Welcome to Stress First-Aid (SFA) Training.

Welcome to Stress First-Aid (SFA) Training.
Introduction Welcome to Stress First-Aid (SFA) Training. This course is brought to you by the National Fallen Firefighters Foundation (NFFF). Logistics/Ground Rules Introduce yourself and the topic. Inform participants of any additional requirements, rules, location of restrooms, approximate length of class and anything else pertinent for successful module delivery. Inform participants that as an instructor, you appreciate their input during class. 1

National Fallen Firefighters Foundation
The NFFF is a non-profit 501(c)3 corporation that was created in 1992 by the United States Congress, and charged with the mission to: Honor and remember America's fallen heroes Provide the necessary resources to assist their survivors in rebuilding their lives Work with the fire service community to reduce firefighter deaths and injuries National Fallen Firefighters Foundation The National Fallen Firefighters Foundation is a non-profit 501(c)3 corporation that was created in 1992 by the United States Congress, and charged with the mission to: Honor and remember America’s fallen heroes Provide necessary resources to assist their survivors in rebuilding their lives Work with the fire service community to reduce firefighter deaths and injuries

National Fallen Firefighters Foundation
The NFFF developed the Everyone Goes Home® program and the 16 Firefighter Life Safety Initiatives to: Change fire service culture, attitudes and behaviors Foster a research and learning environment Obtain and apply technological and engineering solutions Reduce exposure to violent incidents Reduce exposure to risk Reinforce new cultural norms National Fallen Firefighters Foundation The Everyone Goes Home® (EGH) program was developed in 2004 to reduce firefighter line-of-duty deaths and injuries. With input from all of the major fire service stakeholders, 16 Firefighter Life Safety Initiatives were identified as implementation strategies to: Change fire service culture, attitudes and behaviors; Foster a research and learning environment; Promote obtaining and applying technological and engineering solutions to firefighter safety; Reduce exposure to violent incidents; Reinforce new cultural norms.

Fire Life Safety Initiative 13:
Firefighters and their families must have access to counseling and psychological support 4

What We Did… Researchers + reps of key fire service organizations
Identified important behavioral health issues Established the best information currently available Engaged in a knowledge translation process

Consensus Panel Academic/Research National Center for PTSD NIOSH/CDC
National Crime Victims Center Center for Study of Traumatic Stress Employee Assistance Professionals Association Firefighter Health Research Group/KCUMB Fire/EMS International Association of Fire Fighters International Association of Fire Chiefs National Volunteer Fire Council National Fire Protection Association National Association of EMS Physicians North American Fire Training Directors

Every time wheels roll… Ask these five questions:
What was our mission? What went well? What could have gone better? What might we have done differently? Who needs to know? After Action Review The first Firefighter Life Safety Initiative calls for culture change in the fire service relating to every aspect of safety: leadership, management, supervisory, accountability and personal responsibility. We are asking you to use the tool of the After Action Review to help bring about this culture change. At the end of every shift and every call, ask these five questions: What was our mission, what went wrong, what could have gone better, what might we have done differently & who needs to know? No call or response is too insignificant –every time wheels roll—ask these five questions.

Stress First Aid for Fire and Emergency Medical Services Personnel
Course Description Firefighter Life Safety Initiative #13 states that: Firefighters and their families should have access to counseling and psychological support. Stress First Aid (SFA) is an important component in the FLSI #13 toolkit. SFA is a set of supportive actions designed to help you and your fellow emergency responders assist each other in mitigating the negative impacts of stress. 9 9

Course Objectives Identify the core set of principles that guide SFA
After taking this course, participants will be able to: Identify the core set of principles that guide SFA Understand and describe the causes of Stress Injury Understand the Stress Continuum Model Describe the Seven Core Actions of Stress First Aid Course Objectives After taking this course, you will be able to: Identify the core set of principles that guide SFA. Understand and describe the causes of Stress Injury 3. Understand the Stress Continuum Model. 4. Describe the SFA Seven Core Actions.

Introduction

What Is Stress First Aid (SFA)?
A flexible framework that gives guidance on how to quickly assess and respond to stress reactions resulting from both personal and work stress A way to preserve well-being, prevent further harm, and promote recovery A practical tool to use whenever needed for yourself or your peers Stress First Aid is: A practical tool within the workplace peer / CARE program, which should be used at other times whenever needed A flexible framework that gives guidance on how to quickly assess and respond to stress reactions resulting from both personal and work stress A way to preserve well-being, prevent further harm, and promote recovery

Why Learn SFA? Recognize a potential stress injury in a peer
Act: If you see something, say something To the distressed person To a trusted source of support Connect peer to appropriate support Stress Fist Aid is not complex; but neither is it easy. There are three essential SFA skills: 1. Recognize when a peer has a stress injury 2. Act: If you see something, say something Peer (always try to communicate with the peer first) Trusted Support (If communicating with the peer is not within your role then coordinate with a trusted other) 3. Know at least 2 trusted resources you would offer to a peer in distress. This is where you need to know your organization and community resources.

Factors in Recovery From Adversity and Stress
Promote sense of safety Promote calming Promote connectedness Promote sense of self and collective efficacy Promote hope Hobfoll, SE., Watson, P., Bell CC., et al (2007) Psychiatry, 70 (4), 283. SFA Evidence Support The Core Actions of SFA are derived from an exhaustive literature review and international expert panel (Hobfoll, & colleagues, 2007). There are five essential elements of immediate and mid-term intervention that are related to better recovery from stress: Promote a sense of safety—safety can be relative, and it is important to have a balanced view about the levels of danger in the world. Promote calming—some anxiety is normal and healthy. However, extended arousal of heart rate, blood pressure and respiration is associated with disruption of sleep, lack of hydration, poor decision-making and long-term health problems. Promote connectedness—social connectedness is one of the strongest protective factors against stress injury and is linked to emotional well-being and recovery following trauma. Promote sense of self and collective efficacy—people who believe that they have the skills to overcome threat can handle stressful events, solve their problems and show greater recovery in stressful times. Promote a sense of hope.—hope is the belief that things will work in the best possible way. 14

Functions of Stress First Aid
SFA is designed to: Reduce the risk for stress reactions Continuously monitor stress levels Recognize quickly those who are reacting to a wide range of stressors Offer a spectrum of interventions Monitor progress of recovery Bridge individuals to higher levels of care, when needed Functions of Stress First Aid 1. SFA is designed to reduce the risk for stress reactions in fire and rescue personnel. 2. SFA is used to continuously monitor stress levels of every member of the department. With SFA, you will be able quickly recognize those who are reacting to a wide range of stressors in their work and/or personal life, and may need intervention to promote healing. 3. SFA offers a spectrum of one-on-one or group interventions to ensure safety, reduce the risk for more severe stress reactions and promote recovery. 4. SFA is used to monitor the progress of an individual's recovery, to ensure return to full-function and well-being. 5. When needed, SFA bridges individuals to higher levels of care.

