Use daily schedule for work and for breaks/time off.
- Offbeat Humor - Where is the Line…? (How are the victims, survivors, and relief workers using humor struggle with the situation?)
- Reality must be respected. Be realistic with both personal and organizational objectives. We can only do so much work and we can only handle so much pressure/stress.
- Peer Support is critically important. Develop and encourage use of a buddy system. Balance the workload. Share the tough cases. Meet regularly (e.g. beginning and end of each day) to tell the stories and vent the stress.
- Trust in the need for even the most basic forms of self-care. Eat well, get regular sleep, and listen to the inner voice when it tells you things like: "It's time for a break for a break."; "I really don't need that extra (cup of coffee, doughnut, dessert, cigarette, beer,)."
- Self-Talk is a good thing. Encourage use of that same inner voice mentioned above for developing and reinforcing a positive outlook. Self-defusing by keeping a journal is also possible. It can be combined with cognitive-behavioral techniques to help rid yourself of troubling, negative thoughts.
- Dangers-of-downtime are often unexpected challenges to all. With rest there is the accompanying time, energy, and peaceful environment, all of which are conducive for reflection. Some will begin to process their thoughts and feelings. Others may try to escape with hectic entertainment or a premature return to their relief setting and role.
PTSR or PTSD? We expect normal stress reactions and know that they will run their natural course in the first days, weeks, and months following the disaster. Through self-care, peer support, and diligent use of DMHS interventions like defusing and debriefing, we hope to prevent the long-term negative outcomes that may lead to PTSD.
Defusing and Debriefing
Defusing is the term given to the process of talking it out. It works like taking the fuse out of a bomb (or an explosive situation), by allowing victims and workers the opportunity to ventilate about their disaster related memories, stresses, losses, and methods of coping, and allowing them to do so in a safe and supportive atmosphere. Simply giving eye contact to someone who needs to talk is often enough to start the process. The worker simply needs to be present, listen, and offer support.
The defusing process usually involves informal and impromptu sessions. Although they are generally brief and immediate, the defusing sessions often become mini-debriefing sessions and can follow one of the same formats discussed below. Because the allotted time is often too short, it is simply a starting point. Further intervention is often required and this can be anything from offering ongoing support (e.g., briefly touching base with the persons/groups in the coming days/weeks) to scheduling and providing formal debriefing sessions.
Debriefing is a formal meeting, done individually or in small groups. It is generally held shortly after an unusually stressful incident, strictly for the purpose of dealing with the emotional residuals of the event. Any location that is large enough to accommodate the participants, and can be secured so as to assure privacy, is appropriate for use. This session may require a block of time that is several hours in length.
Debriefing sessions are usually held within the first 24-72 hours after the traumatic event, with follow-up sessions as needed. Given the nature of disasters, we do not always identify all of the victims that quickly. Fortunately, the debriefing process is still beneficial, even when the sessions are held long after the event.
Whenever possible, everyone involved in the traumatic event should attend the debriefing(s). Many organizations recommend or even require attending defusing and debriefing sessions, whenever certain types of incidents occur. During most disaster relief operations the American Red Cross (ARC) offers defusing as necessary, throughout a person's tour of duty at a disaster scene. ARC also recommends (but does not require) having a debriefing before leaving for home. Once ARC workers get home, their local ARC chapter usually offers them a formal debriefing.
At the morgue following the 1994 crash of Flight 427 near Pittsburgh, volunteer trackers and scribes (persons who escorted the remains of the 132 victims through the I.D. process) were offered graphic pre-briefings to provide stress inoculation. They were required to attend debriefings at the end of their shifts. Cafeteria trays were used to carry body parts and Vicks was used to mask foul odors. The volunteers were alerted to this and warned that the next time they used these familiar items they would be reminded of this tragedy. Telling them about this in advance offered some measure of stress inoculation. Many expressed their gratitude and all seemed to value the opportunity to be debriefed.
In mass-casualty situations, ARC will require everyone to participate in debriefing sessions. The focus for daily defusing or debriefing sessions should be on sharing the most important issues of the day and answering any specific questions the workers may pose. Teaching about any predictable stresses/reactions that are to come is another important activity. Save any in-depth discussions of feelings for the close-of-business (end-of-job) debriefings, so as to not lower needed defenses and healthy denial too soon to allow completion of the tasks at hand.
