In Times of Crisis : Supporting Others, Supporting Ourselves

In Times of CrisisIn Times of Crisis::Supporting Others,Supporting Others,

Supporting OurselvesSupporting Ourselves

Jeffrey Harris, MFT, CEAPProgram Manager

USC Center for Work and Family Life

Center for Work and Family LifeAvailable Services:Available Services: Faculty and Staff CounselingFaculty and Staff Counseling

Faculty, Management and Departmental Faculty, Management and Departmental Consultation Consultation Critical incident responseCritical incident response

Work/Life SupportWork/Life Support

Family and Dependent Care: Consultation and Family and Dependent Care: Consultation and Resources Resources

Workplace Health and Wellness Programs Workplace Health and Wellness Programs

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?

Unit ObjectivesUnit 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.

Are We Are We Psychologically Prepared?Psychologically Prepared?

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

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

Critical IncidentCritical 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 person’s response involved intense fear, helplessness or horror. (DSM-IV TR)

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.

Coping MechanismsCoping Mechanisms

Into every life a little rain must fall …..

But what happens But what happens when there is a when there is a

flood?flood?

Psychosocial Impact – Psychosocial Impact – ConsiderationsConsiderations

Prior experience with a similar event Prior trauma The intensity of the disruption in the

survivors’ lives The resilience of the individual

Psychosocial Impact – Psychosocial Impact – ConsiderationsConsiderations

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

Consequences of Critical Incidents Consequences of Critical Incidents Often include Often include LOSSLOSS

Tangible LossLoss of loved onesLoss of loved onesLoss of homeLoss of homeLoss of material goodsLoss of material goodsLoss of employment / incomeLoss of employment / income

Consequences of Critical Incidents Consequences of Critical Incidents Often include Often include LOSSLOSS

Intangible LossLoss of safety / security (security (real or perceivedreal or perceived))Loss of predictabilitypredictabilityLoss of social cohesion/connection/supportsocial cohesion/connection/supportLoss of dignity, trust and safetydignity, trust and safetyLoss of positive self-image/self-esteempositive self-image/self-esteemLoss of trust in the future, identity, trust in the future, identity,

independenceindependenceLoss of hope hopeLoss of CONTROLCONTROL

ActivityActivity – What if I lost…What if I lost… You have been given three cards each of three

different colors:Blue CardBlue Card - write the name of a person close

to you on each cardWhite CardWhite Card - write down one of your favorite

belongingsPink CardPink 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.

ActivityActivity – What if I lost…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

Possible Psychological Reactions Possible Psychological Reactions to a Large-Scale Emergencyto 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 Just because you have experienced a disaster does not mean you will be damaged disaster does not mean you will be damaged

by it, but you will be changed by it.” by it, but you will be changed by it.” (Weaver 1995)

Grief and LossGrief 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)

Supporting Supporting

OthersOthers

““We’re a community that We’re a community that believes in believes in

‘‘love thy neighborlove thy neighbor’, ’,

but right now we need to love but right now we need to love our neighbors a little bit more.”our neighbors a little bit more.”

Man talking after devastating tornados ripped through his

Tennessee neighborhood - 2/08

Role of Disaster Mental Health?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.

Role of Disaster Mental Health?Role of Disaster Mental Health? Mitigate post trauma sequelae

May prevent future problemsHelps people to handle problems in a way that

does not create MORE problems

Convey a sense of compassion and support for people.

Psychological Response to TraumaKey ConceptsKey Concepts

Experience has shown that:

No one who sees a disaster is untouched by it.No one who sees a disaster is untouched by it.

Most people pull together & function during and Most people pull together & function during and after a disaster, but their effectiveness is after a disaster, but their effectiveness is diminished.diminished.

Most people do not see themselves as needing Most people do not see themselves as needing mental health services following a disaster and mental health services following a disaster and will not seek such services.will not seek such services.


Experience has shown that:

Survivors respond to active, genuine interest & Survivors respond to active, genuine interest & concern. concern.

Survivors may reject disaster assistance of all Survivors may reject disaster assistance of all types.types.

Disaster mental health assistance is often more Disaster mental health assistance is often more practical than psychological in nature.practical than psychological in nature.

Social support systems are crucial to recovery.Social support systems are crucial to recovery.


