Resilience: Coping with the Stress of Trauma

1
ResilienceCoping with the Stress of Trauma

• Mike McEvoy, PhD, REMT-P, RN, CCRN
• EMS Coordinator Saratoga County
• Medical Editor Fire Engineering magazine
• Sr. RN Cardiothoracic Surgery Albany Med

2
Disclosures

• I am an employee of AMC.
• I have no other financial relationships to
  disclose.
• I am the EMS technical editor for Fire
  Engineering magazine.
• I do not intend to discuss any unlabeled or
  unapproved uses of drugs or products.

3
www.mikemcevoy.com
4
Define Stress
5
Stress

• The confusion created when ones mind overrides
  the bodys basic desire to choke the living shit
  out of some asshole who desperately
• needs it.

6
A response to a demand for change

• BOTH
• Physical
• Psychological

7
A response to a demand for change

• Different for different people.

8
Study of Arousal Level for Sky Divers
9
A response to a demand for change

• Stress is not the event but our reaction to it.

10
Life Events

• Death of spouse
• Jail term
• 20 pay cut
• Fired from job
• Death of friend
• Traffic ticket
• Car accident

11
Life Events

• Divorce
• Marriage
• New home
• Retirement
• New baby
• Vacation
• Christmas

12
Life Events

• Divorce
• Marriage
• New home
• Retirement
• New baby
• Vacation
• Christmas

• Death of spouse
• Jail term
• 20 pay cut
• Fired from job
• Death of friend
• Traffic ticket
• Car accident

13
Do we need stress?
14
Complete absence of stress
15
Hans Selye

• Stress
• Illness
• Disease
• Death

16
Performance Characteristics of people under
stress

• Reduced awareness of environmental cues
• Increased sensitivity to signs of anxiety
• Decreased tolerance for pain and frustration
• Increased emphasis on performance error
• Decreased efficiency in mental processing
• Increased mistakes and injuries

17
PTSD Post Traumatic Stress DisorderandASDAcute
Stress Disorder
18
ASD and PTSD

1. Reliving the event.
2. Emotional anesthesia.
3. Persistent anxiety.

19
Resilience psych behavioral lingo

• People noted for ability to withstand negative
  pressure are resilient
• They have experienced negative circumstances
  associated with poor psychological and social
  outcomes
• Despite odds, they end up healthy productive
• Mentally ill or abusive parents
• Deprived social or economic conditions

20
Perceptions of Life Change

• I cant imagine how I would
• I would not want to live like that

"You're sitting here fighting depression. You're
in shock. You look out the window, and you can't
believe where you are. And the thought that keeps
going through your mind is, 'This can't be my
life. There's been a mistake."'
21
You play the hand youre dealt. I think the
games worthwhile.
22
Some people lack resilience
Vulnerable
23
Personal Resilience related to

• Biology
• temperament, emotions, intelligence, creativity,
  immune resistance, genetics and physical
  condition
• Attachment
• capacity for bonding (forming significant
  relationships with others), capacity for empathy
• Control
• mastery over ones environment, social
  competence, self-esteem, personal autonomy and
  sense of purpose

24
People who are resilient are

• Sociable (form healthy relationships)
• Optimistic (positive about the future)
• Flexible (change easily)
• Self-confident
• Competent (good at something and proud of it)
• Insightful (understand people and situations,
  able to see other sides)
• Persevering (dont give up)
• Objective (view crises as challenges, not
  insurmountable obstacles)
• Self controlling (manage strong feelings and
  impulses)

25
Vulnerable people exhibit

• Substance abuse
• Poor anger management
• Lack of community integration/social isolation
• Multiple chronic illnesses (or symptoms with
  minimal, vague or inadequate organic basis)
• Chronic dysthymia and/or anxiety
• Dysfunctional relationships
• Inadequate school/work/community performance

26
What makes some people resilient and others
vulnerable to life stressors?
27
People who focus on solving their problems are
the most resilient.
28
Bottom Line

• Problem-focused coping increases resiliency while
  emotion-focused coping impairs resiliency
• When faced with a setback or challenge focus
  outward on the things that must be handled, not
  inward on emotions
• Emotions cannot become the focus of attention.

