First Responders: Self Care, Wellness, Health, Resilience

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First RespondersSelf Care, Wellness, Health,
Resilience Recovery

• Dealing with Stress
• Personal, Department/Job, Home Family in the
  Aftermath of Disasters

Philip T. McCabe CSW, CAS, CDVC UMDNJ School
of Public Health- Office of Public Health
Practice Center for Public Health Preparedness
at UMDNJ Robert Wood Johnson Medical
School American Academy of Health Care Providers
in Addictive Disorders American Public Health
Association International Critical Incident
Stress Foundation
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Objectives

• Help first responders better understand stress
  and critical incidents
• Increase awareness of self care and helpful
  resources
• Recognize symptoms in ones self and in others
• Is not intended to certify or credential anyone
  in clinical care, CISM, or other related activity

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STRESS

• Forty-three percent of all adults suffer adverse
  health effects from stress.
• 75 to 90 percent of all physician office visits
  are for stress-related ailments and complaints.
• Stress is linked to the six leading causes of
  death--heart disease, cancer, lung ailments,
  accidents, cirrhosis of the liver, and suicide.
• The Occupational Safety and Health Administration
  has declared stress a hazard of the workplace.

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Managing a mass casualty or bioterrorism
situation is no job for a single provider
organization.
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This is, in fact, the responsibility of the
community a composite that, at a minimum,
includes

• fire, police
• emergency medical services
• The public health system
• local municipalities and government authorities
• local hospitals and other health care
  organizations.

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Disaster Response and the Publics Health

• Public and Private
• Outpatient/ Hospital

Medical Care System
Emergency Response System
Public Health System

• EMS
• Police/Fire
• Water/Electric/ Communication Emerg.
  Response

• Protection
• Prevention
• Promotion

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Mental Health in Disaster and Terrorism

• Change in Safety
• Change in Travel

Distress Responses
Human Behavior in High Stress
Environments
Mental Health/ Illness

• Smoking
• Alcohol/Drugs
• Violence
• Over dedication

• PTSD
• Depression

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Police/Fire/EMS/Rescue Workers

• Individuals who traditionally work is stressful
  environments often develop various coping skills
  and strategies.
• Resilience Recovery
• Core Identity Development/Personality
• learned behavior reactions
• typical response to difficult situations

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Police/Fire/EMS/Rescue Workers

• Often these skills enable you to respond and
  maintain you level of function in performance of
  your duties, especially during difficult
  situations

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Police/Fire/EMS/Rescue Workers

• Some of the approaches can be considered healthy
  or positive
• others may have a negative or unhealthy
  consequence.

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Police/Fire/EMS/Rescue Workers

• they can be appropriate for the individuals
  involved
• they may seem unusual or strange to an outsider.

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• Who we are
• What we do
• Does what we do identifies who we are?
• What else defines us?
• List of characteristics
• Personal
• Professional

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First Responders

• Protectors
• Helpers
• Rescuers
• Caretakers
• Miracle Workers

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Personality Traits

• Obsessive Compulsive
• Control Issues
• Action orientated
• Risk taker
• High need for stimulation\
• Highly dedicated

• Easily bored
• Need to be needed
• Difficulty saying No
• Caretakers
• Family orientated
• High tolerance for stress
• Addiction to trauma

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Critical Incident

• Outside the range of normal coping skills
• Normal reaction to an abnormal situation

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What Is A Critical Incident?

• Any situation that results in an overwhelming
  sense of vulnerability or loss of control.
• Roger Solomon, Ph.D.
• Any situation faced by emergency service
  personnel that causes them to experience
  unusually strong emotional reactions which have
  the potential to interfere with their ability to
  function either at the scene or later.
• Jeff Mitchell, Ph.D.

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Critical Incidents

• Are sudden and unexpected!
• Disrupt our sense of control!
• Involve the perception of a life - damaging
  threat.
• May involve emotional or physical loss!

