Stress is an expected hazard of disaster behavioral health response activities based on the fact that a disaster is a traumatic event and staff are exposed to the survivors’ experiences in an in-depth and intimate way. While the program administrators are responsible for the organizational stress management structure, each disaster response staff member is responsible for the implementation of his or her own individual stress management planning. Education about stress and each person’s self-awareness as to what causes him or her to be stressed are key to managing stress. Practicing stress management in a routine, disciplined manner is what will be helpful for most people. Staff who have a history of exposure to traumatic events or who have suffered with a mental illness prior to working in the disaster behavioral health response program may require more assistance with their stress management efforts. Professional behavioral health support is recommended in these situations. To find local professional behavioral health services, please visit the Behavioral Health Treatment Services Locator at http://findtreatment.samhsa.gov. Typical Stressors for Disaster Response/Crisis Counseling Staff Personal experience with the disaster Direct exposure to the negative effects of the disaster Cumulative stress from repeatedly hearing survivors' stories Chronic stress from approaching strangers who may reject their help Feeling overwhelmed by the depth of others' grief and sadness Feeling unable to alleviate the pain of others Working long hours in difficult environments Lack of or insufficient supervision Inadequate or inexperienced management and leadership that negatively effects crisis counseling staff Warning Signs of Excessive Stress (signs that last for more than 2 to 4 weeks) Bodily sensations and physical effects Rapid heart rate, palpitations, muscle tension, headaches, tremors, gastrointestinal distress, nausea, inability to relax when off duty, trouble falling asleep or staying asleep, nightmares or flashbacks Strong negative feelings Fear or terror in life-threatening situations or perceived danger, anger, frustration, argumentativeness, irritability, deep sadness, difficulty maintaining emotional balance Difficululty thinking clearly Disorientation or confusion, difficulty problem-solving and making decisions, difficulty remembering instructions, inability to see situations clearly, distortion and misinterpretation of comments and events Problematic or risky behaviors Unnecessary risk-taking, failure to use personal protective equipment, refusal to follow orders or leave the disaster scene, endangerment of team members, increased use or misuse of prescription drugs or alcohol Social conflicts Irritability, anger and hostility, blaming, reduced ability to support teammates, conflicts with peers or family, withdrawal, isolation Some disaster-specific warning signs include high adrenaline, physical euphoria, numbness—the endorphin effect (a reduction in feeling) disguises distress.Coupled with fatigue, cognition can change and create an inability to recognize poor judgment. Anger is a common defense against recognizing these problems. Individual Approaches to Stress Management Self-awareness Management of workload Balanced lifestyle Stress-reduction techniques Effective supervision and training Self-Awareness Research has suggested that about half of the people who work in the traumatic stress field have a history of exposure to traumatic events. For some of these individuals, this can be a risk factor, particularly when events that responders have to deal with are similar to their own experiences. It may be harder for responders in the field to process or be resilient because they are often without their usual supports like family and friends, pets, homes, and other supports. Some responders may have health vulnerabilities. For example, someone may be diabetic, or have joint or muscle problems, or may be prone to allergies. Still others may have a mental disorder. None of these things makes a person unable to be an efficient disaster worker, but they do mean that workers must be aware of their health needs and respect what they need to do to stay healthy, especially in the field. If responders are unaware of the need to monitor their physical, emotional, and spiritual needs, they may begin to experience difficulties in their work and personal lives. Irritability with co-workers and family members, difficulty performing routine tasks as well as more serious issues such as increased alcohol and substance use, including prescription medication misuse, are common concerns in the disaster responder community. Understanding that these are the shared experiences of many disaster responders can help reduce the stigma and avoidance of talking about and seeking help to address the stress of disaster response work. Responders can increase the awareness of their work stress by routinely participating in stress debriefing events or stress management exercises. Formal groups that include the opportunity to talk about and learn about the physiology of stress and the opportunity to explore what management techniques work personally for each group member are effective ways to cope with stress. Some examples that are described further in the ‘techniques’ section below include breathing, walking, stretching, talking to others, working out at the gym, running with a buddy, listening to relaxing music, massage, acupuncture, writing, drawing, dancing, and other leisure activities. Scheduling these activities into the work day or the work week and weekend is essential. For those with busy schedules, it is important to actually mark the days and times during each day and week that will be allotted for stress management techniques. Since we are likely to pay attention to our physical responses, it might help to remember the anagram HALT to help recognize that you need to stop whenever you are: Hungry Angry Lonely Tired Know that when these physical reactions are occurring, your body is telling you that it is time to stop and provide whatever type of self-care you require. Pay attention to the messaging. Sometimes when we are full steam ahead in our work, we disregard when our body is trying to alert us to concerns. Know this and tell yourself that you will stop, listen, and respond. Compassion Fatigue Wallet Card This wallet card is a way for disaster response program staff to keep track of their own behavioral health needs. Compassion fatigue wallet card (DOC | 17KB) Management of Workload An effective way to reduce stress is to vary the caseload or outreach to the most severely traumatized versus the nontrauma survivors. The more severely affected disaster survivors that workers are exposed to the more likely they are to experience compassion fatigue and/or secondary traumatic stress. In the field during a disaster, staff may be providing