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In Times of Crisis : Supporting Others, Supporting Ourselves. John Gaspari, LCSW Executive Director USC Center for Work and Family Life. Center for Work and Family Life. Available Services: Faculty and Staff Counseling Faculty, Management and Departmental Consultation

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In times of crisis supporting others supporting ourselves

In Times of Crisis:Supporting Others,Supporting Ourselves

John Gaspari, LCSW

Executive Director

USC Center for Work and Family Life


Center for work and family life
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


Role expectations
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 objectives
Unit Objectives

  • Psychological impacts to expect after a disaster – What happens for people?

  • How to work with the psychological impacts in your role – Providing psychological support.

  • Responder stress management and self-care.


Are we psychologically prepared
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.


Critical incident
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)


Coping Mechanisms

  • 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.


Into every life a little rain must fall
Into every life a little rain must fall …..

But what happens when there is a flood?


Psychosocial impact considerations
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


Psychosocial impact considerations1
Psychosocial Impact – Considerations

  • 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 often include loss
Consequences of Critical Incidents Often include LOSS

  • Tangible Loss

    • Loss of loved ones

    • Loss of home

    • Loss of material goods

    • Loss of employment / income


Consequences of critical incidents often include loss1
Consequences of Critical Incidents Often include LOSS

  • Intangible Loss

    • Loss of safety / security (real or perceived)

    • Loss of predictability

    • Loss of social cohesion/connection/support

    • Loss of dignity, trust and safety

    • Loss of positive self-image/self-esteem

    • Loss of trust in the future, identity, independence

    • Loss of hope

    • Loss of CONTROL


Activity what if i lost
Activity – What if I lost…

  • You have been given three cards each of three different colors:

    • Blue Card - write the name of a person close to you on each card

    • White Card - write down one of your favorite belongings

    • 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.


Activity what if i lost1
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


Possible psychological reactions to a large scale emergency
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)


Grief and loss
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)



“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


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 health1
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 sense of compassion and support for people.


Psychological response to trauma key concepts
Psychological Response to TraumaKey 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.


Psychological response to trauma key concepts1
Psychological Response to TraumaKey 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.


Psychological response to trauma key concepts2
Psychological Response to TraumaKey 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


Phases of Disaster

Honeymoon

(community cohesion)

llllllllllll

Reconstruction

(a new beginning)

Heroic

Pre-Disaster

Disillusionment

Working Through Grief

(coming to terms)

Threat

EVENT

Warning

Inventory

Trigger Events and

Anniversary Reactions

Time 1 to 3 days 1 to 3 years


Honeymoon community cohesion
Honeymoon (community cohesion)

  • Survivors may be elated

  • Happy just to be alive

  • This phase will not last


Disillusionment
Disillusionment

  • Reality of disaster

    “hits home”

  • Loss and Grief

    becomes prominent


What do you think
What Do You Think?

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


Essential attributes and skills
Essential Attributes and Skills

  • Empathetic

  • Non-judgmental approach

  • Kind

  • Committed

  • Flexible

  • Able to tolerate chaos

  • Good Listening skills

  • Patient

  • Caring attitude

  • Trustworthy

  • Approachable

  • Culturally aware


Intense emotions
Intense Emotions

  • Are often appropriate reactions following a disaster

  • Can often be managed by community responders


Supportive communication
Supportive Communication

  • Supportive communication conveys:

    • Empathy

    • Concern

    • Respect

    • Confidence


Activity supportive statements
Activity – Supportive Statements

  • What are some supportive statements that you would find helpful if you were in pain, injured, and/or acute 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 unhelpful statements
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.


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 psychological support in your role
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


Crisis intervention
Crisis Intervention Your Role

  • 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


Goals of psychological first aid
Goals of Psychological First Aid Your Role

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

SAFETY

CALM

CONNECTEDNESS

SELF-EFFICACY

HOPE


Psychological first aid
Psychological First Aid Your Role

  • 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 aid1
Psychological First Aid Your Role

  • 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 aid2
Psychological First Aid Your Role

  • Promote CONNECTEDNESS:

    • Help people contact friends and loved ones.

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


Psychological first aid3
Psychological First Aid Your Role

  • Promote SELF-EFFICACY:

    • Give practical suggestions that steer people toward helping themselves.

    • Engage people in meeting their own needs.