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Fight or Flight

• Faced by a threat, your body responds with a
  complex cascade of chemicals.
• The hypothalamus, alerted by the brain, pumps out
  a specialized hormone that ultimately prompts the
  two adrenal glands (perched atop the kidneys) to
  release the energizing hormone known as
  adrenaline.
• The resultfaster pulse, higher blood pressure,
  sharpened awarenessis the "fight or flight"
  response to fear and anxiety.

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Core Issues

• Suicide
• Substance Abuse
• Stress
• Burn-out/PTSD
• Martial- Family
• Violence
• Shut down
• Spirituality

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Understanding the Blue Culture

• Police Officers taught to take care of everyone
  else.
• To Serve and Protect
• Dont feel
• Use police officer face/persona
• Walking wounded
• Us vs. Them
• Law enforcement officers - all others

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Types of CI for Law Enforcement

• LODD
• Serious injury
• Suicide of co-worker
• Multi-causality Incident
• Police Shooting that ends with injury or death
• Death or violence to a child
• A prolonged event, with a negative results
• Extensive media attention
• Knowing the victim of the event

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Sources of stress for individual officers can be
placed into five general categories

• issues in the officer's personal life
• the pressures of law enforcement work
• the attitude of the general public toward police
  work and officers
• the operation of the criminal justice system
• the law enforcement organization itself.

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Stress in Law Enforcement

• Internal (department)
• External (community)
• Cumulative (career)
• Critical Incident Stress
• Family Stress

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• What we dont often
• talk about

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Police Suicide

• Impulsive Suicide
• Depressed Suicide
• Suicide as an escape to suffering
• Communication Suicide
• Loss of a loved one

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Risk Factors

• Immediate Plan
• Lethality
• Family history
• Alcohol
• Access to weapon
• History of Attempts
• Family Problems

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Suicide Components

• Hopeless
• Helpless
• Worthless

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Disturbing Legacy of Rescues Suicide

• Bob Long, a surveyor credited with finding the
  nine trapped Pennsylvania coal miners, killed
  himself in June.
• Terry Yeakey, an Oklahoma City police sergeant
  who rescued four bombing victims in 1995,
  committed suicide the following year.
• Robert O'Donnell, a paramedic who played a
  crucial role in saving baby Jessica McClure from
  a Texas well shaft in 1987, took his life nearly
  eight years later.

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Common factors in suicide by law enforcement
officers

• Alcohol.
• Coupled with an always-present firearm
• drinking and depression are major causes of
  police officer suicides.

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Common factors in suicide by law enforcement
officers

• Breakup of a relationship or marriage.
• Often, the only people outside law enforcement an
  officer trusts are his or her family.
• When a relationship ends, an officer loses his or
  her emotional support base.
• Stagnated career.
• An officer under investigation.

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Common police suicide warning signs

• An officer who starts having a high number of
  off-duty accidents.
• A rise in citizen complaints about
  aggressiveness.
• A change in personality in which a sullen officer
  suddenly becomes talkative or an officer who is
  normally very vocal becomes silent and withdrawn.
  
• The law enforcement official starts giving away
  prized possessions or telling friends they will
  be missed.
• The officer suddenly writes a will.
• Source The National P.O.L.I.C.E. Suicide
  Foundation

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HEALTH WELLNESS

• What is good health?
• What is wellness?
• What is comfort?

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People can use rituals to find comfort

• Family
• Friends

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People can use rituals to find comfort

• Activity

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People can use rituals to find comfort

• Religion/Spirituality

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• Even the most experienced and skilled
  professional can be affected by their work.

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Whats in a name ?

• Unfortunate Incident
• Urgent situation
• Risky Business
• Disturbance
• Hazardous
• Unsafe
• Treacherous
• Emergency

• Dangerous
• Tragedy
• Distress
• Crisis
• Disaster
• SNAFU
• Critical
• Trauma

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Phases of a Crisis

• Impact
• Inventory
• Rescue
• Recovery

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Topic 1 Psychological Phases of a Disaster
From Zunin Myers (2000)
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Critical Incident

• A critical (or traumatic) incident is any event
  outside the usual realm human experience that is
  markedly distressing
• (e.g. evokes reactions of intense fear,
  helplessness, horror, etc.)

