In Times of Crisis: Supporting Others, Supporting Ourselves

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In Times of CrisisSupporting Others,Supporting
Ourselves

• Jeffrey Harris, MFT, CEAP
• Program Manager
• USC Center for Work and Family Life

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Center for Work and Family Life

• Available Services
• Faculty and Staff Counseling
• Faculty, Management and Departmental Consultation
  
• Critical incident response
• Work/Life Support
• Family and Dependent Care Consultation and
  Resources
• Workplace Health and Wellness Programs

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Role Expectations

• Are you clear about your the role expectations
  you carry as a member of the CERT?
• Can you imagine having any unfulfilled
  expectations or disappointments while functioning
  in this role?
• How might the many other roles you play at any
  given time impact your role as a CERT member?

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Unit Objectives

1. Psychological impacts to expect after a disaster
   What happens for people?
2. How to work with the psychological impacts in
   your role Providing psychological support.
3. Responder stress management and self-care.

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Are We Psychologically Prepared?

• For every physical injury, there may be 5-6
  psychological injuries

• This may overwhelm and impede our emergency
  and/or medical response.

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Critical Incident

• Exposure to a traumatic event in which both of
  the following were present
• The person experiences, witnessed, or was
  confronted with an event or events that involved
  actual or threatened death or serious injury, or
  a threat to the physical integrity of self or
  others.
• The persons response involved intense fear,
  helplessness or horror. (DSM-IV TR)

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Coping Mechanisms

• People typically rely on past strategies to cope
  with new stressful situations
• Past coping mechanisms can be functional or
  dysfunctional.
• Degree of hardiness (resilience) has been
  identified as a characteristic that can buffer
  extreme stress in older populations
• Children can be vulnerable because they have no
  experience or known patterns of actions as a
  response to the experience.

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Into every life a little rain must fall
..

• But what happens when there is a flood?

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Psychosocial Impact Considerations

• Prior experience with a similar event
• Prior trauma
• The intensity of the disruption in the survivors
  lives
• The resilience of the individual

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Psychosocial Impact Considerations

• The length of time that has elapsed between the
  event occurrence and the present
• Pre-existing vulnerabilities
• Human-Caused vs.
• Events of Nature

• Children/families
• Seniors
• Disabled
• Bereaved
• Health impairments
• Women

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Consequences of Critical Incidents Often include
LOSS

• Tangible Loss
• Loss of loved ones
• Loss of home
• Loss of material goods
• Loss of employment / income

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Consequences of Critical Incidents Often include
LOSS

• Intangible Loss
• Loss of safety / security (real or perceived)
• Loss of predictability
• Loss of social cohesion/connection/support
• Loss of dignity, trust and safety
• Loss of positive self-image/self-esteem
• Loss of trust in the future, identity,
  independence
• Loss of hope
• Loss of CONTROL

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Activity What if I lost

• You have been given three cards each of three
  different colors
• Blue Card - write the name of a person close to
  you on each card
• White Card - write down one of your favorite
  belongings
• Pink Card - write down something you enjoy, an
  activity, or hobby.
• After you have written on each card, place them
  face down on the table and shuffle them around.
  Close your eyes and pick three cards.

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Activity What if I lost

• These are the three things you will have lost in
  a disaster.
• Discuss with the group how you feel about losing
  these things or people

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Possible Psychological Reactions to a
Large-Scale Emergency

• Many people survive disasters without developing
  any significant psychological symptoms.
• For other individuals, the reactions will
  disappear over time.

• Just because you have experienced a disaster
  does not mean you will be damaged by it, but you
  will be changed by it.
• (Weaver 1995)

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Grief and Loss

• Not an even process
• Takes time
• Can become stuck in the process
• May spawn other problems
• Nothing like T T (Time and Talking)

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Supporting Others
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• Were a community that believes in
• love thy neighbor,
• but right now we need to love our neighbors a
  little bit more.

