In Times of CrisisIn Times of Crisis::Supporting Others,Supporting Others,
Supporting OurselvesSupporting Ourselves
John Gaspari, LCSWExecutive Director
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
Man-Caused vs. Naturally Occurring Events
•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 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.
Psychological Response to TraumaKey ConceptsKey Concepts
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.
Psychological Response to TraumaKey ConceptsKey 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 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.
Psychological First Aid
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.
Psychological First Aid
Promote CONNECTEDNESS:Promote CONNECTEDNESS:
Help people contact friends and loved ones.
Keep families together. Keep children with parents or other close relatives whenever possible.
Psychological First Aid
Promote SELF-EFFICACY:Promote SELF-EFFICACY:
Give practical suggestions that steer people toward helping themselves.
Engage people in meeting their own needs.
Psychological First Aid
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 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).
Give simple reassurances like “everything will be ok”, or “at least you survived” (statements like these tend to diminish calmness).
Psychological First Aid 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).
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 DON’T:
Make promises that may not be kept (un-kept promises decrease hope).
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
AnxietyAnxiety
A state of intense apprehension, uncertainty and fear
Results from anticipating a threatening event
Intense anxiety = “fight or flight”
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 EscalationElements of Escalation
Not Following DirectionsDo 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
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
Elements of De-escalationElements of De-escalation
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 "Mrs.", especially if they are older than you
Elements of De-escalationElements of De-escalation
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?
Elements of De-escalationElements 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
Elements of De-escalationElements 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
Elements of De-escalationElements of De-escalation
Don't make global statements about the person's character
Use “I” statements
Lavish praise / support / encouragement is not believable
Responder Stress and Responder Stress and Well-Being:Well-Being:
Helping the HelpersHelping the Helpers
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)
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
Possible Physiological Possible Physiological SymptomsSymptoms
Loss of appetite Headaches, chest pain Diarrhea, stomach pain, nausea Hyperactivity Increase in alcohol or drug consumption Nightmares Inability to sleep Fatigue, low energy
Possible Emotional/Psychological Possible Emotional/Psychological SymptomsSymptoms
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 or 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
Possible Psychological Reactions Possible Psychological Reactions to a Large-Scale Emergencyto a Large-Scale Emergency
For most people, things get For most people, things get better with time…better with time…
Possible Psychological Reactions Possible Psychological Reactions to a Large-Scale Emergencyto a Large-Scale Emergency
*Victims of Hurricane Victims of Hurricane KatrinaKatrina: Significant increase in serious mental health problems two years post Katrina (PTSD, suicidality, depression, anxiety, substance abuse, domestic violence) across all racial and socio-economic groups.
For some, however, the reactions may evolve and even worsen.
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.
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
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
Cognitive/Behavioral Approaches to Stress Reduction
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
Cognitive/Behavioral Approaches to Stress Reduction
PlayPlay: Hobbies / Personal Interests : Hobbies / Personal Interests Exposure to NatureExposure to 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 a 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