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Critical Incident

• Such critical incidents usually involve the
  perceived threat to one's physical integrity or
  the physical integrity of someone else.

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Critical Incident

• Most importantly, critical incidents are
  determined by how they undermine a person's sense
  of safety, security and competency in the world.

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Critical Incident

• This results in a form of psychiatric injury,
  also called traumatic impact or traumatic stress.

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What is a Traumatic Incident?

• A situation that is extraordinary and may
  overwhelm coping mechanisms
• Causes the worker to experience a stress reaction
  
• Unusually strong emotional reactions at any time
  during or after the incident

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Symptoms of a Stress Reaction

• Can last
• a few days
• a few weeks
• a few months
• and occasionally longer
• Support and understanding of loved ones needed

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Symptoms of a Stress Reaction

• difficulty feeling love and intimacy

• difficulty taking interest and pleasure in
  day-to-day activities

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Symptoms of a Stress Reaction

• Professional assistance may be necessary

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Can be broken down into 4 categories

• Emotional
• Cognitive
• Behavioral
• Physical

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Emotional

• feelings of shock
• Anxiety
• Guilt
• Grief
• Severe panic
• Fear
• Uncertainty
• Depression
• Apprehension

• Intense Anger
• Irritability
• Agitation
• Resentment
• Shame
• helplessness
• hopelessness
• emotional numbness
• Feeling overwhelmed

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Cognitive

• Blaming someone
• Confusion
• Heightened or lowered awareness
• Indecisiveness
• Worry
• Shortened attention span

• Self-blame
• Poor concentration
• Memory problems
• Hypervigilence
• Poor problem solving
• Nightmares
• Intrusive images

• Loss of time, place, or person orientation

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Behavioral

• Change in activity
• Change in speech patterns
• Withdrawal
• Emotional outbursts
• Increase or decrease in appetite
• Startle reflex intensified

• Change in sexual functioning
• Erratic movement
• Antisocial acts
• Suspiciousness/
• paranoia
• Pacing
• Alcohol and/or drug consumption

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Physical

• Fatigue
• Nausea
• Muscle cramps
• Twitches
• Chest pain
• Difficult breathing
• Grinding of teeth

• Elevated blood pressure
• Rapid heartbeat
• Thirst
• Headaches
• Visual difficulties
• Profuse sweating

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TRAUMATIC STRESS

• Years ago, PTSD was commonly called "combat
  fatigue soldiers heart or "shell shock."

Many people believed that only soldiers or other
people who had been in a war could get PTSD.
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Traumatic Stress

• Trauma is considered an event outside the normal
  range of experience.

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Learning from Our Past Experience

• The mental fallout from the Oklahoma City
  bombings in 1995 didnt peak until 12 to 18
  months after the event.

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Learning from Our Past Experience

• One year after the bombing, three times as many
  residents of Oklahoma City reported increased
  drinking as those in a control community
  (Indianapolis). Rescue workers in Oklahoma City
  experienced elevated rates of substance abuse,
  depression and suicide.

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Beyond the range of normal experience
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Stress-Related Illnesses During the 11 Months
After the Attacks (September 11, 2001--August
22, 2002)

• During the 11 months after the attacks, 1,277
  stress-related incidents were observed among FDNY
  rescue workers, a 17-fold increase compared with
  the 75 stress-related incidents reported during
  the 11 months preceding the attacks.

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• As of August 28, 2002, a total of 250 FDNY rescue
  workers remain on leave with service-connected,
  stress-related problems. Of these, 37 also have
  respiratory problems

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• As of August 28, 2002, a total of 358
  firefighters and five EMS workers remained on
  medical leave or light duty assignment because of
  respiratory illness that occurred after WTC
  exposure.

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• The number of New York City firefighters and
  emergency medical service workers being treated
  for alcohol and drug abuse in 2004 is more than
  50 percent higher than it was the year previous.

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• The counseling unit of the Fire Department has
  seen an increase in every diagnostic category
  since Jan. 1. 2004
• After Sept. 11, the department's caseload went
  from an annual average of 600 cases over all to
  3,600.
• Most of those cases are for anxiety and
  bereavement after the terrorist attack.
• The alcohol and drug treatment cases represent 4
  percent of the counseling unit's total caseload.