• Man talking after devastating tornados ripped
  through his Tennessee neighborhood - 2/08

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Role of Disaster Mental Health?

• Primarily directed toward normal people who are
  responding normally to an abnormal situation
• Improve resistance, resilience and recovery.
• Identifying those at risk for severe social or
  psychological impairment
• Identify those in need of additional or special
  services.

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Role of Disaster Mental Health?

• Mitigate post trauma sequelae
• May prevent future problems
• Helps people to handle problems in a way that
  does not create MORE problems
• Convey a sense of compassion and support for
  people.

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Psychological Response to TraumaKey Concepts

• Experience has shown that
• No one who sees a disaster is untouched by it.
• Most people pull together function during and
  after a disaster, but their effectiveness is
  diminished.
• Most people do not see themselves as needing
  mental health services following a disaster and
  will not seek such services.

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Psychological Response to TraumaKey Concepts

• Experience has shown that
• Survivors respond to active, genuine interest
  concern.
• Survivors may reject disaster assistance of all
  types.
• Disaster mental health assistance is often more
  practical than psychological in nature.
• Social support systems are crucial to recovery.

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Psychological Response to TraumaKey Concepts

• While there may be specific disaster-related
  stressors, underlying concerns and needs are
  consistent across a range of traumatic events.
  These include
• A concern for basic survival
• Grief and loss over loved ones loss of valued
  and meaningful possessions
• Fear anxiety about personal safety the
  physical safety of loved ones
• A need to talk about events feelings associated
  with the disaster, often repeatedly
• A need to feel one is a part of the community
  its recovery efforts

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Phases of Disaster
Honeymoon (community cohesion)
llllllllllll
Reconstruction (a new beginning)
Heroic
Pre-Disaster
Disillusionment
Working Through Grief (coming to terms)
Threat
EVENT
Warning
Inventory
Trigger Events and Anniversary Reactions
Time 1 to 3 days
1 to 3 years
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Honeymoon (community cohesion)

• Survivors may be elated
• Happy just to be alive
• This phase will not last

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Disillusionment

• Reality of disaster
• hits home
• Loss and Grief
• becomes prominent

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What Do You Think?

• What main attributes and skills should a
  volunteer have when offering psychological
  support?

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Essential Attributes and Skills

• Good Listening skills
• Patient
• Caring attitude
• Trustworthy
• Approachable
• Culturally aware

• Empathetic
• Non-judgmental approach
• Kind
• Committed
• Flexible
• Able to tolerate chaos

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Intense Emotions

• Are often appropriate reactions following a
  disaster
• Can often be managed by community responders

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Supportive Communication

• Supportive communication conveys
• Empathy
• Concern
• Respect
• Confidence

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Activity Supportive Statements

• What are some supportive statements that you
  would find helpful if you were in pain, injured,
  and/or acute emotional distress?

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Do Say

• Can you tell me what happened?
• Im Sorry
• This must be difficult for you
• Im here to be with you

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Activity Unhelpful Statements

• What are some statements that you would find
  unhelpful if you were in pain, afraid, injured,
  and/or dealing with tremendous loss.

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Avoid Saying . . .

• I understand what its like for you.
• Dont feel bad.
• Youre strong/Youll get through this.
• Dont cry.
• Its Gods will.
• It could be worse or At least you still have .
  . .

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Guiding Principles in Providing Psychological
Support in Your Role

• Protect from danger
• Be direct and active
• Provide accurate information about what youre
  going to do
• Reassure
• Do not give false assurances
• Recognize the importance of taking action
• Provide and ensure emotional support

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Crisis Intervention

• Observe safe practices by showing concern for
  your own safety
• Remain calm and appear relaxed, confident and
  non-threatening
• You must look and act calm even if you are not

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Goals of Psychological First Aid

• Psychological first aid (PFA) promotes and
  sustains an environment of

SAFETY
CALM
CONNECTEDNESS
SELF-EFFICACY
HOPE
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Psychological First Aid

• Promote SAFETY
• Help people meet basic needs for food and
  shelter, obtain medical attention.
• Provide repeated, simple and accurate information
  on how to get these basic needs met.