Stress First Aid Core Principles
Recovery is promoted through strong leadership, peer support and unit cohesion SFA occurs wherever and whenever it is needed SFA is individualized care, not one-size-fits all SFA is an ongoing process SFA requires a collaborative team effort SFA Principles 1. Strong leadership and unit cohesion are potentially the most powerful forces for healing and recovery that are available to fire and EMS personnel. 2. SFA promotes recovery from stress reactions by augmenting, restoring and leveraging leadership, peer support, and unit cohesion. It never replaces or competes with them. 3. SFA occurs in natural work contexts, wherever and whenever it is needed. 4. SFA is individualized to meet the needs of each person—there are no one-size-fits all SFA solutions. 5. SFA is not a one-time intervention, but rather an on-going process of promoting recovery from stress reactions, monitoring progress and adjusting as needed over time. To be most effective, SFA requires a collaborative team effort. 16 16 16

SFA IS NOT: An event only intervention A one-time only intervention
Necessary for all stress reactions A replacement for medical or behavioral health interventions A replacement for prevention efforts SFA is NOT An event-only intervention. SFA focuses on people and behaviors instead of focusing on events. A one-time only intervention. SFA is a way to identify people in distress and provide long-term emotional support. A replacement for needed medical or behavioral health interventions. A replacement for prevention efforts.

Stress Injuries

Two Faces of Stress Stress is NECESSARY Stress can be TOXIC
Stress is essential for: Strength and toughness Growth and development Acquire new skills Meeting challenges Performing difficult missions Stress can lead to: Persistent internal distress Functional impairment Misconduct Substance abuse Mental disorders Stress is both necessary and potentially harmful. The process of experiencing mild to moderate stress and successfully coping typically builds resilience. Stress that causes persistent internal distress and functional impairment is harmful.

Four Causes of Stress Injury
Intense or Prolonged Stress Life Threat Loss Inner Conflict Wear & Tear A traumatic injury Due to an experience of death-provoking terror, horror or helplessness A grief injury Due to the loss of cherished people, things or parts of oneself A moral injury Due to behaviors or the witnessing of behaviors that violate moral values A fatigue injury Due to the accumulation of stress from all sources over time without sufficient rest and recovery Four Causes of Stress Injury In firefighting and Emergency Medical Services work, trauma is not the only harmful exposure. Stress injuries can arise from four possible mechanisms or causes: Life Threat—due to traumatic life-threatening or other situations that provoke terror, horror or helplessness. This type of injury can include experiencing a near-miss or close call. Loss—grief due to the loss of close comrades, leaders, family members or other cared-for individuals. Inner Conflict—a “beliefs” injury due to conflict between one's moral/ethical beliefs and current experiences. Inner conflict stress injuries can include acting outside of internal, self-imposed morals or values, an inability to prevent harm to others or somehow contributing to or not preventing harm to a fellow firefighter or EMT. Wear and Tear—the result of fatigue and accumulation of prolonged stress, including from non-operational sources, without sufficient sleep, rest and restoration.

Stress Continuum Model
READY (Green) REACTING (Yellow) INJURED (Orange) ILL (Red) DEFINITION Optimal functioning Adaptive growth Wellness FEATURES At one’s best Well-trained and prepared In control Physically, mentally and spiritually fit Mission-focused Motivated Calm and steady Having fun Behaving ethically Mild and transient distress or impairment Always goes away Low risk CAUSES Any stressor Feeling irritable, anxious or down Loss of motivation Loss of focus Difficulty sleeping Muscle tension or other physical changes Not having fun More severe and persistent distress or impairment Leaves a scar Higher risk Life threat Loss Moral injury Wear and tear Loss of control Panic, rage or depression No longer feeling like normal self Excessive guilt, shame or blame Clinical mental disorder Unhealed stress injury causing life impairment TYPES PTSD Depression Anxiety Substance abuse Symptoms persist and worsen over time Severe distress or social or occupational impairment Stress Continuum Model Stress First Aid was adapted from the Navy/Marine Corps Combat Operational Stress First Aid (COSFA). The Stress Continuum Model was developed as a visual tool for assessing an individual's stress responses, and forms the foundation for both COSFA and SFA. Stress responses lie along a spectrum of severity and type — they are neither all normal, transient and self-limiting, nor are they all signs of chronic mental illness. The continuum has four stages: Ready (Green), Reacting (Yellow), Injured (Orange) and Ill (Red). It is important here to note that 100% of people will react when faced with stressful stimuli. However, the way in which they respond will depend on how prepared they are for the stressor event and how they, as individuals, interpret it. During the course of this response, a person’s state can range relatively rapidly from Green to Yellow to Orange to Red and back again. For many years, the ethos in our culture has been that after a difficult event, firefighters should be able to tough it out. This is still the case in many departments, where the stigma associated with reacting to stress or stress injury behaviors is still very real and people will try to conceal stress reactions from supervisors to avoid medical or psychological intervention. However, it is usually not possible to keep these behaviors hidden for long from family members, colleagues and friends. When a co-worker recognizes that a fellow firefighter or EMT is in trouble, it is important to break the code of silence. Getting this individual connected with the next level of help as soon as possible may help prevent his or her reaction from progressing into the Red Zone. 21

Yellow Zone Reactions vs. Orange Zone Injuries
Stress Reactions Bending from stress Very common Normal Always go away Stress Injuries Damage from stress Less common Risk for role failure Risk for stress illness Yellow Zone Reactions vs. Orange Zone Injuries Firefighters and EMS providers are regularly exposed to highly stressful situations. As a result, many emergency responders are experiencing elevated stress levels much of the time. Because they may more commonly be in the Yellow Zone rather than the Green Zone, it is important to clarify the difference between stress reactions and stress injuries. Stress reactions are common, and are a natural part of developing connectedness, competence and confidence as a result of having faced life’s challenges. Most people have sufficient emotional skills and resources to reset their internal equilibrium over time after a stress reaction, or exposure to a potentially traumatic event (PTE). Stress injuries, on the other hand, can cause lasting damage to the mind and brain, and may result in impaired functioning in all domains of a person's life. They also typically require activating additional outside resources to enable the individual to recover and grow from the experience. You may want to think about the concept of stress reactions compared to stress injuries as similar to that of a strained versus a broken ankle. When an ankle or tendon is strained, physical therapy and use are often prescribed. However, when the injury is a broken ankle, a cast and rest are needed.