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Police Organization ProvidingPeer Assistance
(POPPA)

• POPPA is a confidential, voluntary,
• independent, no departmental assistance program
  for the NYPD that uses trained volunteer NYPD
  officers as peer support officers.

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Police Organization ProvidingPeer Assistance
(POPPA)

• In the first year, there were about 250 calls to
  the help line.
• Since 2001, the number of calls has increased to
  between 900 and 1,200 per year.
• The proportion of callers who accept a referral
  for professional assistance has also increased,
  from about 30 percent to 45 percent of callers.

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However, the primary reasons for calls over the
years 2003 and 2004 were in the areas of

• stress or anxiety (34 percent)
• alcohol problem (26 percent)
• marital problem (24 percent)
• Traumatic stress (18 percent)
• depression (14 percent)
• bereavement issues (7percent).
• Because of confidentiality issues, detailed
  information is unavailable.

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New Jersey Cop 2 Cop

• Cop 2 Cop which began in November of 2000 saw an
  immediate increase of 300 in calls following
  9/11.
• Since that time Cop 2 Cop has received over
  15,000 calls and have become a model for other
  programs.

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NJ Cop2Cop

• There were over 550 Critical Incident Stress
  Management Response Services within the first two
  years including at the closing of Ground Zero.
• a specialized large group crisis CMB's called
  "reentry" for the Port Authority Police Dept.
• had Direct Contact with over 1,900 rescuers
  directly involved with the rescue and recovery at
  the WTC Site and have supported and created
  supplemental programs and hotlines.

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On The Front Line The Work of First Responders
in a Post 9/11 World.

• 9/11 attacks on the World Trade Center put
  firefighters and officers, especially those who
  were on the site of the disaster during the month
  of September, at an increased risk of developing
  emotional health problems.
• Samuel B. Bacharach, Ph.D.
• Institute for Workplace Studies School of
• Industrial Labor Relations Cornell University

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• Also highlighted in the report is a unique
  strength of FDNY firefighters and officers they
  work in highly supportive self-managed teams,
  which enable them to operate as highly effective
  work units in fighting fires and confronting
  other emergencies.

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The New York State Office of Alcoholism and
Substance Abuse Services

• reports that demand for alcohol and drug
  treatment in New York City increased immediately
  after the World Trade Center attacks.

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Who is at greatest risk for severe stress
symptoms?
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Groups Potentially Vulnerable to  Terror-Related
Issues  Demartino 2001

• Rescue Workers
• Medical Personnel
• Leaders
• Hero
• Persons deemed responsible
• Media representatives 

• Elderly
• Children
• Single Parents
• Injured
• Bereaved  

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Who is at greatest risk for severe stress
symptoms?

• Rescue workers who directly experience or witness
  any of the following during or after the disaster
  are at greatest risk for severe stress symptoms
  and lasting readjustment problems

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Who is at greatest risk for severe stress
symptoms?

• Life threatening danger or physical harm
  (especially to children)

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Who is at greatest risk for severe stress
symptoms?

• Exposure to gruesome death, bodily injury, or
  dead or maimed bodies

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Who is at greatest risk for severe stress
symptoms?

• Extreme environmental or human violence or
  destruction

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Who is at greatest risk for severe stress
symptoms?

• Loss of home/family
• valued possessions
• neighborhood
• community

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Who is at greatest risk for severe stress
symptoms?

• Workers who experience
• Loss of communication with or support from close
  relations

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Who is at greatest risk for severe stress
symptoms?

• Workers who experience
• Extreme fatigue
• weather exposure
• Hunger
• sleep deprivation

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Who is at greatest risk for severe stress
symptoms?

• Workers who experience
• Intense emotional demands (such as searching for
  possibly dying survivors or interacting with
  bereaved family members)

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Who is at greatest risk for severe stress
symptoms?

• Extended exposure to danger, loss,
  emotional/physical strain

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Who is at greatest risk for severe stress
symptoms?

