Stress Management for Healthcare Providers and Humanitarian Workers Aiding Tsunami Relief Efforts

1. Stress Management for Healthcare Providers and Humanitarian Workers Aiding Tsunami Relief Efforts Richard W. Klomp, MOB, MS, LPC Disaster Mental Health and Terrorism Team CDC’s National Center for Injury Prevention and Control CAPT Merritt Schreiber, Ph.D. USPHS Commissioned Corps/CDC Directors Emergency Operations Center and National Center For Child Traumatic Stress David Geffen School of Medicine at UCLA

2. Goals of Today’s Presentation • Demystify stress in responders • Anticipate the range of reactions • Modify inaccurate/maladaptive assumptions • Build Responder Resilience! • Leave with a Personal Resilience Action Plan

3. Assumptions • Behavioral health issues involved in aspects of preparedness, response & recovery. • Resilience in responders is the norm. • “Normal reactions” to an “abnormal” situations • Even though expected and normal, still cause distress • Mission success over the long haul directly tied to responder knowledge, skills, training and resilience. • Preparedness improves recovery. • Improves probability of mission success • Decreases “costs” of stress to staff • Effective re-integration to “day job”/”my life” • Minimize loss of productivity

4. Findings from Responder Studies • OKC firefighters • Low rates of PTSD • Significant on-going substance use, spouses perceive many changes in responders • UAL Aviation Disaster Sioux City • Higher rates of PTS and mood problems • (16v2%) and Depression(21v13) 13 months post • 9/11 WTC (10-14months post) 13% with presumed PTSD, 3% accessed MH services before the study • LAX anecdote

5. Unique Stress Factors in Mass Casualty Disasters • Unique and unfamiliar exposures • Understanding of emergency response culture & systems • Exposure to catastrophic scale of loss and damage • Massive loss of life • Feeling of not being able to do enough = helplessness, and helplessness can translate to depression • Death of children particularly stressful • Condition of bodies • Damage to roads, schools, hospitals, businesses • Observing so much acute suffering and traumatic loss • Cultural misunderstandings

7. The Nature of Traumatic Stress • Exposure: single event (acute) vs. over time (cumulative): • Embedded in context of multiple events (impact, evacuation, sights of injured & dead, danger, unanswered cries for help) • Mass casualty and death • Condition of bodies • Death of children • Capacity to respond • Unique concerns related to infectious illness (CBRN/terrorism)

8. Dose of Exposure • Proximity • Severity • Duration • Small literature on first responders • Emerging concern of “Compassion Fatigue” for responders

9. Compassion Fatigue Risk Factors • Empathy • Exposure (severity, duration, respite) • Identification with the victims/survivors • Similar traumatic experience • “Unresolved trauma” from the past • Working w/ special populations like children • Baseline stress load

10. Behavioral Indices of Stress • Physiological • Fatigue, Insomnia, Dizziness • Nausea, GI Upset, Tics, etc. • Cognitive • Confusion, Concentration problems • Preoccupation w/disaster, Memory Loss etc. • Affective • Range of reactions/duration: Anxiety, • Fear, Grief, Sadness, Irritability etc.

11. Sources of Stress for Responders • Role ambiguity • Lack of clarity of mission or tasking • Lack of Team Cohesion • Discomfort with the unknown • Comfort level with personal risk • Backlog of accumulated stress with acute stress of mass casualty response. • Cultural “fit”

12. Sources of Stress for Responders • Reentry Home • Family reactions to absence • “Missing them” can become anger on return • Coworkers had to pick up your work… or no one did • Empathic failure of coworkers and family • Lack of understanding, interest or appreciation for what you have been through • Intrusive questions

13. Secondary/Vicarious Exposure • Can resemble direct victim reactions • Perceptual narrowing (frame of reference) • Superimposed on existing stress level • Burnout • Secondary Traumaitzation • Empathy as “double edged” sword • Identification emerges as risk factor • Friends, colleagues as victims • Special risk populations--children

14. Factors Contributing to Burn-Out • Professional isolation • Emotional/physical drain of continuous empathy • Ambiguous success; Erosion of idealism • Lack of expected rewards • Helpers may also be survivors • Belief in a socially modulated world • Continuous vulnerability • Victim comparisons to family members

15. PTSD Demystified • Exposure to life threat or observed life threatening event • Re-experiencing • Avoidance • Numbing • Arousal • Lasting greater than one month • Significant impairment in functioning

16. Building Responder Resilience • Pre-event • Educate and train • Build social support systems • Instill sense of mission & purpose • Create Family communications plan • Response • If possible, deploy as a team or use the “buddy system” • Focus on immediate tasks at hand • Monitor occupational safety, health, and psychological well-being (individual & team)

17. Building Responder Resilience cont’d • “Got to know your limits…” • Activate Family (social support) communications plan • Post-event (Recovery) Monitor health and well-being • Delayed reactions with increased demand for services seen in general public and emergency responders (onset >5 weeks later) • Give yourself time to recover • Seek support when needed

19. 10 Ways to Build Resilience • Make connections (relationships) • Avoid seeing crises as insurmountable • Accept that change is part of living • Move toward your goals • Take decisive actions

20. 10 Ways to Build Resilience • Look for opportunities for self-discovery • Nurture a positive view of yourself • Keep things in perspective • Maintain a hopeful outlook • Take care of yourself “The Road to Resilience” helping.apa.org

21. Personal Resiliency Plan • Minimize unnecessary exposure • Monitor exposure (media, etc.) • Monitor general and personal risk factors • Maintain coping/communication with others • Reestablish cognitive balance • Advocate for changes

22. Personal Resiliency Plan • Focus beyond short term • Multi-modal over time • Know your unique stressors and Red Flags for further assistance • Know unique stressors of the event: extent of damage, death, and current suffering • Demystify/destigmatize normative reactions • Select from menu of coping responses • Monitor on-going internal stress

23. Self-Care Examples Checklist • Physical Diet, Exercise, Sleep, Relax • Emotional Contact w/family & friends • Cognitive Training, Reading, Perspective • Behavioral Civic Involvement, Preparation • Spiritual Meditation, Fellowship, Prayer