2. In Times of Crisis: Supporting Others, Supporting Ourselves Jeffrey Harris, MFT, CEAP Program Manager USC Center for Work and Family Life

3. Center for Work and Family Life Available Services:  Faculty and Staff Counseling  Faculty, Management and Departmental Consultation  Critical incident response  Work/Life Support  Family and Dependent Care: Consultation and Resources  Workplace Health and Wellness Programs

4. 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?

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

6. Are We Psychologically Prepared?  For every physical injury, there may be 5-6 psychological injuries  This may overwhelm and impede our emergency and/or medical response.

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

8.  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 Mechanisms

9. Into every life a little rain must fall ….. But what happens when there is a flood?

10. Psychosocial Impact – Considerations  Prior experience with a similar event  Prior trauma  The intensity of the disruption in the survivors’ lives  The resilience of the individual

11. Psychosocial Impact – Considerations  The length of time that has elapsed between the event occurrence and the present  Pre-existing vulnerabilities  Human-Caused vs. Events of Nature Children/families Seniors Disabled Bereaved Health impairments Women

12. Consequences of Critical Incidents Often include LOSS  Tangible Loss  Loss of loved ones  Loss of home  Loss of material goods  Loss of employment / income

13. Consequences of Critical Incidents Often include LOSS  Intangible Loss security (real or perceived)  Loss of safety / security (real or perceived) predictability  Loss of predictability social cohesion/connection/support  Loss of social cohesion/connection/support dignity, trust and safety  Loss of dignity, trust and safety positive self-image/self-esteem  Loss of positive self-image/self-esteem trust in the future, identity, independence  Loss of trust in the future, identity, independence hope  Loss of hope CONTROL  Loss of CONTROL

14. ActivityWhat if I lost… Activity – What if I lost…  You have been given three cards each of three different colors:  Blue Card  Blue Card - write the name of a person close to you on each card  White Card  White Card - write down one of your favorite belongings  Pink Card  Pink Card - write down something you enjoy, an activity, or hobby.  After you have written on each card, place them face down on the table and shuffle them around. Close your eyes and pick three cards.

15. ActivityWhat if I lost… Activity – What if I lost…  These are the three things you will have lost in a disaster.  Discuss with the group how you feel about losing these things or people

16. Possible Psychological Reactions to a Large-Scale Emergency  Many people survive disasters without developing any significant psychological symptoms.  For other individuals, the reactions will disappear over time. “Just because you have experienced a disaster does not mean you will be damaged by it, but you will be changed by it.” (Weaver 1995)

17. Grief and Loss  Not an even process  Takes time  Can become stuck in the process  May spawn other problems  Nothing like T & T (Time and Talking)

18. Supporting Others

19. “We’re a community that believes in ‘love thy neighbor’, but right now we need to love our neighbors a little bit more.”  Man talking after devastating tornados ripped through his Tennessee neighborhood - 2/08

20. 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.

21. Role of Disaster Mental Health?  Mitigate post trauma sequelae  May prevent future problems  Helps people to handle problems in a way that does not create MORE problems  Convey a sense of compassion and support for people.

22. Key Concepts Psychological Response to Trauma Key Concepts  Experience has shown that:  No one who sees a disaster is untouched by it.  Most people pull together & function during and after a disaster, but their effectiveness is diminished.  Most people do not see themselves as needing mental health services following a disaster and will not seek such services.

23. Key Concepts Psychological Response to Trauma Key Concepts  Experience has shown that:  Survivors respond to active, genuine interest & concern.  Survivors may reject disaster assistance of all types.  Disaster mental health assistance is often more practical than psychological in nature.  Social support systems are crucial to recovery.

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

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

26. Honeymoon Honeymoon (community cohesion)  Survivors may be elated  Happy just to be alive  This phase will not last

27. Disillusionment  Reality of disaster “hits home”  Loss and Grief becomes prominent

28. What Do You Think?  What main attributes and skills should a volunteer have when offering psychological support?

29. Essential Attributes and Skills  Good Listening skills  Patient  Caring attitude  Trustworthy  Approachable  Culturally aware  Empathetic  Non-judgmental approach  Kind  Committed  Flexible  Able to tolerate chaos

30. Intense Emotions  Are often appropriate reactions following a disaster  Can often be managed by community responders

31. Supportive Communication  Supportive communication conveys:  Empathy  Concern  Respect  Confidence

32. Activity – Supportive Statements  What are some supportive statements that you would find helpful if you were in pain, injured, and/or acute emotional distress?

33. Do Say…  Can you tell me what happened?  I’m Sorry  This must be difficult for you  I’m here to be with you

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

35. 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...”

36. Guiding Principles in Providing Psychological 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

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

38. Goals of Psychological First Aid  Psychological first aid (PFA) promotes and sustains an environment of: SAFETY CALM CONNECTEDNESS SELF-EFFICACY HOPE HOPE

39. Psychological First Aid  Promote SAFETY:  Help people meet basic needs for food and shelter, & obtain medical attention.  Provide repeated, simple and accurate information on how to get these basic needs met.

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

41. Psychological First Aid  Promote CONNECTEDNESS:  Help people contact friends and loved ones.  Keep families together. Keep children with parents or other close relatives whenever possible.

42. Psychological First Aid  Promote SELF-EFFICACY:  Give practical suggestions that steer people toward helping themselves.  Engage people in meeting their own needs.