• Workers who experience
• Exposure to toxic contamination
• gas or fumes
• Chemicals
• radioactivity

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Risk Factors

• Life threatening danger/physical harm
• Exposure to gruesome death or bodily injury
• Extreme environmental/human violence or
  destruction
• Loss of home, possessions, community
• Loss of communication with, or support from,
  close relations
• Extreme fatigue, weather exposure, hunger or
  sleep deprivation
• Extended exposure to danger, loss, or
  emotional/physical strain
• Exposure to toxic contamination

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The psychological problems that may result from
disaster experiences include Physical reactions

• Tension
• Fatigue
• Edginess
• difficulty sleeping
• bodily aches or pain

• startling easily
• racing heartbeat
• Nausea
• change in appetite
• change in sex drive

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The psychological problems that may result from
disaster experiences include

• Interpersonal reactions in relationships at
  school, work, in friendships, in marriage, or as
  a parent

• feeling rejected or abandoned
• being distant
• Judgmental
• over-controlling

• Distrust
• Irritability
• Conflict
• Withdrawal
• Isolation

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What severe stress symptoms can result from
disasters?

• Most responders only experience mild, normal
  stress reactions, and disaster experiences may
  even promote personal growth and strengthen
  relationships.

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Severe Stress Symptoms

• However, as many as one out of every three rescue
  workers experience some or all of the following
  severe stress symptoms, which may lead to lasting
  Post Traumatic Stress Disorder (PTSD), anxiety
  disorders, or depression.

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Severe stress symptoms

• Dissociation (feeling completely unreal or
  outside yourself, like in a dream having "blank"
  periods of time you cannot remember)

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Severe stress symptoms

• Intrusive re-experiencing
• terrifying memories
• Nightmares
• Flashbacks

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Severe stress symptoms

• Extreme attempts to avoid disturbing memories
  (such as through substance use)

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Severe stress symptoms

• Extreme emotional numbing (completely unable to
  feel emotion, as if empty)

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Hyper-arousal

• panic attacks
• rage
• extreme irritability
• intense agitation

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Severe anxiety

• paralyzing worry
• extreme helplessness
• compulsions or obsessions

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Severe depression

• complete loss of hope
• self-worth
• motivation
• purpose in life

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TERRORISM
Crisis Stress Trauma Terror
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The ultimate tool of the terrorist

• is not chemical, biological, nuclear or
  radiological.

It is psychological. Terror is fear.
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How is Terrorism Different? 

• Terrorism wins only if you respond to it in the
  way the terrorist wants you to 
• You can control the fate of the terrorist act in
  terms of your response to it.
• Psychologically speaking, the impact is up to you
  and not to the terrorist. 
• Adopted from DeMartino 11/15/01 and his
  interpretation of Franklin 1975 

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Traumatic Crisis

• An event in which people experience or witness
• Actual or potential death or injury to self or
  others.
• Serious injury.
• Destruction of homes, neighborhood, or valued
  possessions.
• Loss of contact with family/close relationships.

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Mediating Factors

• Prior experience with a similar event
• The intensity of the disruption in the survivors
  lives
• Individual feelings that there is no escape,
  which sets the stage for panic
• The emotional strength of the individual
• The length of time that has elapsed between the
  event occurrence and the present

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• On Site
• Trauma
• Response

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Stabilizing Individual

• Assess the survivors for injury and shock.
• Get uninjured people involved in helping.
• Provide support by
• Listening.
• Empathizing.
• Help survivors connect with natural support
  systems.

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Avoid Saying . . .

• I understand.
• Dont feel bad.
• Youre strong/Youll get through this.
• Dont cry.
• Its Gods will.
• It could be worse or At least you still have .
  . .

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Managing the Death Scene

• Cover the body treat it with respect.
• Have one family member look at the body and
  decide if the rest of the family should see it.
• Allow family members to hold or spend time with
  the deceased.
• Let the family grieve.

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Informing Family of a Death

• Separate the family members from others in a
  quiet, private place.
• Have the person(s) sit down, if possible.
• Make eye contact and use a calm, kind voice.
• Use the following words to tell the family
  members about the death Im sorry, but your
  family member has died. I am so sorry.

