Operational Stress Injury Resource for Caregivers

1. Operational Stress Injury Resource for Caregivers

2. Disclaimer This resource is designed and intended to provide operational stress injury (OSI) education as well as self-care tools to support individuals in a caregiver role. It is not intended as a clinical therapy. Some of the content in this resource may trigger sensitivities. If you experience sensitivities, please reach out to the resources that are referenced throughout the program.

3. Help Right Now • If you or your loved one are in crisis and you need help right now please contact: • 911 (emergency) or your local emergency number if 911 is not available in your area • Family Information Line1-800-866-4546 • Canadian Forces Member Assistance Program1-800-268-7708 • Veterans Affairs Canada (VAC) Assistance Service1-800-268-7708 or for hearing impaired 1-800-567-5803

4. Context • As a caregiver of a Veteran or military member living with an OSI, you may be facing significant challenges in supporting your loved one while managing other responsibilities related to work, life and family. This resource is designed for you, and is intended to provide OSI education as well as self-care tools to support you in your caregiver role. • We take this opportunity as well to thank you for the essential role you play in supporting your loved who has served or continues to serve the country.

5. Purpose of the Resource • The term operational stress injury (OSI) is used to describe any persistent psychological difficulty resulting from operational duties performed. This resource offers assistance to families and friends who are at different stages in their journey of supporting a loved one with an OSI: • Please focus on sections that are most helpful to you and your loved one, depending on where you are on this journey. • Please skip over sections that are less helpful.

6. How To Use This Resource • Activities: • Activities are provided throughout this resource to help you think about what you are learning in greater depth and for you to put what you are learning into practice. • Recording Responses: • You are encouraged to record your responses to refer to at a later time. • Navigation: • The Overview/Contents slide outlines the resource’s five sections. It has built-in navigation to allow you to move between sections easily. To get to a section, click on the section title. There is also a three line navigation menu on the top right hand side of each slide that looks like this: • To advance or go back a slide you can use your keyboard arrow keys or the built in navigation on the screen. Mouse clicks will also advance you forward.

7. Overview | Contents Introduction HELP RIGHT NOW Section 1: Introduction to Operational Stress Injury (OSI) and Detecting the Need for Change Section 2: How to Support Operational Stress Injury (OSI) Treatment Section 3: Effects of Operational Stress Injury (OSI) on the Family Section 4: The Caregiver Role BEGIN SECTION 1 > Section 5: Other Resources

8. Section 1

9. Introduction • The purpose of this section is to help you determine whether there is a need for change in how you and your loved one with an OSI are coping. • This section provides important information about how to provide support to a loved one with an OSI and how to take care of your needs during this difficult time. • OSI resources and avenues for support are provided. “In our home an OSI means that the person occasionally has trouble collecting their thoughts in a productive and rational way. Communication and coping skills must practically be relearned, and family involvement through the process is vital in achieving any form of manageable recovery level.” – Testimony from a military spouse

10. What Is An OSI? • An Operational Stress Injury (OSI) is best described as any persistent psychological difficulty resulting from operational duties performed. –The Royal Mental Health Care Watch the video to learn what an OSI is. This video may be challenging to view as some of the content may cause difficult feelings. It is available in English only.

11. “An OSI is an injury attained during service: can be in deployment or exercise. It affects mental and physical health and impacts family and everyday life. An OSI is permanent and can have periods of remission.” • – Testimony from a veteran spouse

12. Caregiver Behaviours • Click on the caregiver behaviours on the left to learn about their characteristics. Which of these behaviours do you exhibit? Taking on more responsibilities to shield someone from possible consequences. Enabling Keeping away from uncomfortable situations, conversations, emotions. Avoidance Encouraging someone to gain the skills and experience to overcome obstacles on their own. Empowering Setting personal limits to what you are comfortable with. Boundaries