Officer Role Challenges
Many Causes vs Only Four: Yellow Zone Reactions vs Orange Zone Injuries Politics Wear-and-tear Inner Conflict Loss Life threat Orange Zone Stress Officer Role Challenges Family separation Lack of sleep Advancement Barriers Money problems TIME Family Role Demands Relationship problems Boredom Conflicts with bosses Extra Duties Peer conflicts Physical injuries Many transient stressors can cause reactions while there are four sources of stress injury. The causes of stress reactions will influence the four sources of stress injury. Orange Zone Stress Injuries Understanding the difference between stress reactions and stress injury behaviors will determine whether or not stress first aid is even needed. Yellow Zone Stress

Orange Zone Indicators
To recognize those who need help, look for: Recent Stressor Events Distress Changes in Functioning Orange Zone Indicators So what are we looking for when we perform Check? To recognize those who need help, you will need to be aware of three Orange Zone Indicators: Recent Stressor Events: An individual was involved in a situation that has a high potential to cause stress injury. Examples include life threat (a close call or near miss), the loss of someone or something cherished (such as a divorce, a death, retirement or being passed over for promotion) or violations of the individual’s moral codes. Recent exposure to a PTE, such as responding to a multi-fatality fire or experiencing a line-of-duty death in the department, may be an important Orange Zone Indicator. Distress: The individual is experiencing significant and persistently troubling feelings, such as fear, anger, anxiety, sadness, guilt or shame. Changes in Functioning: Significant and persistent changes in the individual’s physical, mental, social or spiritual functioning seem to be outside of the individual’s control

Indicators of Severe Stress
Not feeling in control of one’s body, emotions or thinking Significant and persistent negative changes in behavior / habits Frequently unable to fall or stay asleep Numb, removed from all feelings Becoming uncharacteristically more isolated from others Excessive inner turmoil Wanting to avoid any reminders/triggers related to an incident Significant anxiety about reminders/places related to an incident Signs of Severe Stress Reactions The experiences, behaviors and symptoms that characterize stress reactions are similar. They include: Not feeling in control of one’s body, emotions or thinking Significant and persistent negative changes in behavior / habits Frequently unable to fall or stay asleep Numb, removed from all feelings Becoming uncharacteristically more isolated from others Excessive inner turmoil Wanting to avoid any reminders or triggers related to stress Significant anxiety about reminders or places related to an incident Becoming obsessive about information or factors related to an incident Waking up from recurrent or vivid nightmares Feeling persistent, intense guilt or shame Feeling unusually remorseless Experiencing attacks of panic, anger or rage Loss of memory or the ability to think rationally Inability to enjoy usually pleasurable activities Loss of grounding in previously held moral values

Indicators of Severe Stress
Obsessing about information related to an incident Recurrent or vivid nightmares Persistent, intense guilt or shame Experiencing attacks of panic, anger or rage Loss of memory or the ability to think rationally Inability to enjoy usually pleasurable activities Loss of grounding in previously held moral values Impaired or diminished role function Employee, Spouse, Parent, Friend Signs of Severe Stress Reactions The experiences, behaviors and symptoms that characterize stress reactions are similar. They include: Not feeling in control of one’s body, emotions or thinking Significant and persistent negative changes in behavior / habits Frequently unable to fall or stay asleep Numb, removed from all feelings Becoming uncharacteristically more isolated from others Excessive inner turmoil Wanting to avoid any reminders or triggers related to stress Significant anxiety about reminders or places related to an incident Becoming obsessive about information or factors related to an incident Waking up from recurrent or vivid nightmares Feeling persistent, intense guilt or shame Feeling unusually remorseless Experiencing attacks of panic, anger or rage Loss of memory or the ability to think rationally Inability to enjoy usually pleasurable activities Loss of grounding in previously held moral values

Where SFA Fits In the Stress Continuum
READY (Green) REACTING (Yellow) INJURED (Orange) ILL (Red) Leader Tools Train Identify Re-train Treat Reintegrate Policies Job Requirements Peer Support Tools Self, Buddy & Family Tools Fitness Nutrition Social Involvement Spirituality Therapy Medication Other Treatments SFA SFA Where SFA Fits in the Stress Continuum SFA was created to fill the care gap between training, stress management and prevention at the left end of the Stress Continuum and clinical treatments available from healthcare providers on the right. SFA is a set of procedures for the management of Yellow and Orange Zone stress that can be applied by anyone, anywhere. SFA

Stress First Aid Actions

We are going to spend the rest of today learning about and using this model. I am going to provide a brief overview as a starting point. How many here are CPR certified? (show hands) How many here, during your lifetime, actually performed BLS to save a life? (show hands) How many here in the last 30 days have interacted with someone who was having a strong stress reaction or possible stress injury? (show hands) If we should invest time and energy for responding to a relatively rare experience, we should probably spend at some time learning how to respond to a common, and arguably, just a lethal experience. SFA is similar to CPR. First we recognize that something might be wrong. Next we say, “Annie, Annie, are you OK?” If Annie wakes from a nap you do not initiate rescue breaths. If Annie is not OK, we do a quick Airway, Breathing, and Circulation check and then yell, “Call 911” to get help. Similarly, we look, listen and feel (situational awareness) and determine that a peer may be in trouble. You ask, “Are you OK?” You look to see if someone else is nearby who could assist if needed. If there is a physical safety risk you act immediately to make sure the person is safe (cover). Once safe, you assess if they are calm. We know that people with post-stress elevated HR, respiration, and BP show greater risk for long term health problems. This is where calming reduces the risk for further injury. Once a person is safe and calm, we then act in concert with others to facilitate connectedness, competence, and confidence. We use the model to remind people that stress reactions or injuries can be delayed and that they should be ready to respond in the future if stress injury behaviors emerge. At the end of the day, we will talk about how this model is used by good leaders everyday. 29