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Emergency Mental Health and Traumatic Stress

• Disasters, whether natural or terrorist-related,
  may result in human trauma that requires special
  attention.
• Following such events, the need for crisis
  counseling is just as important as the need to
  clean up debris and reconstruct property.

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Emergency Mental Health and Traumatic Stress

• Most people who are coping with the aftermath of
  a disaster have normal reactions as they struggle
  with the disruption and loss caused by the
  disaster.

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Emergency Mental Health and Traumatic Stress

• They do not see themselves as needing mental
  health services and are unlikely to request them.
  
• Community outreach may be necessary to seek out
  and provide mental health services to individuals
  who may be affected by a disaster.

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Individual Stress Management Training

• Primary Stress Prevention
• How we think,
• how we live,
• how we work

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Traditional Mental Health Practice
Crisis Counseling

• Is primarily home and community based.
• Focuses on assessment of strengths, adaptation of
  existing coping skills and development of new
  ones.
• Seeks to restore people to pre-disaster levels of
  functioning.
• Accepts content at face value.
• Validates the appropriateness of reactions to the
  event and its aftermath and normalizes the
  experience.
• Has a psycho-educational focus.

• Is often office based.
• Focuses on diagnosis and treatment of a mental
  illness.
• Attempts to impact the baseline of personality
  and functioning.
• Examines content.
• Encourages insight into past life experiences and
  their influence
• on current problems.
• Has a psycho-therapeutic focus.

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COMMON CRISIS COUNSELING SERVICES

• Information
• Education
• Outreach
• Counseling
• Supportive listening
• Referrals
• Training
• Collaboration with other programs

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Individual Stress Management Training

• Secondary Stress Prevention Relaxation
  exercises, physical fitness, spirituality and
  faith, emotional outlets.

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Individual Stress Management Training

• Tertiary Stress Prevention Psychological
  counseling/therapy, medical care for
  stress-related physical or psychological
  illnesses.

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Disaster Stress Interventions

• Individual stress management training
• Social support and creating a supportive
  organization
• Traumatic incident stress management techniques

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Disaster Stress Interventions

• Social support is one of the most important and
  powerful stress reducers.

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Disaster Stress Interventions

• Two powerful ways of healing from disaster
• For the individual, creating and telling the
  story of the disaster
• Rituals and memorials, which bring the community
  of responders, victims and public together

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Traumatic Incident Stress Management Techniques

• An intervention specifically for dealing with
  traumatic events
• Helps those involved in a traumatic incident to
  share their experiences, vent emotions, learn
  about stress reactions and symptoms
• Confidential, voluntary and educative process
• NOT psychotherapy

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Types of Traumatic/ Critical Incident Stress
Management

• Emergency Preparedness
• Crisis Management Briefing
• Defusing
• Debriefing
• Critical Incident Stress Debriefing
• FEMA/CMHS
• Red Cross Crisis Response Team
• NOVA

• Grief and Loss
• Individual Crisis Intervention
• Family CISM
• Organizational Consultation
• Follow-up/ Referral

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Types of Traumatic Incident Stress Management
Debriefing

• Proactive intervention involving a group
  meeting/discussion about a particularly
  distressing event

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Debriefing

• Designed to mitigate the impact of the event and
  assist those in recovery from the associated
  stress

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Debriefing

• Facilitated by a specially trained team
• Ideal to have it conducted between 24 and 72
  hours after the incident

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Critical Incident Stress Debriefing

• CONDUCTED BY TRAINED PROFESSIONALS

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Types of Traumatic Incident Stress Management
Defusing

• Shorter, less formal version of a debriefing
• Best conducted within 1 to 4 hours after an
  incident

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Defusing

• Confidential and voluntary
• Sharing of reactions to an incident and venting
  emotions
• Main purpose stabilize people affected by the
  incident so that they can return to their normal
  routines

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Types of Traumatic Incident Stress Management
Grief and Loss Session

• Structured group or individual session following
  a death
• Assists people in understanding their own grief
  reactions
• Creates a healthy atmosphere of openness and
  dialogue around the circumstances of the death