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Psychological First Aid

• Promote CALM
• Listen to people who wish to share their stories
  and emotions, remember that there is no right
  or wrong way to feel.
• Be friendly compassionate even if people are
  being difficult.
• Offer accurate information about the disaster or
  trauma, and the relief efforts underway to help
  victims understand the situation.

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Psychological First Aid

• Promote CONNECTEDNESS
• Help people contact friends and loved ones.
• Keep families together. Keep children with
  parents or other close relatives whenever
  possible.

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Psychological First Aid

• Promote SELF-EFFICACY
• Give practical suggestions that steer people
  toward helping themselves.
• Engage people in meeting their own needs.

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Psychological First Aid

• Promote HELP
• Find out the types and locations of government
  non-government services and direct people to
  those services that are available.
• When they express fear or worry, remind people
  (if you know) that more help and services are on
  the way.

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Psychological First Aid

• Some DONTs
• Dont force people to share their stories with
  you, especially very personal details
• this may decrease calmness in people who are not
  ready to share their experiences
• Dont give simple reassurances like everything
  will be ok, or at least you survived
• statements like these tend to diminish calmness

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Psychological First Aid

• More DONTs
• Dont tell people what you think they should be
  feeling, thinking or doing now or how they should
  have acted earlier
• this decreases self-efficacy
• Dont tell people why you think they have
  suffered by giving reasons about their personal
  behaviors or beliefs
• this also decreases self-efficacy

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Psychological First Aid

• Some final DONTs
• Dont make promises that may not be kept
• un-kept promises decrease hope
• Dont criticize existing services or relief
  activities in front of people in need of these
  services
• this may decrease hopefulness or decrease calming
• Source Center for the Study of Traumatic Stress

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Anxiety

• A state of intense apprehension, uncertainty and
  fear
• Results from anticipating a threatening event
• Intense anxiety triggers fight or flight
  syndrome

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Agitation

• Sometimes, despite our best attempts at active
  listening, people become agitated
• It is usually not personal
• This is their reaction to an extremely abnormal
  situation, and it has nothing to do with you

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The Energy Curve
Agitation
Anxiety
Tension Reduction
Baseline
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Elements of Escalation

• Challenging authority or questioning
• Refusal to follow directions
• Loss of control, becoming verbally agitated
• Becoming threatening

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Elements of Escalation

• Challenging Authority or Questioning
• Answer the question
• Repeat your request in a neutral tone of voice
• Remember that an ounce of prevention is worth a
  pound of cure

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Elements of De-escalation

• For Those Not Following Directions
• Do not take control help the individual gain
  control of him/herself
• Remain professional
• Consider restructuring your request
• Give the person time to think about your request
• Give reflective feedback
• you are screaming at me, Joe

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Elements of De-escalation

• Establish a relationship
• Introduce yourself if they do not know you
• Ask the person what they would like to be called
• Don't shorten their name or use their first name
  without their permission
• With some cultures, it is important to always
  address them as Mr. or Ms., especially if
  they are older than you

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Elements of De-escalation

• Use concrete questions to help the person focus
• Use closed ended questions (yes/no)
• If the person is not too agitated, briefly
  explain why you are asking the question
• For example
• I'd like to get some basic information from you
  so that I can help you better. Where do you
  hurt?