There are now several debriefing models. While they differ in the number and type of phases (or stages), they all get at the same basic elements that Jeff Mitchell's original CISD process sought to examine. All help people examine the sights, sounds, smells, thoughts, feelings, symptoms, and memories that are all part of a normal stress reaction to a traumatic event. ARC DMHS workers are taught the Multiple Stressor Debriefing Model. Here are the phases used in that approach:
Introductions
Phase 1 - Disclosure of Events
Phase 2 - Feelings and Reactions
Phase 3 - Coping Strategies
Phase 4 - Termination
To be most effective, workers need to allow lots of time for participants to ventilate, especially during the initial phases/stages of the process, when facts, thoughts, and feelings are being discussed. Encourage detailed expression of the most vivid or graphic, negative images and memories. Think of it as cleaning out an emotional wound before allowing it to heal with foreign material still on the inside. Improper procedure with a bad cut promotes infection. Improper procedure here will mean the emotional wounds can be too easily reopened by future stressful events.
Normalize the experiences that people share. Teach them about stress reactions. Provide stress inoculation about anniversary reactions and other issues they will eventually face. Offer lots of support and try to anchor a positive image and outlook for their successful recovery. End by thanking them for coming and taking part in the debriefing process; shake their hands and/or give a hug as each person leaves the session.
Here are some general debriefing guidelines that will also apply to work in the childcare settings:
- Try to group participants by common experiences and exposure levels.
- Use several leaders (2 per group and a 3rd as gatekeeper near the door).
- When running formal groups with people seated in a circle, leaders should sit opposite each other.
- Go around in a circle a couple of times for introductions and descriptions of the events as they experienced them (get everyone involved from the beginning).
- Clean the wounds by spending lots of time on the facts, feelings, and reactions.
- Highlight the common elements of their stories, writings, art, and/or play.
- Validate their feelings and normalize their reactions.
- BE SURE TO ANCHOR A POSITIVE.
- Thank everyone for coming and sharing his or her stories.
- Leaders must be the last ones to leave the room (anyone needing special attention will seek you out).
Feel free to call upon the DMHS workers for help and support whenever the routine activities (talking, playing, drawing, etc.) seem to be creating a need for a more structured intervention. This might occur if one child shares troubling material and upsets several others with his or her comments and reactions.
What Else Can Be Done?
- When you have the opportunity, allow yourself to feel sadness and grief over what has happened. Talking to others about how you are feeling is useful.
- Try to keep in place routines such as regular meal times and other rituals. These will help you to feel some sense of order.
- Upsetting times can cause people to drink alcohol or to use drugs in a way that causes other problems. Recognize that potential in yourself and your team.
- Forgive yourself and others when you act out because you are stressed. This is a difficult time, and everyone's emotions are closer to the surface. But also be certain that your stress does not become an excuse for abusive management styles.
- Don't let yourself become isolated. Maintain connections with your team, but also with friends and family. Try to keep a sense that there is a real world outside the operation.
- Maintain boundaries between your life and your assignment. Having some measure of healthy emotional distance from your work is very useful. For instance, it is not a good idea to read all the news reports or watch all of the media broadcasts that detail the lives of those who were lost. This tends to make things too personal and workers will begin to over-identify themselves with the situation.
- Set aside time to maintain your spirituality. Attending memorial services and engaging in contemplative prayer are helpful to many relief workers.
When Things Get Tough
A few general guidelines may be useful in deciding when normal reactions to disaster become problems requiring a referral:
- When disturbing behaviors or emotions last more than four to six weeks;
- When a person's behaviors or emotions impair his/her normal functioning (including functioning on and/or off duty); or
- Anytime an individual feels uncomfortable or concerned about his or her behaviors, emotions, or thought processes.
You are responsible for your own well being and that of your of your staff. You must ensure that the components of self-care, including both the physical and emotional, may be met by each worker.
Follow-up Care When You Head Home
You should receive defusing sessions during the assignment and a debriefing prior to departure. Upon your return home, seek an additional debriefing with a local disaster mental health (DMH) worker. The emotional impact of your assignment may not sink in until you return home. This is not unusual and should be expected. The follow-up debriefing will help you put your experiences in perspective and re-enter your normal lifestyle.
