# Presentation: 493762

## 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

##  Goals of Today’s Presentation

- Demystify stress in responders
- Anticipate the range of reactions
- Modify inaccurate/maladaptive assumptions
- Build Responder Resilience!
- Leave with a **P**ersonal **R**esilience **A**ction **P**lan

##     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

## 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

## 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

## Slide 6

## 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)

## Dose of Exposure

- Proximity
- Severity
- Duration
- Small literature on first responders
- Emerging concern of  “Compassion Fatigue” for responders

##   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

##    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.

##  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”

**Notes:**
This list does not even touch the field situational issues

##  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

## 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

## 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

## 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

##   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)

##  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

## Slide 18

## 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

## 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

## 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

## 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

## 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