How Can You Use SFA? Check Approach Decide what is most needed:
Guilt/Shame Anxiety Sleep Problems Isolation Grief Severe Inability to Function Competence How Can You Use SFA? Which action would be most acceptable to the person? Which action would foster the most recovery? As you can see, when you are using SFA, you will always start with CHECK - either through your own observations or being informed about a high risk event, sign of distress, or change in functioning. Then you will be approaching the person to make contact first, to gather information that helps you make a decision about what to do based on the information you gathered. Depending on the symptoms and circumstances, you may also be utilizing more than one SFA action concurrently. It is important to keep an open, flexible stance towards Stress First Aid and use it as a framework for remembering the factors that should be considered when someone is exhibiting moderate to severe stress reactions. SFA is not one-size-fits-all. More than one core action can fit different stress reactions, so the decision of how to act will depend first on what type of stress reaction a person is experiencing, but also on a number of other factors, including: How much time do you have to spend with this person? What is the nature of your relationship? Which action would bring the greatest benefit? Calm Connect Coordinate Cover Confidence

CHECK Awareness

Check Check Actions: Observe Keep Track Examine Decide Look Listen
Stressors Distress Changes in functioning Response to interventions One-to-one interactions Collateral information Dangerousness Stress Zone Needs Check We will now move into discussing each of the seven core actions of SFA, starting with Check. This slide shows the broad components of Check: a) The first and most important procedure of Check is to observe: to look, listen, see and hear what is going on with the stressed individual, noting how he or she is being affected and by what. This is not meant to be an intrusive process, but one of awareness and caring. b) While looking and listening, it is important to keep track of the key indicators of the Stress Zones that we will learn about shortly. Special attention should be paid to stressor events (both at work and on the home front) and the internal distress and changes in functioning that these events (or their accumulation over time) may provoke. If SFA actions have already been used, we need to keep track of whether or not they have been effective. c) Observing from a distance is not usually enough to really get to know others. By examine, we mean talking one-on-one to the person we’re checking and, when appropriate, asking about how he or she is feeling and functioning. We can also gather information from other sources that might be helpful, including from peers and family members. d) The final component of Check is to decide on helpful interventions based on this information. We must also decide in every case whether anyone is in danger, and make decisions about Stress Zones and the need for further care. Check often begins with awareness that an individual has been exposed to specific stressors. These stressors may be discrete events such as a situation involving life threat, or the loss of loved ones. They can also be family life difficulties, financial strains or challenges to one’s value systems. Sometimes these stressors may also be an accumulation of small and seemingly insignificant challenges that can add up over time, and have a sizable impact on an individual's stress level. However, exposure to stressors is not enough to warrant SFA or other direct aid. Most people who experience even intense stressors don’t need help. What triggers the sequence of Checks that initiate SFA are not the events themselves but indications that someone who has been exposed to these events is operating in the Orange Zone. If serious stress reaction indicators are present, a quick assessment should indicate whether or not the person is currently in danger of being unable to function effectively. If so, Cover and Calm are indicated. Coordination with others may also be needed. Then, ask yourself “What are the individual's physical, mental, social, and spiritual needs?” Depending on the answer, it may be appropriate to use Connect, Confidence and Competence, and to identify what resources to mobilize on this person’s behalf, and who else needs to know. 32

Check: Why is it Needed? Those injured by stress may be the last to recognize it Stigma can be an obstacle to asking for help Stress zones and needs change over time Risks from stress injuries may last a long time Check: Why Is It Needed? This slide lists some reasons to utilize Check on a regular basis. As we cover each SFA action, we will discuss potential scenarios in which to use them--for whom and in what circumstances. The action of Check is different in that it is not triggered by certain situations, but rather should be an ongoing process. This is because most people are unaware of their stress zones and needs, and can’t afford to pay attention to such things when focusing on work and the demands of daily life. When people have been significantly changed by stress—injured by it—they may not recognize the ways that it has impacted their lives. Others, though, may notice if they are paying attention and know what to look for. Even if the person affected by stress recognizes distress or changes in functioning, the stigma that surrounds such problems can be a powerful barrier to seeking help. Telling others about our problems and asking for assistance is very difficult for most of us. Both the stress zones of individuals and the resources available to help can change drastically over time. A continuous process of assessment is often the only way to match needs with appropriate levels of help each step of the way. It is also important to remember that the after-effects of stress injuries can be delayed by weeks, months or even years. Those who have been seriously affected by stress at any one point in time will need to be periodically followed up with and reassessed. 33

Check Tool: “OSCAR” Communication
Observe: Actively observe behaviors; look for patterns State observations: State your observations of the behaviors; just the facts without interpretations or judgments Clarify Role: State why you are concerned about the behavior to validate why you are addressing the issue Ask why: Seek clarification; try to understand the other person's perception of the behaviors Respond: Clarify concern if indicated; discuss desired behaviors and state options in behavioral terms Check Tool: “OSCAR” Communication Many people feel uncomfortable asking others about their stress reactions. We know how to have casual conversations with peers, but when it comes to discussing personal issues or emotions, people often don’t know where or how to start. Another common barrier to accurate assessment is the almost automatic denial of experiencing any stressors, distress, or changes in functioning. One tool that can be effective in overcoming these obstacles is “OSCAR” communication—a mnemonic (memory device) for the five steps of: Observe State Observations Clarify Role Ask Why Respond. Here’s how it works: you have observed a co-worker keeping to themselves after a stressful event, such as the death or injury of another member of the department.. You approach the withdrawn person and strike up a friendly conversation. After a while, you ask something open-ended like “How are you doing? or “How are you feeling?” If he or she quickly brushes you off with a denial such as “I’m fine,” you next state your observation, such as “Well, I asked because I noticed you’ve been keeping to yourself a lot lately.” Before the individual has a chance to get defensive, you add—to clarify your role—that you only bring it up because you are concerned, and want to know if there is any way that you can help. If you can then establish a common perception about the person’s behavior (i.e. he or she admits to isolating more than usual), you next ask why, or maybe simply “What’s going on?” The final step is to respond with a statement that makes it clear that you both heard and understood what you were told, and that you might have some ideas about what might make the person feel or function better.