13. Mental Health: A State of Well-Being • Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. –World Health Organization “The perception of the public about an OSI is that it strictly impacts a person's mental health. In our family, my wife's OSI impacts not only her mental health, but also her physical health. “ – Veteran spouse

14. Impact of Stress on Well-Being • When the body is confronted with stress, its stress response mechanism involves the release of different chemicals, among which are hormones (cortisol and adrenaline) that will affect body and brain functioning. • For any event that is perceived as overwhelming, the release of stress hormones causes the body to become on high alert. • When a person deals with ongoing stress for a long period of time without any breaks, the person’s body and mind become “stuck” in a high alert stress state. • As a result, there may be “wear and tear” on the body and mind; this may be the case for a person experiencing an OSI and also for the people supporting them. • – Adapted from R2MR

15. Impact of Stress • “A serving military member expects a certain level of stress in relation to the job, but there are definitely some stresses that can become more difficult to overcome than others…When a member is diagnosed with an OSI, or begins showing symptoms of an OSI prior to diagnosis, there are many work-related stresses that become less easy for the member to accept…It is extremely beneficial to serving members to have time to relax each evening after work, and to participate in fun activities when possible.” • – Testimony from a military spouse

16. Traumatic Stress Reactions Thoughts Emotions Behaviours Physical • Trauma involves exposure to actual or threatened death, serious injury (accident, assault, torture), or sexual violence. –DSM-5 Click on the tabs to learn about common reactions to trauma the person with an OSI you support may be showing.

17. Traumatic Stress Reactions THOUGHTS Thoughts Emotions Behaviour Physical • Unwanted thoughts (intrusive thoughts, nightmares, images, suicidal thoughts); • Thinking Errors ( e.g. all or nothing thinking, overgeneralization, and/or catastrophizing); and • Poor concentration. Click on the tabs to learn about common reactions to trauma the person with an OSI you support may be showing. Thoughts associated with traumatic stress include:

18. Traumatic Stress Reactions Thoughts EMOTIONS Emotions Behaviours Physical • Fear, anxiety; • Anger, irritability; • Guilt, shame; and • Grief, sadness. Click on the tabs to learn about common reactions to trauma the person with an OSI you support may be showing. Emotions associated with traumatic stress include:

19. Traumatic Stress Reactions Thoughts Emotions BEHAVIOURS Behaviours Physical Click on the tabs to learn about common reactions to trauma the person with an OSI you support may be showing. Behavioursassociated with traumatic stress include: Effortful avoidance; Withdrawal; Alcohol or substance use; and Checking / vigilance.

20. Traumatic Stress Reactions Thoughts Emotions Behaviours PHYSICAL Physical • Insomnia • Changes in appetite • Fatigue • Tension • Headache Click on the tabs to learn about common reactions to trauma the person with an OSI you support may be showing. Physical symptoms associated with traumatic stress include:

21. “My husband always seemed cranky and never well rested. Much of the anger displayed seemed attributable to the lack of sleep, so it wasn't immediately recognized that this could be a bigger issue…I knew he had some experiences he wasn't willing to talk to me about right away. He spent a lot of time on the computer and playing games. He didn't like silence, but was also greatly bothered by the kids getting too loud or crying. It was difficult not to know whether these behaviours were something to be concerned about or if they would subside over time.” • – Testimony from a military spouse

22. OSI and Intimate Relationships Self-Intimacy Emotional Intimacy Sexual Intimacy Effects of Psychiatric Medication • Intimacy can be affected by an OSI. Click on the tabs to learn more about how an OSI can impact self-intimacy, emotional, sexual intimacy and effects of psychiatric medication on sexual intimacy. Click on the tabs to learn about OSI and intimate relationships.