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 survivalA concern for basic survivalGrief and loss over loved ones & loss of valued and Grief and loss over loved ones & loss of valued and

meaningful possessionsmeaningful possessionsFear & anxiety about personal safety & the physical Fear & anxiety about personal safety & the physical

safety of loved onessafety of loved onesA need to talk about events & feelings associated with A need to talk about events & feelings associated with

the disaster, often repeatedlythe disaster, often repeatedlyA need to feel one is a part of the community & its A need to feel one is a part of the community & its

recovery effortsrecovery efforts

Phases of DisasterPhases of Disaster

Pre-DisasterPre-Disaster

Threat

Warning

HeroicHeroic

Honeymoon Honeymoon (community cohesion)(community cohesion)

Reconstruction Reconstruction (a new beginning)(a new beginning)

llllllllllll

Time 1 to 3 days 1 to 3 years

Inventory

DisillusionmentDisillusionment

Trigger Events andTrigger Events andAnniversary ReactionsAnniversary Reactions

Work

ing T

hrough G

rief

Work

ing T

hrough G

rief

(com

ing to

term

s)

EVENTEVENT

Honeymoon Honeymoon (community cohesion)

Survivors may be elated

Happy just to be alive

This phase will not last

DisillusionmentDisillusionment

Reality of disaster “hits home”

Loss and Grief becomes prominent

What Do You Think?

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

Essential Attributes and SkillsEssential Attributes and Skills

Good Listening skills

Patient Caring attitude Trustworthy Approachable Culturally aware

EmpatheticNon-judgmental approachKindCommittedFlexibleAble to tolerate chaos

Intense EmotionsIntense Emotions

Are often appropriate reactions following a disaster

Can often be managed by community responders

Supportive CommunicationSupportive Communication

Supportive communication conveys:

EmpathyConcernRespectConfidence

Activity – Activity – Supportive StatementsSupportive Statements

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

Do Say…Do Say…

Can you tell me what happened?

I’m Sorry

This must be difficult for you

I’m here to be with you

Activity – Activity – Unhelpful StatementsUnhelpful Statements

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

Avoid Saying . . .Avoid Saying . . .

“I understand what it’s like for you.” “Don’t feel bad.” “You’re strong/You’ll get through this.” “Don’t cry.” “It’s God’s will.” “It could be worse” or “At least you still

have . . .”

Guiding Principles in Providing Guiding Principles in Providing Psychological Support in Your RolePsychological Support in Your Role

Protect from danger Be direct and active Provide accurate information about what

you’re going to do Reassure Do not give false assurances Recognize the importance of taking action Provide and ensure emotional support

Crisis InterventionCrisis Intervention

Observe safe practices by showing concern for your own safety

Remain calm and appear relaxed, confident and non-threateningYou must look and act calm even if you are

not

Goals of Psychological First Aid

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

SAFETYSAFETY

CALMCALM

CONNECTEDNESSCONNECTEDNESS

SELF-EFFICACYSELF-EFFICACY

HOPEHOPE

Psychological First Aid

Promote SAFETY: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.


Promote CALM: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.


Promote CONNECTEDNESS:Promote CONNECTEDNESS:

Help people contact friends and loved ones.

Keep families together. Keep children with parents or other close relatives whenever possible.


Promote SELF-EFFICACY:Promote SELF-EFFICACY:

Give practical suggestions that steer people toward helping themselves.

Engage people in meeting their own needs.


Promote HELP: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.

Psychological First Aid Some DON’Ts:

Don’t force people to share their stories with you, especially very personal detailsthis may decrease calmness in people who are not

ready to share their experiences

Don’t give simple reassurances like “everything will be ok”, or “at least you survived”statements like these tend to diminish calmness

Psychological First Aid More DON’Ts:

Don’t tell people what you think they should be feeling, thinking or doing now or how they should have acted earlier this decreases self-efficacy

Don’t tell people why you think they have suffered by giving reasons about their personal behaviors or beliefs this also decreases self-efficacy

Psychological First Aid Some final DON’Ts:

Don’t make promises that may not be kept un-kept promises decrease hope

Don’t criticize existing services or relief activities in front of people in need of these servicesthis may decrease hopefulness or decrease

calming

Source: Center for the Study of Traumatic Stress

AnxietyAnxiety

A state of intense apprehension, uncertainty and fear

Results from anticipating a threatening event

Intense anxiety triggers “fight or flight” syndrome

AgitationAgitation

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

The Energy CurveThe Energy Curve

AnxietyAnxiety

AgitationAgitation

BaselineBaseline

Tension ReductionTension Reduction

Elements of EscalationElements of Escalation

Challenging authority or questioning

Refusal to follow directions

Loss of control, becoming verbally agitated

Becoming threatening

Elements of EscalationElements of Escalation

Challenging Authority or Questioning Answer the questionRepeat your request in a neutral tone of

voice

Remember that an ounce of prevention Remember that an ounce of prevention is worth a pound of cureis worth a pound of cure

Elements of De-escalationElements of De-escalation

For Those Not Following Directions…Do not take control; help the individual gain

control of him/herselfRemain professionalConsider restructuring your requestGive the person time to think about your

requestGive reflective feedback:

“you are screaming at me, Joe”


Establish a relationshipEstablish 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


Use concrete questions to help the Use concrete questions to help the person focusperson focusUse 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?”