Check: Fire/EMS Example
“I try to get to know each of my guys individually, so I know their baselines and what could potentially be a red flag. Instead of sitting on the couch and watching television, I go out and catch a football and talk. That helped when one of my crew members had a pregnant wife, and we responded to a stillborn birth. After that call I took a little extra time to sit and talk with him, to make sure that he was okay.” Check: Fire/EMS Example Here is a real example of how the SFA Check function can be incorporated into your work in a seamless and natural way: “I try to get to know each of my guys individually, so I know their baselines and what could potentially be a red flag. Instead of sitting on the couch and watching television, I go out and catch a football and talk. That helped when one of my crew members had a pregnant wife, and we responded to a stillborn birth. After that call I took a little extra time to sit and talk with him, to make sure that he was okay.” ASK: Can you think of any other examples where you have seen the Check action used? 35

COORDINATE Know Resources

To get more information
Coordinate Coordinate Actions: Collaborate Inform Refer To promote recovery To ensure safety To get more information Chain of command Family Peers Recommend resources Consultation Direct hand-off Coordinate Coordinating care is something that firefighters and EMTs do all the time. The next core action of SFA is Coordinate, which should come naturally to you. Within SFA, providers consult and collaborate with others, and inform those who need to know. The key components of the Coordinate action are: To collaborate with everyone who has a stake in the well-being and future of the stressed individual. To get assistance from others at any step in the process in which help is needed to assess and care for individuals with stress problems. To inform the chain of command to the extent they need to know. To refer individuals in need to others who can help either in a direct hand-off or through a more gradual consultation process. 37

Coordinate: Reasons for Referral
Threat to self or others Uncertainty regarding stress level, dangerousness or level of impairment Suspicion that key facts are missing Uncertainty about the strength of the working alliance Worsening over time or failure to improve Coordinate: Reasons for Referral In all cases, asking for someone else’s opinion or help early rather than late in the process is a good idea. A referral to a BHAP provider or clinician is indicated if: The individual poses a threat to self or others. There is uncertainty regarding stress level, dangerousness or level of impairment. You suspect that key facts may be missing from the picture. You are uncertain about the strength of your working alliance with the individual The individual's stress impairment seems to be worsening over time, or failing to improve. 38

Coordinate: Fire/EMS Example
“We had an irritable, difficult firefighter who wouldn’t open up to anyone, but we knew a good friend of his and let this friend know that we had some concerns. He took the crew member out fishing and made more time to do things with him. After that, we stayed in touch with his friend to make sure the crew member was doing okay.” Coordinate Example Here is a real example of how Coordinate can be incorporated into your work in a seamless and natural way: “We had an irritable, difficult firefighter who wouldn’t open up to anyone, but we knew a good friend of his and let this friend know that we had some concerns. He took the crew member out fishing and made more time to do things with him. After that, we stayed in touch with his friend to make sure the crew member was doing okay.” As you can see, coordinating doesn’t have to lead to an action that might be perceived of as intrusive. It should be a natural way of reducing risk, and securing resources that the person might need. ASK: Can you think of any examples that you have seen the Coordinate action used? 39

Encourage Perception of Safety
Cover Cover Actions: Stand By Make Safe Make Others Safe Encourage Perception of Safety Ready to assist Watch and listen Hold attention Authoritative presence Warn Protect Assist Caring presence Reduced chaos Reduced danger Listen and communicate Cover This slide shows the primary components of the next SFA action, Cover. To provide Cover means to ensure continued safety. This most often takes the form of standing by a stress-injured person, and remaining available and ready to assist as needed. The most basic component of Cover is to make the stress-injured person safe in any way you can. When necessary, Cover also encompasses making others safe from the stress-injured person. Cover is also about encouraging a perception of safety. In situations where there is either real danger or risk surrounding an individual, a greater commitment to organizational safety and order can generate a perception of safety that is important for both affected individuals and their families. 40

Cover: Fire/EMS Example
“After a line-of-duty death, my crew members were telling me that they couldn’t go home to their families and say ‘my job is safe.’ They felt more vulnerable, and were being pressured to quit by family members. So we had a family meeting where we brought in firefighters from a department which had previously had a LODD. They talked to our families about how they had gotten through the situation. It helped our families to feel like they could get through it, and our crew members felt less pressure.” Cover Example Here is a real example of how a longer-term Cover procedure can be incorporated into your work: “After a line-of-duty death, my crew was telling me that they couldn’t go home to their families and say ‘my job is safe.’ They felt more vulnerable, and were being pressured to quit by family members. So we had a family meeting where we brought in firefighters from a department which had previously had a LODD. They talked to our families about how they had gotten through the situation. It helped our family members feel like they could get through it, and our crew members felt less pressure.” ASK: Can you think of any other examples where you have seen the Cover action used?

Calm Calm Actions: Quiet Compose Foster Rest Soothe
Stop physical exertion Reduce hyper- alertness Slow down heart rate Relax Draw attention outwards Distract Re-focus Recuperate Sleep Time out Listen empathically Reduce emotional intensity Calm This slide shows the major components of the next SFA action, Calm. You may notice there is some overlap between the concepts that make up Cover and Calm. Procedures that promote one of these two actions often also help with the other. The major difference is that while the goal of Cover is safety, Calm’s goal is to reduce the intensity of physiological, emotional and behavioral activation. The first and most basic procedure of Calm is simply to stop, quiet, and cease physical exertion if possible. Some examples of this are to sit down or lie down, put down any items and relax, with the goal of slowing heart rate. Regaining composure will help to restore cognitive function. The word “compose” means to help to pull back together that which is scattered or fragmented into a more orderly and coherent state. In the Calm function of SFA, we help people compose by drawing their attention away from their frightening and chaotic inner thoughts and feelings, and refocusing them in a calming way. The next component of Calm is simply to rest—including sleep--for as long as is necessary to return to baseline levels of arousal and physical and emotional function. Pay particular attention to the sleep of a stress-injured person. Sometimes a good night’s rest is the only thing that will restore a stress-injured person to baseline mental and emotional functioning, so make sure they actually get to sleep.. The final component of Calm is soothing, which means to reduce the intensity of destructive emotions like fear and anger, by providing a calm physical presence and listening empathically. 42

