MENTAL HEALTH IN TIME OF CRISIS

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MENTAL HEALTH IN TIME OF CRISIS

• Francisco I Perez, Ph.D., ABPP
• UT School of Public Health
• Houston, Texas

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INTRODUCTION

• The effect of a disaster or traumatic event goes
  far beyond its immediate devastation.
• Just as it takes time to reconstruct damaged
  buildings, it takes time to grieve and rebuild
  our lives.
• Life may not return to normal for months, or even
  years, following a disaster or traumatic event.

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• There may be changes in living conditions that
  cause changes in day-to-day activities, leading
  to strains in relationships, changes in
  expectations, and shifts in responsibility.
• These disruptions in relationships, roles, and
  routines can make life unfamiliar and
  unpredictable.

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UNDERSTANDING REACTIONS TO DISASTER EVENTS

• No one who experiences a disaster is untouched by
  it.
• It is normal to feel anxious about you and your
  familys safety.
• Profound sadness, grief, and anger are normal
  reactions to an abnormal event.
• Acknowledging our feelings helps us recover.
• Focusing on you strengths and abilities will help
  you heal.

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• Accepting help from community programs and
  resources is healthy.
• We each have different needs and different ways
  of coping.
• It is common to want to strike back at people who
  have caused great pain.
• However, nothing good is accomplished by hateful
  language and actions.

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SIGNS THAT STRESS MANAGEMENT IS NEEDED

• Disorientation or confusion and difficulty
  communicating thoughts.
• Limited attention span and difficulty
  concentrating.
• Becoming easily frustrated.
• Overwhelming guilt and self-doubts.
• Depression, sadness, and feelings of
  hopelessness.
• Mood swings and crying easily.
• Difficulty maintaining balance
• Headaches/stomach problems.

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• Tunnel vision/muffled hearing.
• Colds or flu-like symptoms.
• Difficulty sleeping.
• Poor work performance.
• Reluctance to leave home.
• Fear of crowds, strangers, or being alone.
• Increased use of drugs/alcohol.

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WAYS TO EASE THE STRESS

• Talk with someone about your feelings even though
  it may be difficult.
• Dont hold yourself responsible for the
  disastrous event.
• Dont become frustrated because you feel that you
  cant help directly in the rescue work.
• Take steps to promote your own physical and
  emotional healing by staying active in your daily
  life patterns or by adjusting them.

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• A healthy approach to life will help both you and
  your family.
• Maintain a normal household and daily routine,
  limiting demanding responsibilities of yourself
  and your family.
• Spend time with family and friends.
• Participate in memorials, rituals, and the use of
  symbols as a way to express feelings.

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• Use existing supports groups of family, friends,
  and spiritual/religious outlets.
• Establish a family emergency plan. It can be
  comforting to know that there is something you
  can do.
• Knowing what to expect can help ease the
  transition back to a normal life.

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FACING PERSONAL UNCERTAINTIES

• Feeling mentally drained and physically exhausted
  is normal and common.
• The loss of a home, business, or income may
  result in displacement and confusion about the
  future.
• Unresolved emotional issues or pre-existing
  problems may resurface.
• Anniversaries of the disaster remind us of our
  losses.

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FACING FAMILY RELATIONSHIPS CHANGES

• Relationships may become stressed when everyones
  emotions are heightened, and conflicts with
  spouses and other family members may increase.
• When homes are destroyed or damaged, families may
  have to live in temporary housing or with
  relatives and friends, leading to overcrowding
  and added tension.
• Family members or friends may be forced to move
  out of the area, disrupting relationships and
  usual support systems.

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• Parents may be physically or emotionally
  unavailable to their children, because they are
  busy cleaning up or are preoccupied, distracted,
  or stressed by difficulties related to the event.
• Parents may become overprotective of their
  children and their childrens safety.
• Children may be expected to take more adult
  roles, leaving less time to spend with friends or
  participate in routine activities.