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

44. Psychological First Aid  Some DON’Ts:  Don’t force people to share their stories with you, especially very personal details  this may decrease calmness in people who are not ready to share their experiences  Don’t give simple reassurances like “everything will be ok”, or “at least you survived”  statements like these tend to diminish calmness

45. 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

46. 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 services  this may decrease hopefulness or decrease calming  Source: Center for the Study of Traumatic Stress

47. Anxiety  A state of intense apprehension, uncertainty and fear  Results from anticipating a threatening event  Intense anxiety triggers “fight or flight” syndrome

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

49. The Energy Curve Anxiety Agitation Baseline Tension Reduction

50. Elements of Escalation  Challenging authority or questioning  Refusal to follow directions  Loss of control, becoming verbally agitated  Becoming threatening

51. Elements of Escalation  Challenging Authority or Questioning  Answer the question  Repeat your request in a neutral tone of voice  Remember that an ounce of prevention is worth a pound of cure

52. Elements of De-escalation  For Those Not Following Directions…  Do not take control; help the individual gain control of him/herself  Remain professional  Consider restructuring your request  Give the person time to think about your request  Give reflective feedback:  “you are screaming at me, Joe”

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

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

55. Elements of De-escalation  Come to an agreement on something  Establishing a point of agreement will help solidify your relationship and help gain their trust  Positive language has more influence than negative language  Active listening will assist you in finding a point of agreement

56. Elements of De-escalation  Speak to the person with respect This is communicated with:  Words  Para-verbal Communication  how we say the words – e.g. tone, pitch  Non-verbal behavior  Use of words like please and thank you

57. Elements of De-escalation  Don't make global statements about the person's character  Use “I” statements  Avoid lavishing praise, or using encouragement that is not believable

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

59. Survivors’ Needs and Reactions Psychological Response to Trauma Survivors’ 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 & anxietyFear & anxiety Grief & lossGrief & loss ShockShock HopelessnessHopelessness Loss of ConfidenceLoss of Confidence MistrustMistrust Sleep disturbancesSleep disturbances Physical painPhysical pain ConfusionConfusion ShameShame Shaken faithShaken faith AggressivenessAggressiveness

60. 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)

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

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

63. Fear of darkness Fear of being alone; fear of crowds or strangers Sensitivity to loud noises Somatic complaints Guilt, anger, grief Reliving past traumas Main point – Disaster stress is a normal response to an abnormal circumstance. If symptoms persist, they must be treated. More Typical Reactions… C. Fasser, 2004; B. Young, 2006

64. Possible Psychological Reactions to a Large-Scale Emergency For most people, things get better with time… For some, however, the reactions may evolve and even worsen

65. Possible Psychological Reactions to a Large-Scale Emergency  Victims of Hurricane Katrina  Victims of Hurricane Katrina:  Significant increase in serious mental health problems, two years post-Katrina, across all racial and socio-economic groups  PTSD  Suicidality  Depression  Anxiety  substance abuse  domestic violence

66. Categories of Reactions After the Incident ASD / PTSDASD / PTSD GriefGrief DepressionDepression ResilienceResilience Mental Health and Illness Human Behavior in High Stress Environments Distress Responses Fear / worryFear / worry Sleep disturbanceSleep disturbance Altered productivityAltered productivity Avoidance (emotional)Avoidance (emotional) Substance abuseSubstance abuse Risk takingRisk taking Over DedicationOver Dedication

67. Loss and Grief – Signs of Trouble  Avoiding or minimizing emotions  Using alcohol or drugs to self-medicate  Using work or other distractions to avoid feelings  Hostility and aggression toward others

68. Stress  A state of physical and/or psychological arousal  Often brought about by a perceived threat or challenge  May be expressed differently by different people / cultures

69. Coping with Stress  Coping is a way to prevent, delay, avoid, or manage stress  Coping mechanism categories:  Changing the source of stress  Changing the view of the situation  Tolerating the stressor until it passes or becomes less troublesome

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

71. 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

72. Responder Stress and Well-Being: Helping the Helpers

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

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

75. 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.

76. What Are Your Preferred Approaches to Managing Stress?  Do you practice ‘stress management’ regularly?

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

78. Self-Help Techniques (cont.)  Work on routine tasks if it is too difficult to concentrate on demanding duties  If you cannot sleep or feel too anxious, discuss this with someone you can trust  Express your feelings in ways other than talking:  Draw  Paint  Play music  Journal

79. Self-Help Techniques (cont.)  Do not self-medicate  Go easy on yourself  Avoid inflated or perfectionistic expectations  Seek professional advice if reactions continue

80. Cognitive/Behavioral Approaches to Stress Reduction  Adequate Rest  Exercise / Movement  Diet / Balanced Nutrition  Enough H 2 O  Moderate Chemical Use  Laughter / Tears  Time Away From Work Role

81. Cognitive/Behavioral Approaches to Stress Reduction  Religious / Spiritual  Relaxation Techniques / Breathing  Yoga  Meditation  Social Support / Discuss Feelings  Allow yourself to receive as well as give

82. Cognitive/Behavioral Approaches to Stress Reduction  Play: Hobbies / Personal Interests  Connecting with Nature  Biofeedback  Massage / Human Touch  Sex  Professional Assistance  Medication  What Else Works for You???

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

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

85. No Macho (Wo)Man, No Pity Party Do not create an expectation there will be a problem, but when there is a problem, go get help. Lt. Col Dave Grossman (ret.)

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

87. Questions / Discussion