Calm: How Does it Work? Reduces muscular activity
Reduces mental and emotional effort Slows heart rate Reduces levels of stress chemicals in the blood and brain Reduces intensity of negative emotions like fear and anger Increases positive emotions like safety and trust Increases ability of the individual for self-control Restores mental clarity and focus Calm: How Does It Work? How do Calm procedures help to achieve these goals? Ultimately, we are trying to restore optimal mental functioning and put a halt to any potential damage caused by excessive stress. We cannot directly control nerve cells or levels of stress chemicals, but we can influence them indirectly by controlling the larger systems of the affected person, including level of physical activity, breathing, attention and emotional state. All these systems are interconnected. For instance, by slowing down large muscle activity (for example by lying down) many other systems in the brain and body will also slow down. By promoting slow, deep breathing we can reduce heart-rate, which in turn causes other systems to also calm down. 43

Calm: Fire/EMS Examples
“After we had a couple of particularly tough calls, I brought pistachio nuts in for the crew. Shelling pistachios takes time and makes people slow down, so it gave us a chance to unwind and talk about what happened. Doing something supportive doesn’t have to look like a mental health intervention. In fact, the best interventions are often the least noticeable ones.” “After a line-of-duty death, we made sure that the memorial activities were voluntary, and that crew members knew what to do if memorial activities were distressing (i.e. that it was okay to bring an iPod in to listen to if testimonials were triggering them). We also decided to make the memorial a scholarship fund rather than a statue or plaque that would be a constant visual reminder of the death.” Calm Examples Here are a few real examples of how Calm procedures can be incorporated into your work: “When we had a couple of particularly tough calls, I brought pistachio nuts in for the crew. Shelling pistachios takes time, and makes people slow down, so it gave us a chance to unwind and talk about what happened. Doing something supportive doesn't have to look like a mental health intervention. In fact, the best interventions are often the least noticeable ones." “After a line-of-duty death, we made sure that the memorial activities were voluntary, and that crew members knew what to do if the events were distressing (i.e. that it was okay to bring an iPod in to listen to if testimonials were triggering them). We also decided to make the memorial a scholarship fund rather than a statue or plaque that would be a constant visual reminder of the death.” ASK: Can you think of any other examples that you have seen where the Coordinate action has been used?

CONNECT Mobilize Resources

Connect Connect Actions: Promote Reduce Isolation Be With Connection
Maintain Presence Keep Eye contact Listen Empathize Accept Find Trusted Others Foster contact with others Encourage Contact with others Improve understanding Correct misconceptions Restore trust Invite and include Connect This slide shows the three components of the next SFA core action, Connect. . As with all SFA actions, these components designed to be adapted to fit your setting, your personality and the needs at that time of the individual experiencing a stress reaction. The first component is to simply be with the stress-injured person. This means being present, making eye contact, listening and/or mentoring and empathizing. The next component is to comfort. This implies accepting the person and his or her reactions, providing encouragement if that is what is needed, or soothing in a way that fits your style and is acceptable to the individual. The final component is to reduce the stress-injured person’s sense of isolation, which can often occur when Orange Zone reactions make the individual want to isolate, or when he or she feels shame about what is happening. Assisting in such a case may involve helping to improve the person's understanding of the situation and of stress reactions. Often, the SFA provider must help the person to see that stress reactions are understandable and acceptable. This component also involves correcting misconceptions and misperceptions that will reduce the stressed person's alienation and isolation. This includes clearing up those held by the stress-injured person about his or her own stress reactions, as well as those held by others. Doing so will effectively restore the individual's trust in him or herself, and restore the trust of others. In its simplest form, you can help reduce isolation by simply inviting and including the stress-injured person into department or crew activities. Research has shown that many people who are experiencing significant stress respond well to being included in an activity, having casual friendly encounters or receiving help and information in strictly practical way rather than directly discussing emotional problems or reactions. This is particularly true of men, and could be because many try to repress their symptoms, and emotional support brings adverse events to their attention again. Individuals suffering from post-traumatic stress may prefer to keep away from this type of emotional support, especially in work contexts. These Connect strategies are designed to help the stress-injured individual feel that he or she is not alone, there are caring others around and there are ways to stay connected to others. As was previously mentioned, social connectedness is one of the strongest protective factors against stress injury, and is linked to emotional well-being and recovery following traumatic stress and loss. 46

Different Types of Support
Connect targets three types of social support: Instrumental support: the provision of material aid (such as assistance with daily tasks) Informational support: the provision of relevant information (such as advice or guidance) intended to help the individual cope with current difficulties Emotional support: the expression of empathy, caring, reassurance and provision of opportunities for emotional expression and venting Connect: Different Types of Support The Connect function targets three types of social support: Instrumental support: providing material aid, such as assistance or help with daily tasks. Many firefighters and EMS providers have indicated that they prefer this type of support to emotional support in difficult times. Informational support: providing relevant information (e.g. advice or guidance) intended to help the individual cope with current difficulties. Emotional support: the expression of empathy, caring and reassurance, as well as providing opportunities for emotional expression and venting. 47

Connect: Fire/EMS Example
“A firefighter was drinking all the time. He had been on the crew with the two guys who died, but it was hard to get him to talk to us. He had a kitchen remodeling project underway, so I went over and hung out in his home and helped him. While we worked on it, he opened up and I was able to get him some help.” Connect Example Here is a real example of how Connect procedures can be incorporated into your work: “A firefighter was drinking all the time. He had been on the crew with the two guys who died, but it was hard to get him to talk to us. He had a kitchen remodeling project under way, so I went over and hung out in his home and helped him. While we worked on it, he opened up, and I was able to get him some help.” This is a situation in which providing natural, helpful assistance with an unrelated activity can facilitate authentic connectedness. Often this is more effective than using artificial means to force a person to talk before they are ready. ASK: Can you think of any other examples that you have seen where the Coordinate action has been used?