You may be asked to speak with the media or do presentations regarding your experience. It is your call whether or not you take on these opportunities. It is recommended that you complete your debriefing at home before you talk about your assignment publicly.
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REFERENCES Armstrong, K. R., Lund, P. E., McWright, L. T., & Tichenor, V. (1995, January). Multiple Stressor Debriefing and the American Red Cross: The East Bay Fire Experience. Social Work, 40, 83-90.
Dingman, R. (Editor). (1995, July). Disasters and Crises: A Mental Health Counseling Perspective. Journal of Mental Health Counseling (Special Issue), 17, 3.
Everly, G. S., Jr. (1995, July). The Role of the Critical Incident Stress Debriefing (CISD) Process in Disaster Counseling. Journal of Mental Health Counseling (Special Issue - Disasters and Crises: A Mental Health Counseling Perspective), 17, 3, 278-290.
Figley, C. R. (Editor). (1995). Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner/Mazel.
Fullerton, C.S., & Ursano, R. J. (Editor). (1997). Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. Washington, DC: American Psychiatric Press. (Phone 1-800-368-5777)
Mitchell, J. T. (1983, January). When Disaster Strikes...The Critical Incident Stress Debriefing Process. Journal of Emergency Services, 8, 1, 36-39.
Stern, P. N., & Kerry, J. (1996). Restructuring Life After Home Loss by Fire. Image: Journal of Nursing Scholarship, 28, 1, 11-16.
Weaver, J. D. (1999). How to Assist in the Aftermath of Disasters and Other Life Crises. In L. VandeCreek, S. Knapp, & T.L. Jackson (Eds.), Innovations in Clinical Practice: A Source Book (Vol. 17), Sarasota, FL: Professional Resource Press, pp. 397-411.
Weaver, J. D. (1996). Disaster Mental Health Services (Chapter 19). In L. Grobman, (Ed.), Days in the Lives of Social Workers, Harrisburg, PA: White Hat Communications, pp. 115-119.
Weaver, J. D. (1995). Disasters: Mental Health Interventions. Sarasota, FL: Professional Resource Press.
Weeks, S. M. (1999). Disaster Mental Health Services: A Personal Perspective. Journal of Psychosocial Nursing, 37, 2, 14-18.
Young, B. H., et al. (1998). Disaster Mental Health Services: A Guidebook for Clinicians and Administrators. Menlo Park, CA: Department of Veterans Affairs.
Disasters. Audiotape produced in 1995 by Barbara Alexander, On-Good-Authority, Vol. IV, Tape 6. Side One contains John Weaver speaking on disaster mental health issues. Side Two contains Jeff Mitchell, Ph.D., describing his Critical Incident Stress Debriefing process. For information or to order, please phone: 1-800-835-9636.
To search for books on disasters and disaster mental
health topics, leaders, leadership, orgainizations,
crisis intervention, leaders and crises, and related
topics and purchase them online, go to the following url:
https://www.angelfire.com/biz/odochartaigh/searchbooks.html
RECOMMENDED READING
The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms
by Mary Beth, Ph.D. Williams, Soili Poijula, Lasse A. Nurmi
Book Review
October 25, 2002 Reviewer: Diana L. Steketee from Grand Rapids, Michigan United States
This is a good book that is challenging and rewarding for PTSDers to read and work through. The cautions and reminders to take care of oneself while working through the exercises are helpful. There is lots of information presented about PTSD in a very readable fashion. If a survivor of trauma had to work through those experiences and the resulting symptoms of PTSD alone, this is definitely a good place to start. I like to use some of the exercises with my teenage clients who are dealing with trauma-related symptoms.
Additional Readings at: Traumatic Stress in the search engine. Also try looking here for Disaster and Traumatic Stress.
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Contact your local Mental Health Center or
check the yellow pages for counselors, psychologists,
therapists, and other Mental health Professionals in
your area for further information.
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George W. Doherty
Rocky Mountain Region
Disaster Mental Health Institute
Box 786
Laramie, WY 82073-0786
MENTAL HEALTH MOMENT Online: https://www.angelfire.com/biz3/news
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