outreach to hard hit communities and everyone they come in contact with may have suffered extensive losses. This can be difficult for the staff day in and day out. Whenever possible, staff should vary their exposure with survivors so they are not always with those most highly affected. This might mean changing the geographic areas they cover every day or every other day to vary the intensity of the exposure. If that is not possible, then use the buddy system. Even switching roles between buddies so that the same responder is not always the one doing the introductions and taking the lead can be somewhat of a relief. Additionally, when responders are exposed to very distressed survivors, survivors who have suffered the loss of a loved one or other heavy personal losses or those who have very difficult experiences for whatever reason, responders should have more and immediate access to supervision. Supervisors can listen and support responders, help problem solve and make decisions about rotation as well as keeping a worker in the field or not. Supervisors can also mandate rotation and use of benefit time especially when responders will not take needed breaks or remove themselves from difficult assignments. Balanced Lifestyle As mentioned earlier, disaster responders can introduce ways to provide stress relief at work and during time off, even when in the field. One of the most effective ways to create a balanced lifestyle for yourself is to actually schedule the activities that you have identified as stress reducing, relaxing, and renewing. Often, responders will say that if they don’t schedule leisure activities, they do not participate in them. Schedule time off for yourself, time to exercise, time to write, and time to connect with family and friends just as you would schedule a business appointment. This allows you to see you have the time set aside, and can prompt you to follow through with the scheduled stress management or self-care activity. During the work day, creating balance can be as simple as stopping to take a few deep breaths every couple of hours or using breaks as a time to engage in simple exercise such as walking and stretching (yoga) or even just quieting your mind (meditation and mindfulness). Some people are fortunate enough to have the opportunity to use a gym near the workplace or access a place to swim. Take advantage of such facilities if these are available and you find exercising helps you relax. Many responders discover that just taking a short break is difficult—feeling like they cannot take themselves away from what they are doing. Sometimes, this is a cognitive problem in that it is the responders giving themselves the message that they cannot take a break. Practicing messaging that gives you permission to provide self-care may help you think differently. For example, messaging such as, "It is ok that I take a 15-minute break. My colleagues will fill in for me." Or "I am not conducting lifesaving activities right now. I can take a lunch break or a walk to reenergize myself." Think about what words you need to say, what messages you need to give yourself to allow you to bring balance into the work day. Write the message down on an index card and put it somewhere you will likely see it during the course of the day. In the field, when you are deployed but not working, take that time to schedule and engage in stress management and self-care activities. Again, these activities can be as simple as taking a walk and talking with colleagues. Writing notes, keeping a journal, or writing letters to family and friends can also be relaxing and decrease the stress of working in the midst of traumatic events such as disasters. Sending letters has the dual effect of connecting with others, which is one of the most effective ways of coping with stress. Also important, preparing yourself for your fieldwork can also decrease anxiety and stress related to working in the field. A note of caution here is to make sure that you don’t spend all of your down time prepping for work, thinking and talking about work with colleagues, or, essentially, “working” even when you are not. In your personal life, many of the previous tips can help. During your day, whether involved in caring for children or an aging parent, conducting daily household chores or dealing with stressful situations around finances, relationships, illness, or other concerns, take a few moments several times a day to engage in breathing exercises and make sure you are aware of your stress level. Most important, take the time to create a personal life. Identify those people who care about and understand you. Reach out to them and plan to spend time with them routinely—even if it is just a walk together or a weekly lunch meeting. Engage in some kind of group meeting, exercise, sport, mindfulness, or meditation. Research on both the mind and body informs us that people who are in relationships tend to be healthier, live longer, and live happier. Social support and body movement are great activities for reducing stress and increasing a sense of well-being. Do what you need to in order to have a personal life, social contacts, and physical activity. Stress-Reduction Techniques We have referred to various stress management techniques in this section. Be aware that there may be many different examples of stress management techniques in the literature. This section contains samples of these tools, but responders should seek additional examples and use what fits their needs best. In addition to using general stress management technique, disaster responders can look at how their work adds to stress and implement specific ways of thinking and working that can make them stronger in the face of the distressing aspects of their work. We list several ways to address disaster-specific stressors: Expect, seek, and accept peer support Responders are stronger when they work in strike teams and task forces that train together and debrief together. Well-functioning responders expect that they will be able to manage their stress better when they seek out help from peers and accept peer support. Peers are our best defense in the field against both physical and emotional pain. Make sure you know who your peers are and if you find yourself working on an isolated job, use the phone or Internet to reach out to those peers who understand and accept you. Master controlled, limited empathy Exposure to survivors who are in great physical or emotional pain can be very difficult at times. As humans and helpers, most of us have great empathy and can "feel the pain" of others. Often it is why we entered our professions. Responders can learn to control their feelings during an acute crisis and limit their empathy, so that they do not actually experience the same level of distress as the survivors. This is often accomplished by training, awareness, and cognitive messaging. Some