COMPETENCE Build/Restore Effectiveness

Competence Actions Foster / improve:
Social Skills Occupational Skills Well-Being Develop family relationships Develop peer relationships Seek mentoring Brief operational pause Mentor back to duty Retrain Reassign Problem-solving skills Health and fitness Managing trauma and loss reminders Competence You may notice there is overlap between the concepts that make up Connect and Competence. Procedures that promote one of these two functions often help with the other. The same is often also true with the Confidence function. You will probably find that efforts in any one of these areas will have an impact on the others, resulting in a psychological sense of greater safety and calm for the stress-injured individual. The Competence action focuses on enhancing and restoring individual capacities to function and perform in all important life roles, including occupational, personal, and social domains. The term “Competence” is really shorthand for “help restore previous capabilities” or “cultivate personal competence.” The need for Competence is usually signaled by the loss due to stress exposure of an individual's mental, emotional or physical capabilities. To what extent these capabilities are lost will depend greatly on the situation and the individual involved. When providing Competence, SFA providers do something with (not for) affected individuals or crews to restore previous capabilities or cultivate personal competence. We know from the research literature that increasing Competence: Improves functioning and fosters better connections and supports, as well as augmenting individual and group morale. Reestablishes the confidence of others in the stressed individual. Helps to overcome injury to mind, body and spirit. Builds resilience. The first component of Competence is to improve social skills with both family members and peers. These skills are often damaged by stress, which can negatively affect an individual's ability to function with others at home and on the job. The next component is to augment occupational skills that may have been damaged by stress injury. This may require mentoring, respite and retraining for the stressed individual to feel capable again and to once again gain self-esteem from his or her work. SFA can be employed for stress-related injuries that impair abilities on the job.To grow out of stress-induced decrements in functioning may require developing capabilities. in the same way that physical therapy is a skill set that is used in physical rehabilitation, The last component is to foster the development personal competence and well-being skills that can help the stressed individual establish self-control, self-modulation, health and restore and improve abilities to cope with life’s challenges. 50

Competence: Lack of Experience
Operational challenges are new Unprepared for emotional impact Lack of sufficient training Overwhelming/low frequency event Competence: When Is It Needed? Generally there are three signals for the need for Competence: Indications that an individual does not have the experience or skill level to address the demands of his or her position within the crew or the department. The temporary or persistent loss of previous skills or abilities due to Orange Zone stress. The emergence of new life challenges with which the individual has not yet developed the ability to cope, such as Orange Zone symptoms of distress. Competence can be needed for many reasons, and these are just a few focused lack of training and experience contributing to difficulty meeting job demands. Operational challenges are new to a crew member. Lack of experience in handling specific emotional aspects of the job. Lack of sufficient training in certain aspects of the job. An overwhelming event (PTE) leaves the entire unit feeling unprepared to handle aspects of the challenge. 51

Competence: Loss of Skill or Ability
Mental focus or clarity, cognitive functioning Emotional/behavioral/physiological self-control Enthusiasm and motivation Social aptitude Ability to see the “big picture” Stress-induced physical symptoms Avoidance Competence: When Is It Needed? (cont.) On this slide are examples of the need for Competence, in situations in which stress reaction may have caused the loss of previous skill or abilities: Mental focus or clarity, cognitive functioning. Emotional or behavioral, physiological self-control. Enthusiasm and motivation. Social aptitude. Ability to see the "big picture." Dread and desire to avoid re-exposure. Stress-induced physical symptoms. 52

Competence: Coping Challenge
Trauma or loss reminders Disturbing memories Difficulty relaxing, slowing down or getting to sleep Difficulty maintaining an emotional “even keel” Dread and desire to avoid re-exposure Stress-induced physical symptoms Competence: When Is It Needed? (cont.) On this slide are examples of the need for Competence, in situations in which stress reaction may have caused challenges to copying: Trauma or loss reminders. Disturbing memories. Difficulty relaxing, slowing down or getting to sleep. Difficulty maintaining an "even keel" emotionally. Dread and desire to avoid re-exposure. Stress-induced physical symptoms. When you are dealing with a stress injury that affects an individual's competence, you must be cognizant of pre-event competence, event-based competence and post-event competence. Rebuilding potency is a critical factor, so that the individuals can feel capable of managing both job duties and the stress reactions. In other words, this isn’t exclusively about work competence, but also about regaining the ability one's life back together, and to feel positively about one's own skills and abilities. 53

Stop Back Up Move Forward Again
Rest, take time to recover Identify challenges to functional capabilities Don’t keep doing what isn’t working Back Up Retrain and refresh skills Mentor/problem solve Learn new skills Enhance wellness Move Forward Again Practice new and refreshed skills Gradually increase responsibilities Set achievable goals Explore and trouble-shoot obstacles Reinforce successes and motivation Competence: Procedures The core process for the Competence function of SFA is to take one step backward in order to take two steps forward. As a result, restoring or enhancing Competence in the face of Orange Zone stress can require the following sequence of actions: (1) stop, (2) back up, and (3) move forward again. This slide shows examples of procedures that can be used to restore an individual's sense of competence.: 1. Stop procedures can include: Providing rest and time to recover (indicated time off). Ceasing what isn’t working. Assessing any functional capabilities and limitations in occupational, social and personal well-being spheres. Identifying challenges to recovering functional capabilities. 2. Back up procedures can include: Retraining and refreshing old skills. Mentoring and coaching in problem-solving. Learning new skills Enhancing wellness through sleep, nutrition, exercise, meditation, prayer, etc. One of the key tools you can use to improve competence is partnering with the peer in simple problem-solving. We know from the trauma literature that cognitive functioning becomes much more rigid and less creative for people who are experiencing a stress reaction. By forming a partnership with the stressed individual, SFA providers that will make him or her feel supported, and together they can collaborate creatively in seeing solutions to current difficulties and generating ideas about how to cope. This will foster a sense of agency--one's ability to take action, be effective, influence one's own life and to assume responsibility for behavior through disciplined, focused thinking about personal needs and wants, and generating solutions.. The SFA provider can be instrumental in helping individuals to get "unstuck" and move towards small, clear steps that will help the individual to tackle problems and feel better about him or herself. In the process of providing Competence, it is important to remind stressed individuals that they can do it, show them that they are not alone, and model behaviors for them what they can do if they get stuck. This SFA action also includes increasing competence in managing stress reactions. SFA caregivers should become adept at teaching a variety of stress coping skills that are relevant to Orange Zone stress, such as: • Sleep hygiene • Relaxation • Meditation or prayer • Anger management • Goal setting • Problem solving • Nutrition • Physical exercise and conditioning • Preparing for reminders and triggers, so that the individual is not taken by surprise and can deal with them when and if they occur. 3. Move forward again procedures include: Practicing new and refreshed skills. Gradually increasing responsibilities. Setting achievable goals. 54