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Types of Traumatic Incident Stress Management
Crisis Management Briefing

• A large homogeneous group intervention used
  before, during and after crisis
• Present facts, facilitate a brief controlled
  discussion, Q A and information on stress
  survival skills and/
• or other available support services
• May be repeated as situation changes

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Managing Stress During Disaster

• On scene briefings for incoming responders
• Develop a buddy system
• Watch out for each other

130
Managing Stress During Disaster

• Take care of yourself physically
• Take frequent rest breaks
• Drink plenty of fluids
• Eat healthy foods

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Managing Stress During Disaster

• Take breaks away from the work area
• Give yourself permission to feel rotten

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Fatigue as a Health HazardThe Health Effects of
Working Long Hours

• Stress
• Causes a lack of concentration, memory loss and
  errors in judgment
• Depression
• May be caused by extended periods of stress
• Can be caused when workers experience high
  demands and low levels of control over their work
  
• Burnout (Work Exhaustion)
• When workers undergo extended periods of high
  demanding high stress situations coupled with
  long hours work overload

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• Psychological First Aid

134
Psychological First Aid

• Recognizing that some phases of disasters, such
  as the impact phase, and some type of disasters,
  such as bioterrorism and other public health
  emergencies, are characterized more by acute fear
  and anxiety than by classic traumatic stress
  reactions, the Institute of Medicine and other
  leading mental health authorities are
  increasingly promoting the use of "Psychological
  First Aid"  as means of addressing the intense
  physiological and emotional arousal that
  accompanies certain crisis events.

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Psychological First Aid

• (PFA) is quickly becoming another necessary tool
  in the disaster mental health responder's tool
  kit, and training in for New Jersey's disaster
  mental health responders will soon be offered in
  several counties.

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Psychological First Aid

• This research is beginning to suggest that
  waiting several hours, or days, before providing
  basic psycho-social support may miss an important
  window of opportunity in helping people
  emotionally recover from the aftershock of a
  traumatic event.
• Psychological first aid may be best applied
  during a critical incident and in the minutes and
  hours immediately following the event.

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Psychological First Aid is not new

• Long established principle of buddy-care in
  U.S. military
• Growing body of empirical evidence demonstrating
  relationship between physiological arousal and
  PTSD development following crises
• Recommended by the National Academy of
  Sciences-Institute of Medicine and National
  Center for PTSD

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Working Definition

• Psychological first aid (PFA) refers to a set of
  skills identified to limit the distress and
  negative behaviors that can increase fear and
  arousal.
• (National Academy of Sciences, 2003)

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Psychological First Aid is

• Psychological first aid (PFA) is as natural,
  necessary and accessible as medical first aid.
• Psychological first aid means nothing more
  complicated than assisting people with emotional
  distress resulting from an accident, injury or
  sudden shocking event.

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Psychological First Aid

• Like medical first aid skills, you don't need to
  be a doctor, nurse or highly trained
  professional to provide immediate care to those
  in need.

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General Principles of Psychological First Aid

• The most urgent tasks for the Psychological
  First Responder is to focus on restoring
  emotional equilibrium.

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Psychological First Aid responders should

• Present a calm, reassuring demeanor
• Be direct, informative, authoritative, nurturing,
  and problem-solving oriented

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Psychological First Aid

• Counter denial, by encouraging 
• individuals to deal with the facts of the event
• give accurate information and explanations of
  what happened and what to expect
• never offer false or unrealistic assurances

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Psychological First Aid

• Talk to individuals about their emotional
  reactions and encourage them to deal with such
  reactions as another facet of countering denial
  and other defenses that interfere with restoring
  equilibrium

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Psychological First Aid

• Convey a sense of hope and positive
  expectation--that a crisis changes things, there
  are ways to deal with the impact
• Normalize the individual's emotional reaction as
  much as feasible

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Psychological First Aid

• Facilitate emotional expression (e.g., through
  use of empathy, warmth, and genuine concern)
• Explain what can and will be done to assist the
  individual, their family and community