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Elements of De-escalation

• Come to an agreement on something
• Establishing a point of agreement will help
  solidify your relationship and help gain their
  trust
• Positive language has more influence than
  negative language
• Active listening will assist you in finding a
  point of agreement

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Elements of De-escalation

• Speak to the person with respect
• This is communicated with
• Words
• Para-verbal Communication
• how we say the words e.g. tone, pitch
• Non-verbal behavior
• Use of words like please and thank you

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Elements of De-escalation

• Don't make global statements about the person's
  character
• Use I statements
• Avoid lavishing praise, or using encouragement
  that is not believable

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Seek Assistance

• Loss of Control, Becoming Verbally Threatening
• Verbal Vomit
• If the person becomes threatening or intimidating
  and does not respond to your attempts to calm
  them, seek immediate assistance

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Psychological Response to TraumaSurvivors Needs
and Reactions

• People often experience strong and unpleasant
  emotional and physical responses following
  exposure to traumatic events (e.g. disasters).
• These may include a combination of

• Fear anxiety
• Grief loss
• Shock
• Hopelessness
• Loss of Confidence
• Mistrust

• Sleep disturbances
• Physical pain
• Confusion
• Shame
• Shaken faith
• Aggressiveness

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Adrenaline, Friend or Foe?

• Increase in speed and strength
• Tunnel vision eyes revert to default survival
  position.
• Reduced Near, peripheral, depth
• Hearing muted
• Changes in reaction time
• Freezing and unable to react
• Overreacting
• Increase in sensory acuity
• Slow motion time
• May act in a way that seems inappropriate for the
  situation (e.g. giggle, yell)

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Possible Physiological Symptoms

• Loss of appetite
• Headaches, chest pain
• Diarrhea, stomach pain, nausea
• Hyperactivity
• Increase in alcohol or drug consumption
• Nightmares, night terrors
• Inability to sleep
• Fatigue, low energy.

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Possible Emotional/Psychological Symptoms

• Irritability, anger
• Self-blame, blaming others
• Isolation, withdrawal
• Fear of recurrence
• Feeling stunned, numb, or overwhelmed
• Feeling helpless
• Mood swings
• Sadness, depression, grief
• Denial
• Concentration, memory problems, confusion
• Relationship conflicts/marital discord.

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More Typical Reactions

• Fear of darkness
• Fear of being alone fear of crowds or strangers
• Sensitivity to loud noises
• Somatic complaints
• Guilt, anger, grief
• Reliving past traumas
• Main point Disaster stress is a normal
  response to an abnormal circumstance. If symptoms
  persist, they must be treated.

C. Fasser, 2004 B. Young, 2006
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Possible Psychological Reactions to a
Large-Scale Emergency

• For most people, things get better with time

For some, however, the reactions may evolve and
even worsen
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Possible Psychological Reactions to a
Large-Scale Emergency

• Victims of Hurricane Katrina
• Significant increase in serious mental health
  problems, two years post-Katrina, across all
  racial and socio-economic groups
• PTSD
• Suicidality
• Depression
• Anxiety
• substance abuse
• domestic violence

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Categories of Reactions After the Incident

• ASD / PTSD
• Grief
• Depression
• Resilience

Mental Health and Illness

• Avoidance (emotional)
• Substance abuse
• Risk taking
• Over Dedication

Human Behavior in High Stress Environments
Distress Responses

• Fear / worry
• Sleep disturbance
• Altered productivity

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Loss and Grief Signs of Trouble

• Avoiding or minimizing emotions
• Using alcohol or drugs to self-medicate
• Using work or other distractions to avoid
  feelings
• Hostility and aggression toward others

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Stress

• A state of physical and/or psychological arousal
• Often brought about by a perceived threat or
  challenge

• May be expressed differently by different people
  / cultures

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Coping with Stress

• Coping is a way to prevent, delay, avoid, or
  manage stress
• Coping mechanism categories
• Changing the source of stress
• Changing the view of the situation
• Tolerating the stressor until it passes or
  becomes less troublesome

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Examples of Coping

• Seeking help from others or offering to help
  others
• Using natural support systems
• Talking about their experiences and trying to
  make sense of what happened
• Hiding until the danger has passed
• Seeking information about the welfare of loved
  ones
• Gathering remaining belongings

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Examples of Coping (cont.)