Competence: Fire/EMS Example
“Our fire department had training on conflict resolution because we saw that when our young firefighters were under stress, they didn’t really know how to manage their irritability and anger. They also did not know how to communicate directly, effectively and assertively with others—they were more used to texting than talking. The training helped all of us improve the ways we handle conflict individually, and as an organization.” Competence: Fire/EMS Example Here is an example of promoting Competence at an organizational level: “Our department had a training on conflict resolution because we saw that when our young firefighters were under stress, they didn’t really know how to manage their irritability and anger. They also didn't know how to communicate directly, effectively or assertively with others--they were more used to texting than talking. The training helped them all of us improve the ways we handle conflict individually, and as an organization..” ASK: Can you think of any other examples that you have seen where the Competence action has been used? 55

CONFIDENCE Restore Hope/Self-Esteem

Confidence Actions Rebuild:
Trust Hope Self-Worth Meaning Trust in: Peers Equipment Leaders Mission Forgiveness of self Forgiveness of others Imagining the future Belief in self Accurate self- concept Self-respect Making sense Purpose Faith Confidence The final SFA action is Confidence, originally derived from the literature on “hope.” Confidence actions are intended to: Promote realistic hope and build self-esteem that may have been damaged or lost as a result of stress. Promote confidence in core values and beliefs. Bolster pride and commitment. This slide shows the four components of Confidence: The first is trust, which can be trust in many things, such as peers, equipment, leaders, self or mission. The second component is hope, which is often the result of forgiving self or others, or being able to imagine the future in a positive way. The third component is self-worth, which includes belief in self; an accurate and mostly positive self-image; self-respect or a thinking process that taps a sense of agency or will; and the awareness of the steps necessary to achieve one’s life goals. The fourth component is meaning, which includes the process of making sense of life; having a sense of purpose or faith; holding a spiritual perspective related to the human condition; or a belief in strong others and/or a higher power who will intervene on the person’s behalf. All of these functions lead to a sense of confidence – in the self, in others, in life or in spiritual sources of solace 57

Confidence: When is it Needed?
Needed by everyone who has: A feeling of having betrayed self or others Significant loss of self-worth and self-trust A feeling of having been betrayed by others Loss of confidence in leadership/mission/work values Overly negative, rigidly-held beliefs about self and world A strong sense of either shame or bitterness/anger Loss of faith in God or previously-held values Confidence: When Is It Needed? The challenges addressed by Confidence are common to all human beings throughout our lives, and the Confidence action would benefit every one who has ever sustained a stress injury. Examples in which firefighters and EMS providers would benefit from Confidence include those who are experiencing: Feelings of having betrayed self or others. Significant loss of self-worth and self-trust. Feelings of having been betrayed by others. A marked loss of confidence in leadership, organizational mission and/or values. Overly negative, rigidly-held beliefs about the self and world. A strong sense of either shame or bitterness/anger. Loss of faith in previously held spiritual values. Confidence is closely related to having a sense of positive self-worth, meaning, trust and hope. When one considers the alternatives to a sense of confidence, the urgency and importance of the Confidence function of SFA become apparent. The alternative to hope is despair, the alternative to trust is alienation, the alternative to meaning is emptiness and the alternative to self-worth may be suicide. 58

Confidence: Why Is It Important?
Alternative Hope Despair Trust Alienation Meaning Emptiness Self-Worth Maybe Suicide This slide shows the importance of the actions of Confidence in possibly mitigating negative impacts/outcomes

Confidence: Fire/EMS Example
“I give my crew members the message that you don’t take ownership of injuries or deaths unless you clearly stepped over the line. Did we do everything that could be done? If so, we did our job. We don’t control who lives or dies; our job is to provide the best service possible. If not, let’s do an AAR and improve what we do the next time. We can learn something from every incident.” “It’s about reframing. A traumatic event is like a tattoo. It hurts and it will stay with you forever, but you learn to live with it and after a period of time it won’t hurt as much. I try to use what I’ve learned from these events to help others.” Confidence: Fire/EMS Example Here is an example of promoting Confidence at the organizational level: “I give my crew members the message that you don’t take ownership of injuries or deaths unless you’ve clearly stepped over the line. Did we do everything that could be done? If so, God decides who lives or dies, and we just try to buy a few extra minutes in case he changes his mind. If not, let’s do an AAR and improve what we do the next time. Every incident can bring learning.” ASK: Can you think of any other examples that you have seen where the Confidence action has been used? 60

Wrap Up

Review the seven actions of SFA
62

How Can You Use SFA? Check Approach Decide what is most needed:
Guilt/Shame Anxiety Sleep Problems Isolation Grief Severe Inability to Function Review how you might use SFA reminding participants that we always begin with Check, and decide what approach and action is necessary Competence Calm Connect Coordinate Cover Confidence

Why Learn SFA? Recognize a potential stress injury in a peer
Act: If you see something, say something To the distressed person To a trusted source of support Connect peer to appropriate support

Take Home Messages Stress as a continuum Four sources of stress injury
Good leaders are the best medicine One size does not fit all If you see something, say something! Take care of yourself and one another! Take Home Messages The basic take home messages for using SFA are: View stress on a continuum Four sources of stress injury Good leaders are the best medicine One size does not fit all If you see something, say something! Take care of yourself and one another! ASK: Does anyone have any closing comments and questions?

Resources National Fallen Firefighters Foundation: Fire Life Safety Initiative 13 website: Fire Hero Learning Network website: Resources Here are some additional resources if you want to learn more about the National Fallen Firefighters Foundation, or more about PTSD and traumatic stress. National Fallen Firefighters Foundation: National Center for PTSD: Fire Life Safety Initiative 13 website

Capt. Frank Leto frank. leto@fdny. nyc
Capt. Frank Leto Vickie Taylor, LCSW

Welcome to Stress First-Aid (SFA) Training.

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Welcome to Stress First-Aid (SFA) Training.

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