responders will use an image of a screen or a short wall in front of them to remind them to manage their feelings and especially their empathy in an effort to remain professional and functional. Monitor and control over-identification Relating to survivors or "over-identifying" with them can also be a concern for responders, especially when helping survivors who may be of the same age as the responder’s own family, or have some similar characteristics of someone they know. For example, when faced with an injured child, a responder might need to give themselves the message, "This is not happening to my child. My family is safe. I can help and care for this child without feeling afraid that this has happened to someone I care about." Define structure and boundaries Responders come from varied professions and disciplines. Some people hold a license while others are beholden to a set of guidelines or policies established by their employer; and most responders have many layers of structure and rules they need to follow. The most important structure in helping responders manage stress is to make sure that they are very clear on their roles and responsibilities in general as well as in each specific disaster situation. In some cases, even when one staff member’s job is not covered, it can create a hazardous situation for the rest of the team. Duplication of effort is equally problematic. Operational meetings held just before the start of deployment (and often on a daily basis thereafter) help define such structures, and responders who are unclear of what they should be doing and how to do it need to seek out supervisory direction immediately. In the disaster behavioral health response field, there are established boundaries that include limiting the work timeframes, places, and types of interactions that responders have with survivors. A few examples include: Responders should refrain from visiting a survivor after their service is completed; when giving survivors an opportunity to call for a followup visit, responders should indicate their work hours, setting up the expectation that the survivors will call within those timeframes; responders should not offer personal funds to survivors or transport survivors in their personal vehicles. These are just examples of boundaries and each provider agency, employer, and manager is responsible for ensuring that responders are aware of the policies that define appropriate structure and boundaries for that specific job and/or agency. Self-assessment is vital to successful stress management and self-care One of the hazards of the disaster response profession is the lack of recognition as to the effects of the many stressors faced and how these impact the responders’ lives. Using peers for feedback is one way to assess how you are managing. Self-reflection is another way: Take a look at yourself and your life and ask, "Do I have meaningful relationships?" and "What is the quality of my relationships?" Supervision can also help with assessment. Too often, employers do not use supervision as a helpful tool to seek out constructive criticism or examples of poor functioning. Employees who see peers as well as supervisors as equals in many ways are often more open to learning from them. Also, one of the empirically tested tools for assessing the level of compassion fatigue, compassion satisfaction, and burnout referred to previously in this section is the ProQOL, which can be used by responders on their own as well as in a formal setting to assess how they are doing. Commit to implementing self-care This is the only way that responders will keep themselves well and healthy. Your health and well-being is up to you. Make a commitment to care for yourself and invite family members and friends to work with you on this journey. Effective Supervision and Training Responders need to be adequately trained prior to being deployed into the field. As with any profession, training is essential to conducting one's job well and efficiently. The training section of this toolkit speaks to what types of training are recommended for behavioral health responders. Here, we emphasize that responders are responsible for working with their supervisors and identifying those skills and techniques they feel they must improve in order to perform their work at a safe and adequate level. Evaluating performance requires the help of a skilled supervisor. The supervisor might choose to accompany responders in the field to observe their work "in vivo" or use other adult learning techniques such as role playing to determine if a responder is field ready. It is the responsibility of the supervisor to ensure that responders are ready for deployment by having participated in training activities and demonstrating adequate skills and the understanding of “do no harm” to those survivors who depend on the assistance of disaster behavioral health responders to guide them to recovery. Stress Management Techniques Handouts These handout templates provide information about stress management and ways of coping. The templates are intended for the general public who may be experiencing disaster distress. Your program logo and contact information can be inserted into the brochures. Mini Relaxation Exercises: A Quick Fix in Stressful Moments (DOC | 28KB) Breathing Retraining—Adults (DOC | 48KB) "Dial Down" Exercise (DOC | 117KB) Healthy Coping Strategies Checklist (DOC | 27KB) Pleasant Activities Scheduling (DOC | 36KB) Tips for Better Sleep (DOC | 23KB) Examples From the Field SAMHSA Disaster Technical Assistance Center. (2012). "Self-care for disaster behavioral health responders podcast." Retrieved from https://www.youtube.com/watch?v=G957P6w1Xfs&list=PLBXgZMI_zqfRcTt9ndxkbieQ-pQslk-R6 This 60-minute podcast by SAMHSA DTAC provides information, best practices, and tools that enable disaster behavioral health responders and supervisors to identify and effectively manage stress and secondary traumatic stress through workplace structures and self-care practices. Professional Quality of Life. (2012). The Professional Quality of Life Scale (ProQOL) Measure. Retrieved from http://www.proqol.org/ProQol_Test.html The ProQOL is the most commonly used measure of the negative and positive effects of helping others who experience suffering and trauma. The ProQoL has sub-scales for compassion satisfaction, burnout, and compassion fatigue. This is one of the few scientifically valid and reliable tools for assessment of helpers and can help staff see how they are managing. The ProQOL is available in a variety of languages. East Carolina University. (n.d.). "Self-care assessment worksheet." Retrieved from http://www.ecu.edu/cs-dhs/rehb/upload/Wellness_Assessment.pdf (PDF | 12.31 KB) This assessment tool, from the "Transforming the Pain" workbook, provides an overview of effective strategies to engage in self-care and prepare self-care goals.