23. OSI and Intimate Relationships Self-Intimacy Emotional Intimacy Sexual Intimacy Effects of Psychiatric Medication • Self-intimacy is the ability of someone to engage in coping, self-control and appropriate self-soothing without relying heavily on external methods of soothing. • Challenge: • Alcohol or drug abuse, abusing food, compulsive spending or gambling is often the biggest challenge of self-intimacy. • These behaviours teach the individual that they must be dependent on external methods of soothing and cause them to believe that they cannot take care of themselves, essentially becoming dependent. Click on the tabs to learn about OSI and intimate relationships.

24. OSI and Intimate Relationships Self-Intimacy Emotional Intimacy Sexual Intimacy Effects of Psychiatric Medication • Two types of intimacy are often issues: • Closeness with family and friends • Sexual intimacy • Often times, people with OSIs withdraw from people who could be supportive and avoid being close to others as a way of protecting themselves from possible rejection, blame or further harm. • Challenge:Relationships dissolve and traumatized patients avoid developing new relationships. Consequently, they feel alone and isolated during their recovery from the OSI. Click on the tabs to learn about OSI and intimate relationships.

25. OSI and Intimate Relationships Self-Intimacy Emotional Intimacy Sexual Intimacy Effects of Psychiatric Medication • Specific injuries such as sexual assault, depression and PTSD can interfere with normal sexual functioning, particularly sexual desire. For sexual assault victims sexual behaviour becomes threatening because the act of being sexual has become a cue associated with the assault, especially in regards to the level of trust and vulnerability that is necessary for sexual intimacy. • Challenge:The individual withdraws from others, however, they are in direct conflict with their need for comfort and support from others. • Intimacy issues are often interwoven with trust issues that may still be unresolved and therefore deserve continued attention. • (Cognitive Processing Therapy – Intimacy Issues & Meaning of the Event) Click on the tabs to learn about OSI and intimate relationships.

26. OSI and Intimate Relationships Self-Intimacy Emotional Intimacy Sexual Intimacy Effects of Psychiatric Medication • Psychiatric medications may impair sexual function, for example delay orgasm, decrease libido or cause erectile dysfunction. These side-effects can be more or less problematic and depend on the type and dose of the medication. There are various ways to manage these issues, for example wait it out, schedule sex, switch medication or add another medication. It is helpful to bring this up with the treating doctor to find solutions (Jakov). Click on the tabs to learn about OSI and intimate relationships.

27. Natural Recovery • Immediately after someone experiences a trauma, changes in thoughts, feelings, and behaviours are common for a period of time. • Changes include: nightmares, distressing memories, feeling difficult emotions, feeling constantly “on edge,” and having difficulty relaxing. • Among those who will recover, symptoms begin to decline within several weeks of the trauma; most natural recovery occurs within the first year. • Recovery is helped by reestablishing previous activities/routines.

28. Roadblocks to Recovery • Ongoing avoidance • Being extra careful/safe • Trying to push away thoughts & memories • Distraction/keeping very busy • Medication misuse • Financial risk taking • Social isolation Ruminating – thinking and re-thinking Vigilance – looking for signs of threat Alcohol/medication use Giving up enjoyable activities Do you see any of these as roadblocks in your loved one? Which ones?

29. Navigating Recovery • Open up communication with your loved one focusing on: • Using “I” statements to help. • Acknowledging the emotions. • Normalizing the emotions. For example, ask yourselves “Is it okay to have emotions over what has just happened?” • Asking what they need. For example, “What would make you feel more secure right now?” • Setting limits and pausing/stopping the conversation if it becomes unmanageable.

30. What Happens When Communication Fails? • When your loved one with an OSI won’t listen: • Take some time to refine your communication. • When your loved one with an OSI won’t respond: • Ask open ended questions to encourage the conversation. • Talk about what you see/feel and the impact on you. Use “I” statements.