Psychological first aid4
Psychological First Aid Your Role

  • 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 aid5
Psychological First Aid Your Role

  • 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 aid6
Psychological First Aid Your Role

  • 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 aid7
Psychological First Aid Your Role

  • 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


Anxiety
Anxiety Your Role

  • A state of intense apprehension, uncertainty and fear

  • Results from anticipating a threatening event

  • Intense anxiety = “fight or flight”


Agitation
Agitation Your Role

  • 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 curve
The Energy Curve Your Role

Agitation

Anxiety

Tension Reduction

Baseline


Elements of escalation
Elements of Escalation Your Role

  • Challenging authority or questioning

  • Refusal to follow directions

  • Loss of control, becoming verbally agitated

  • Becoming threatening


Elements of escalation1
Elements of Escalation Your Role

  • 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


Elements of escalation2
Elements of Escalation Your Role

  • 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


Seek assistance
Seek Assistance Your Role

  • 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


Elements of de escalation
Elements of De-escalation Your Role

  • 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 "Mrs.", especially if they are older than you


Elements of de escalation1
Elements of De-escalation Your Role

  • 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?


Elements of de escalation2
Elements of De-escalation Your Role

  • 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 escalation3
Elements of De-escalation Your Role

  • 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 escalation4
Elements of De-escalation Your Role

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

  • Use “I” statements

  • Lavish praise / support / encouragement is not believable


Responder stress and well being

Responder Stress and Your RoleWell-Being:

Helping the Helpers


Adrenaline friend or foe
Adrenaline, Friend or Foe? Your Role

  • 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 trauma survivors needs and reactions
Psychological Response to Trauma Your RoleSurvivors’ 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

  • Grief & loss

  • Shock

  • Hopelessness

  • Loss of Confidence

  • Mistrust

  • Sleep disturbances

  • Physical pain

  • Confusion

  • Shame

  • Shaken faith

  • Aggressiveness


Possible physiological symptoms
Possible Physiological Symptoms Your Role

  • 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 symptoms
Possible Emotional/Psychological Symptoms Your Role

  • 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


More typical reactions
More Typical Reactions… Your Role

  • Fear of darkness

  • Fear of being alone or 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.

C. Fasser, 2004; B. Young, 2006


Possible psychological reactions to a large scale emergency1
Possible Psychological Reactions Your Roleto a Large-Scale Emergency

For most people, things get better with time…


Possible psychological reactions to a large scale emergency2
Possible Psychological Reactions Your Roleto a Large-Scale Emergency

  • For some, however, the reactions may evolve and even worsen.

  • *Victims of Hurricane Katrina: 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.


Helpers
Helpers Your Role

  • 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 helpers
Challenge to Helpers Your Role

  • 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.) Your Role

  • 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 after the incident
Categories of Reactions Your RoleAfter the Incident

  • ASD / PTSD

  • Grief

  • Depression

  • Resilience

Mental Health

and Illness

  • Avoidance (emotional)

  • Substance abuse

  • Risk taking

  • Over Dedication

Human Behavior in High Stress Environments

Distress

Responses

  • Fear / worry

  • Sleep disturbance

  • Altered productivity


Loss and grief signs of trouble
Loss and Grief – Your RoleSigns 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


Stress
Stress Your Role

  • 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 stress
Coping with Stress Your Role

  • 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


Examples of coping
Examples of Coping Your Role

  • 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.) Your Role

  • 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 preferred approaches to managing stress
What Are Your Your RolePreferred Approaches to Managing Stress?

  • Do you practice ‘stress management’ regularly?


Self help techniques
Self-Help Techniques Your Role

  • 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.) Your Role

  • 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


Self help techniques cont1
Self-Help Techniques (cont.) Your Role

  • 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
Cognitive/Behavioral Approaches Your Roleto Stress Reduction

  • Adequate Rest

  • Exercise / Movement

  • Diet / Balanced Nutrition

  • Enough H2O

  • Moderate Chemical Use

  • Laughter / Tears

  • Time Away From Work Role


Cognitive behavioral approaches to stress reduction1
Cognitive/Behavioral Approaches Your Roleto Stress Reduction

  • Religious / Spiritual

  • Relaxation Techniques / Breathing

  • Yoga

  • Meditation

  • Social Support / Discuss Feelings

    • Allow yourself to receive as well as give


Cognitive behavioral approaches to stress reduction2
Cognitive/Behavioral Approaches Your Roleto Stress Reduction

  • Play: Hobbies / Personal Interests Exposure to Nature

  • Biofeedback

  • Massage / Human Touch

  • Sex

  • Professional Assistance

  • Medication

  • What Else Works for You???


Team well being
Team Well-Being Your Role

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 stress debriefing cisd
Critical Incident Stress Your RoleDebriefing (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.


No macho wo man no pity party
No Macho (Wo)Man, Your RoleNo 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.)


When you come to the edge Your Role

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



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