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Protect

• Individuals from further physical or emotional
  harm, including gruesome or graphic sights and
  sounds
• Individuals' dignity and privacy following a
  crisis
• Individuals from media intrusion or curious
  well-wishers
• Individuals from danger to self or others

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Direct

• Individuals toward quiet, safe areas
• With calm, compassionate but authoritative tone
• Any available personnel to appropriate tasks and
  to offer support to co-workers

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Connect

• Individuals with mental health and social service
  resources
• Individuals and their families with available
  printed and online resources for coping with the
  emotional consequences of crises
• Friends, family, co-workers and other sources of
  emotional support
• Individuals to information about the event or any
  relevant news pertaining to the situation

150
Psychological First Aid is not

• Debriefing
• Counseling
• Psychotherapy
• Mental health treatment

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Managing Stress after a Disaster

• Attend end of shift briefing
• Reach out
• Reconnect
• No big life decisions
• Rest
• Eat well
• Mood swings

• Slow down
• Dont overwhelm children
• Stress relief
• Recall what is important
• Avoid use of drugs or alcohol

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Workers Families

• Workers have valid concerns for their families.
• Families worry about workers health and safety.

153
Helping Children Feel Better

• Carry out daily routines and outings
• (when possible)

154
Helping Children Feel Better

• Encourage children to talk and ask questions

155
Helping Children Feel Better

• Reassure children they are safe

156
Helping Children Feel Better

• Screen TV

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Self Care for Critical Incidents

• Alternate strenuous exercise and relaxation for
  the first 24-48 hours after the incident.
• Keep busy.  Structure your time.  Be with people,
  especially those who have "been there."
• Remember that your reactions are normal and
  expected.  Don't label yourself as "crazy" or
  "weak."
• Keep your life as routine as possible.  Avoid
  making any big life changing decisions. However,
  you should make a lot of small choices about your
  daily life this will return a sense of being
  back in control to you.

158
Self Care for Critical Incidents

• Avoid alcohol and drug usage.  Any relief that is
  felt will be short lived and your feelings
  afterwards will be more extreme than before.
• Give yourself permission to feel rotten.
• Watch your diet.  You should avoid sugars and
  caffeine.  Eat regular, balanced meals.  Increase
  your intake of fruits and vegetables.
• Realize that others have gone through this before
  and have felt the same way you are feeling now.
• Don't hesitate to call a trusted and experienced
  peer anytime you need to talk.

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A day at the Jersey Shore
Small Group Exercise
160
SUMMARY of CISM

• When implemented as prescribed, CISM appears to
  be an effective crisis intervention, capable of
  reducing signs and symptoms of distress
  associated with an acute psychological crisis.
• When providers are not properly trained and
  experienced and when the debriefing is provided
  as a stand-alone intervention, it is likely to
  ineffectual and perhaps harmful.
• When providers apply CISM tactics to individuals
  for whom it was never intended under
  circumstances for which it was never designed and
  with a complete disregard for standardization and
  quality assurance the interventions may be
  ineffective and possibly harmful.

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KISS Keep it Simple Silly

• Remember you are dealing with a very stressful
  situation and its aftermath
• TALK- especially to other who relate to your
  situation
• DONT make major decisions alone
• LIMIT Expectations on self and others

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HALT

• Avoid Being
• Hungry
• Angry
• Lonely
• Tired

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REMEMBER

• Take care of yourself.
• Take care of family.

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Available Resources

• Mental health benefits may be available
• Local and national organizations
• Community services and hotlines
• Mental health resources
• Financial resources
• Legal resources

165
Acknowledgments

• Dr. George Everly, International Critical
  Incident Stress Foundation
• Jamie F. Becker of the Laborers Health and
  Safety Fund of North America.
• Steven M. Crimando MA, BCETS
• Deborah J DeWolfe PHD, MSPH Training Manual for
  Mental Health and Human Service Workers in Major
  Disaster. SAMHSA Publication
• National Centers for Posttraumatic Stress
  Disorders
• Dept of Veterans Affairs
• American Psychological Association
• American Psychiatric Association
• American Public Health Association
• The American Academy of Experts in Traumatic
  Stress
• FEMA
• CDC
• NIDA, NIH, NIAAA

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