• Beginning to repair the damage
• Burying or cremating the dead
• Following religious or cultural practices
• Setting goals and making plans
• Using defenses like denial
• Remaining fearful and alert to further danger
• Thinking long and hard about the event

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Responder Stress and Well-Being

• Helping the Helpers

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Helpers

• Responders are, by definition, exposed to a
  critical incident
• They may experience critical incident stress
  because of the work they do
• Often have a feeling of not having done enough
• Are sometimes overwhelmed by the needs of the
  community
• Need to cope with their own fears

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Challenge to Helpers

• Being part of the collective crisis
• Repeated exposure to grim experiences
• Carrying out physically difficult, exhausting or
  dangerous tasks
• Lacking sleep and feeling fatigued
• Facing the perceived inability to ever do enough

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Challenge to Helpers (cont.)

• Facing moral and ethical dilemmas
• Being exposed to anger and lack of gratitude
• Being detached from personal support systems
• Feeling frustrated by policies and decisions by
  supervisors
• Feeling guilt over access to food, shelter, etc.

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What Are Your Preferred Approaches to Managing
Stress?

• Do you practice stress management regularly?

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Self-Help Techniques

• Know the normal reactions to stressful events
• Be aware of your tension and consciously try to
  relax
• Use the buddy system
• Talk to someone you trust and with whom feel at
  ease
• Listen to what people close to you say and think
  about the event
• Reconcile expectations with results

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Self-Help Techniques (cont.)

• Work on routine tasks if it is too difficult to
  concentrate on demanding duties
• If you cannot sleep or feel too anxious, discuss
  this with someone you can trust
• Express your feelings in ways other than talking
• Draw
• Paint
• Play music
• Journal

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Self-Help Techniques (cont.)

• Do not self-medicate
• Go easy on yourself
• Avoid inflated or perfectionistic expectations
• Seek professional advice if reactions continue

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Cognitive/Behavioral Approaches to Stress
Reduction

• Adequate Rest
• Exercise / Movement
• Diet / Balanced Nutrition
• Enough H2O
• Moderate Chemical Use
• Laughter / Tears
• Time Away From Work Role

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Cognitive/Behavioral Approaches to Stress
Reduction

• Religious / Spiritual
• Relaxation Techniques / Breathing
• Yoga
• Meditation
• Social Support / Discuss Feelings
• Allow yourself to receive as well as give

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Cognitive/Behavioral Approaches to Stress
Reduction

• Play Hobbies / Personal Interests
• Connecting with Nature
• Biofeedback
• Massage / Human Touch
• Sex
• Professional Assistance
• Medication
• What Else Works for You???

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Team Well-Being

• CERT team leaders
• Provide pre-disaster stress management training
• Brief personnel before response
• Emphasize teamwork
• Encourage breaks
• Provide for proper nutrition
• Rotate staff
• Phase out workers gradually
• Arrange for an intermittent and post-event
  debriefing
• Conduct follow-up with CERT team members

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Critical Incident Stress Debriefing (CISD)

• Debriefing / Defusing
• is a specific technique designed to assist
  responders in dealing with the physical or
  psychological symptoms that are generally
  associated with trauma exposure.
• allows those involved with the incident to
  process the event and reflect on its impact.
• allows for the ventilation of emotions and
  thoughts associated with the crisis event.
• provided as soon as possible but typically no
  longer than the first 24 to 72 hours after the
  initial impact of the critical event.

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No Macho (Wo)Man, No Pity Party

• Do not create an expectation there will be a
  problem, but when there is a problem,
• go get help.
• Lt. Col Dave Grossman (ret.)

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• When you come to the edge
• of all that you know,
• You must believe in
• one of two things
• There will be earth
• on which to stand,
• or You will be given wings.
• 
  Anonymous

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Questions / Discussion