29
Problem Focused Coping

1. Examine the situation to see what solutions may
   be possible
2. Consider various actions
3. Select the best
4. Take action
5. Observe effects of the action
6. Modify for best results

30
People bounce back by having

• Caring and supportive relationships
• High expectations for success
• Opportunities for meaningful participation
• Positive bonds
• Clear and consistent boundaries
• Life skills

31
Mental Health Interventions

• Cognitive Behavioral Therapy(CBT)

32
CBT Cognitive Behavioral Tx

• No single school multiple approaches
• Premise is thoughts cause feelings and behaviors
  (not external things or situations)
• Change thinking changes feelings/behavior
• Brief, time-limited, collaborative, stoic
• Structured, directive, educational model
• Includes homework

33
Critical Incident Stress DebriefingCISD
34
CISD History 1970s

• Jeffrey Mitchell
• Vol. Arbutus FD (Baltimore, MD)
• Regional Training Coordinator for State of
  Maryland
• Concerned about high attrition
• 1974 conducts debriefing after drunk driver kills
  a family

35
CISD 7 Phases

1. Introduction
2. Facts
3. Thoughts and experiences
4. Reactions (feelings)
5. Symptoms
6. Teaching
7. Re-entry

When disaster strikes The Critical Incident
Stress Debriefing process Mitchell JT. JEMS
836-39, 1983.
36
Critical Incident Stress DebriefingCISD
Does it help?
37
Cochrane Collaboration

• Worldwide network of centers, based in England
• Launched 1995
• Definitive source for evidence based practice
• Quarterly publication, several separate
  databases, position papers define best practices.

38
CISD Summary of Scientific Literature (Peer
Reviewed)

• Mitchell model
• CISD (not CISM)
• Emergency Services (vs. general population)
• Cochrane Library Database (last CISD revision 14
  Nov 2005, last substantiative update Dec 2001)

39
CISD - Conclusions

1. Value neutral to negative.
2. Not effective compared to all forms of debriefing
   and no debriefing at all.
3. While perceived as helpful, rescuer satisfaction
   ? effectiveness.
4. Some evidence of harm to certain individuals,
   often iatrogenic.

40
CISD General Population

• Unsafe!
• Adds to trauma
• Complicates recovery
• Should not be used
• Recently banned in some countries
• US Institute of Mental Health and World Health
  Organization both recommend AGAINST it

41
CISD Emergency Services

• Not appropriate for 60 of police, fire, EMS, and
  medical personnel.
• 85 talk about critical incidents afterwards
  (colleagues and peers preferred).
• 15 prefer not to talk at all.

42
(No Transcript)
43
CISD Iatrogenic Harm

• (Worsen anxiety, depression, PTSD)
• Mandatory attendance
• Discussion of event (relive emotional trauma)
  MH error
• Mixing groups
• Peripheral personnel with those directly involved
  in the incident.
• People lost loved one with people whose loved one
  survived.

44
CISD Harm Risk Factors

• Repeated or accumulated severe unresolved
  stressors
• Lack of social supports
• Injury
• Preexisting psychological problems
• Traumatic bereavement
• Strong negative beliefs about meanings of normal
  stress reactions
• People who most seek CISD show poorer long term
  outcomes

45
PFA - Working Definition

• Psychological first aid (PFA) refers to a set of
  skills identified to limit the distress and
  negative behaviors that can increase fear and
  arousal.
• (National Academy of Sciences, 2003)

46
General Principles of PFA

• The most urgent task is to focus on restoring
  emotional equilibrium (Protect-Direct-Connect)

47
Protect

• From physical or emotional harm, including
  gruesome or graphic sights and sounds
• Immediate physical needs
• Bathroom, food, fluids, breaks, clothing changes,
  sleep, time off.
• Dignity and privacy
• From media or curious well-wishers
• From danger to self or others

48
Direct

• Recognition for job well done.
• Encourage normal routines roles.
• Discuss self care strategies to reduce anxiety.
• Exercise, rest, relaxation
• Encourage people to support and assist others.
• Identify resources that promote effective coping.
• Accurate, simple information about plans,
  schedules, events.
• MH follow-up assessment _at_ 3 months.

49
Connect

• Help connect with family, friends, children,
  significant others.
• Talking in homogenous groups (ie firefighters
  vs. heterogeneous strangers).
• Provide information on normal signs and symptoms
  including suggestions for what to do.
• Educate significant others on s/s and how they
  can help.
• With mental health resources
• Individuals to information about the event

50
Summary

• People are resilient
• Friends are important
• Conversation helps
• Time is a great healer
• Look out for others while you look out for
  yourself

Gist, et al., The origins and natural history of
debriefing, 1998. www.mikemcevoy.com