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


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


Don't make global statements about the person's character

Use “I” statements

Avoid lavishing praise, or using encouragement that is not believable

Seek AssistanceSeek Assistance

Loss of Control, Becoming Verbally ThreateningVerbal Vomit

If the person becomes threatening or intimidating and does not respond to your attempts to calm them, seek immediate assistance

Psychological Response to TraumaSurvivors’ Needs and ReactionsSurvivors’ 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 Fear & anxiety •Grief & lossGrief & loss •ShockShock•HopelessnessHopelessness•Loss of ConfidenceLoss of Confidence•MistrustMistrust

•Sleep disturbancesSleep disturbances•Physical painPhysical pain•ConfusionConfusion•ShameShame•Shaken faithShaken faith•AggressivenessAggressiveness

Adrenaline, Friend or Foe?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)

Possible Physiological Possible Physiological SymptomsSymptoms

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.

Possible Emotional/Possible Emotional/Psychological SymptomsPsychological 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.

Fear of darknessFear of being alone; fear of crowds or

strangersSensitivity to loud noises Somatic complaintsGuilt, anger, griefReliving past traumas

Main point – Disaster stress is a Main point – Disaster stress is a normal response to an abnormal normal response to an abnormal circumstance. If symptoms persist, circumstance. If symptoms persist, they must be treated.they must be treated.

More Typical Reactions…More Typical Reactions…

C. Fasser, 2004; B. Young, 2006


For most people, things get For most people, things get better with time…better with time…

For some, however, the For some, however, the reactions may evolve and reactions may evolve and even worseneven worsen


Victims of Hurricane KatrinaVictims 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

Categories of Reactions Categories of Reactions After the IncidentAfter the Incident

•ASD / PTSD ASD / PTSD •GriefGrief•DepressionDepression•ResilienceResilience

Mental Health Mental Health and Illnessand Illness

Human Human Behavior in Behavior in High Stress High Stress

EnvironmentsEnvironments

DistressResponses

•Fear / worryFear / worry•Sleep disturbanceSleep disturbance•Altered productivityAltered productivity

•Avoidance Avoidance (emotional)(emotional)

•Substance abuseSubstance abuse•Risk takingRisk taking•Over DedicationOver Dedication

Loss and Grief – Loss and Grief – Signs of TroubleSigns 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

StressStress 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

Coping with StressCoping with Stress

Coping is a way to prevent, delay, avoid, or manage stress

Coping mechanism categories:Changing the source of stressChanging the view of the situationTolerating the stressor until it passes or

becomes less troublesome

Examples of CopingExamples 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

Examples of Coping (cont.)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

Responder Stress and Responder Stress and Well-Being:Well-Being:

Helping the HelpersHelping the Helpers

HelpersHelpers 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

Challenge to HelpersChallenge 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

Challenge to Helpers (cont.)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.

What Are Your What Are Your Preferred Approaches to Preferred Approaches to

Managing Stress?Managing Stress? Do you practice ‘stress Do you practice ‘stress management’ regularly?management’ regularly?

Self-Help TechniquesSelf-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

Self-Help Techniques (cont.)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:DrawPaintPlay musicJournal

Self-Help Techniques (cont.)Self-Help Techniques (cont.)

Do not self-medicate

Go easy on yourself

Avoid inflated or perfectionistic expectations

Seek professional advice if reactions continue

Cognitive/Behavioral Approaches to Stress Reduction

Adequate RestAdequate Rest Exercise / MovementExercise / Movement Diet / Balanced NutritionDiet / Balanced Nutrition Enough HEnough H22OO

Moderate Chemical UseModerate Chemical Use Laughter / TearsLaughter / Tears Time Away From Work RoleTime Away From Work Role


Religious / Spiritual Religious / Spiritual Relaxation Techniques / BreathingRelaxation Techniques / Breathing YogaYoga MeditationMeditation Social Support / Discuss FeelingsSocial Support / Discuss Feelings

Allow yourself to receive as well as give


PlayPlay: Hobbies / Personal Interests : Hobbies / Personal Interests Connecting with NatureConnecting with Nature BiofeedbackBiofeedback Massage / Human TouchMassage / Human Touch SexSex Professional AssistanceProfessional Assistance MedicationMedication

What Else Works for You???

Team Well-BeingTeam 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

Critical Incident StressCritical Incident Stress Debriefing Debriefing (CISD)(CISD)

DebriefingDebriefing / Defusing: / 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.

No Macho (Wo)Man, No Pity Party

Do not create an expectation Do not create an expectation there will be a problem, but there will be a problem, but when there is a problem, when there is a problem,

go get help.go get help.

Lt. Col Dave Grossman (ret.)

When you come to the edge When you come to the edge

of all that you know,of all that you know,

You must believe in You must believe in

one of two things:one of two things:

There will be earth There will be earth

on which to stand,on which to stand,

or You will be given wings.or You will be given wings.

AnonymousAnonymous

Questions / DiscussionQuestions / Discussion

In Times of Crisis : Supporting Others, Supporting Ourselves

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