31. “My husband and I seemed to be speaking two different languages when he returned from tour…I found a simple request like asking him to take out the garbage was perceived as a personal attack…it honestly felt like I was speaking to a teenager instead of the husband I loved. His reactions to conversations and situations were turning into anger fairly quickly…within the few discussions we were able to have, we recognized that more might be happening than just a small, marital communication issue.” • – Testimony from a military spouse

32. “I” Statements • Using “I” statements to communicate your point of view will decrease the other person’s defensiveness and increase communication. • Talk about the situation as you see it. Here are some steps in using “I Statements”: • Discuss how you feel about the situation. • Include what the behaviour is. • Discuss how it affects you. • To prevent the other person from becoming defensive, it is important to follow up by asking about your loved one’s perspective as well.

33. “My husband was given a double life sentence, ALS & PTSD; however instead of becoming bitter and angry, he counted everyday he had left, as a blessing. He reflected on all the positive things he did on each deployment and in his career. As a family, we changed our outlook and treated each day like a precious gift, worthy of celebration and appreciation. As a couple, we savoured every quiet moment together, making it last a lifetime.” • – Testimony from a military spouse • “Life is short, live it. Love is rare, grab it. Anger is bad, dump it. Fear is awful, face it. Memories are sweet, cherish them.” • – Testimony from a military spouse

34. Taking “Note” Of Your Need for Change • Need for Change Within Self • As a person supporting a loved one with an OSI, you may be recognizing a need for change within yourself because you have adjusted your thinking, behaviours, and emotions to cope with your situation. • The notes on this bulletin board identify what you may be experiencing. • Click on the notes to learn details. Thinking Emotions Behaviours Compassion Fatigue

35. Taking “Note” Of Your Need for Change • Thinking • As a result of your support role, you may be experiencing the following thoughts: • I need to “walk on eggshells” around the person with an OSI • Nothing I do is good enough • My needs don't matter • This is not the person I used to know • I feel like I am a parent to the person with an OSI • I have thoughts about ending my life Thinking Emotions Behaviours Compassion Fatigue

36. Taking “Note” Of Your Need for Change • Emotions • As a result of your support role, you may be experiencing the following emotions: • I feel alone • I feel afraid • I feel betrayed • I feel angry • I resent the person with an OSI • I feel emotionally disconnected from the person with an OSI • I feel like life is not worth living Thinking Emotions Behaviours Compassion Fatigue

37. Taking “Note” Of Your Need for Change • Behaviours • As a result of your support role, you may be exhibiting the following behaviours: • I don’t tell the person with an OSI how I feel • I keep to myself • I spend a lot of time and energy on the needs of the person with an OSI • I put my own needs at the bottom of the list Thinking Emotions Behaviours Compassion Fatigue

38. Taking “Note” Of Your Need for Change • Compassion Fatigue • To learn about Compassion Fatigue, read the article, Giving Too Much.This article is available in English only. • Activity: • Review the 10 signs of caregiver burnout from the article. • Do you think you might have caregiver burnout? If so, what steps will you take to lead a healthier life? Thinking Emotions Behaviours Compassion Fatigue

39. Taking “Note” Of Your Need for Change • Summary • As a person supporting someone with an OSI, you may be aware of changes in your thinking, behaviours, and emotions. Can you relate to any of the changes identified? Which ones? • While some of these adjustments may have helped you cope in the short-term, they are not really positive and you may recognize the need to make changes within your self. The next few slides discuss where to start. Thinking Emotions Behaviours Compassion Fatigue

40. Coping Through Thinking • Positive self-talk can be helpful when coping with stress. It can help one to feel better about oneself and a situation, it can help build self-esteem, and it can help gain a sense of control. Below are some examples of positive self talk. It’s okay to do something for myself. I have a right to my feelings. I have the right to have my needs met. I am not responsible for the person with an OSI’s way of coping.

41. Coping Through Action • There are many ways to cope through action when you experience a challenging time: • Recognize what your needs are, including physical and emotional needs. • Communicate your needs; and ask for your needs to be met in an assertive way. • Seek support from a trusted friend, family member, or professional.

42. Effective Communication • Review the Assertive Communicationtip sheet. • This resource is available in English only. • Activity: Consider one need you would like to be met. • After reviewing the tip sheet, think about how you can ask for your need to be met in an assertive manner.

43. Coping with Emotions • If you recognize, or others comment on changes they see in you it is important to remember: • that it is normal and healthy to have a range of positive and negative emotions; • to allow yourself to recognize what you are feeling; • to allow yourself to feel any emotion; and • if you need a break from a difficult feeling, try techniques from grounding, mindfulness, and/or relaxation techniques.

44. Relaxation Techniques for Stress Relief • Review the Relaxation Techniques for Stress Reliefresource. This resource is available in English only. • Activity: Try one of the techniques from the resource. • How effective was it in helping you deal with difficult emotions? If it wasn’t effective, try some other options until you find one or more techniques that work for you.

45. Relaxation Apps • There are free relaxation apps available on Smartphones. Here are a few you may want to try: • Relax Melodies: relax to one of this app’s 50 calming sounds. • Breathe2Relax: this app uses guided breathing to help you relax. • Sleep Time- The Alarm Clock: this app tells you about your sleep patterns. It can be set to wake you up at just the right time (when a sleep cycle has ended). • Self-Help for Anxiety Management (SAM): this app walks you through calming/ relaxation practices when you are anxious.

46. Staying Safe What is Safety? Feeling Safe Recognize Unsafe Behaviours Where To Turn In Crisis Staying Safe Resources • Establishing Safety • People who have experienced trauma need to feel safe. To establish safety, trauma victims may need help freeing themselves from self-destructive behaviours. Establishing safety is life-enhancing; it includes asking for help from safe people, using community resources, self-care, and “recovery thinking”. • – adapted from Seeking Safety, Najavits (2002) Click on the tabs to learn about staying safe.

47. Staying Safe What is Safety? Feeling Safe Recognize Unsafe Behaviours Where To Turn In Crisis Staying Safe Resources • What is Safety? • Staying safe while you and the person with an OSI you support are going through a difficult time is very important because it is the first step in the journey towards recovery. • Safety can mean different things for different people. • Staying safe generally means that your basic physical needs are met, you are out of harm’s way (both physical and emotional harm), and you have trusted people who you can turn to for support. Click on the tabs to learn about staying safe.

48. Staying Safe What is Safety? Feeling Safe Recognize Unsafe Behaviours Where To Turn In Crisis Staying Safe Resources • Feeling Safe • What makes you feel safe? Take a few minutes to think about who you feel safe with, what activities you feel safe doing, and where you feel safe. You may want to write out your thoughts. • How can you use this information to help yourself and someone you are supporting with an OSI through difficult times? Click on the tabs to learn about staying safe.

49. Staying Safe What is Safety? Feeling Safe Recognize Unsafe Behaviours Where To Turn In Crisis Staying Safe Resources • Recognizing Unsafe Behaviours • Unsafe behaviours are destructive. If you recognize any of the following unsafe behaviours in you or the person with an OSI you are supporting, please seek help at once: • Feeling an urge to hurt myself or take my own life • Unable to control my anger • Overspending • Becoming physically violent • Using substances to cope • Driving while under the influence • Being threatened (physically or emotionally) by someone • Be forced to engage in sexual activity against my will Click on the tabs to learn about staying safe.

50. Staying Safe What is Safety? Feeling Safe Recognize Unsafe Behaviours Where To Turn In Crisis Staying Safe Resources • 911 (emergency) or your local emergency number if 911 is not available in your area • Family Information Line1-800-866-4546 • Canadian Forces Member Assistance Program1-800-268-7708 • Veterans Affairs Canada (VAC) Assistance Service1-800-268-7708 or for hearing impaired 1-800-567-5803 • Once the crisis is resolved and you and your loved ones are safe, create a safety plan (available in English only) to ensure safety in the future. Click on the tabs to learn about staying safe.