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FACING WORK DISRUPTIONS

• Fatigue and increased stress from preoccupations
  with personal issues can lead to poor work
  performance.
• Conflicts with co-workers may increase, because
  of the added stress.
• Business may be forced to lay off employees, or
  company work hours and wages may be cut.
• Reduced income may require taking a second job.
• Daily travel and commute patterns may be
  disrupted.

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FACING FINANCIAL WORRIES

• Those who experience work disruptions may be
  unable to regain their previous standard of
  living, leading to financial concerns and unpaid
  bills.
• Seeking financial assistance to rebuild and
  repair damages adds to the already high levels of
  stress caused by the disaster or traumatic event,
  and the hassles of dealing with a bureaucracy can
  add to the frustration.

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TIPS ON HOW TO BE A SURVIVOR

• Accept the reality of the loss.
• Allow yourself and other family members to feel
  sadness and grief over what happened.
• Adjust to a new environment.
• Acknowledge that the person or possessions lost
  are gone forever.
• Put closure on the situation and move on.
• Have faith in better times to come.
• Return to doing things you enjoy.

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• Reestablish the routines of your life.
• Make commitments and keep them.
• Ask for help.

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POSTTRAUMATIC STRESS DISORDER

• Background
• 1. PTSD is a pathological anxiety that usually
  occurs after an individual experiences or
  witnesses severe trauma or events that constitute
  a threat to the physical integrity or life of the
  individual or of another person.
• 2. The individual initially responds with
  intense fear, helplessness, or horror.
• 3. The person later develops episodes of
  re-experiencing the event (flashbacks).

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• 4. Symptoms of numbness, avoidance, and
  hyper-arousal develop.
• 5. These symptoms result in clinically
  significant distress or functional impairment.
• 6. The symptoms should be present for at least
  one month.
• 7. PTSD can be acute (lt 3 months), chronic (gt 3
  months), or delayed of delayed onset (6 months
  after the event).

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• Pathophysiology
• The amygdala is a key brain structure implicated
  in PTSD. Research has shown that exposure to
  traumatic stimuli can lead to fear conditioning.
  Flashbulb memories are common in PTSD.
• Prevalence
• PTSD has a lifetime prevalence of 8 10
  accounts for considerable disability and
  morbidity.

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• Mortality/Morbidity
• Increased risk of impulsive behavior, suicide,
  and homicide.
• A direct relationship is observed between the
  severity of the trauma and the risk for PTSD.
• There is a strong correlation between early
  trauma exposure and subsequent re-traumatization.

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• Sex
• Females may be at a higher risk that males.
• Age
• PTSD can occur in persons of any age, including
  children.
• Children may have different reactions to trauma
  than adults.
• Children tend to be strongly affected by their
  parents reactions to the traumatic event.

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• Factors that interact to influence vulnerability
  to developing PTSD
• Characteristics of the trauma exposure itself
  Proximity to, severity of, and duration of
  exposure to the trauma.
• Characteristics of the individual prior trauma
  exposure, history of mental health problems, sex.
• Post-trauma factors social support.

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TIPS FOR EMERGENCY RESPONSE AND PUBLIC SAFETY
WOEKERS

• Stress prevention and management should be
  addressed in two critical contexts the
  organization and the individual.
• Adopting a preventive perspective allows both
  workers and organizations to anticipate stressors
  and shape responses, rather that simply reacting
  to a crisis when it occurs.
• Tips for organizational and individual stress
  prevention and management follow.

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Organizational approaches

• 1. Provide effective management structure and
  leadership. Elements include
• Clear chain of command and reporting
  relationships.
• Available and accessible supervisors.
• Disaster orientation for all workers.
• Shifts no longer that 12 hours, followed by 12
  hours off.
• Briefings at the beginning of shifts as workers
  enter the operation.

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• Shifts should overlap so the outgoing workers
  brief incoming workers.
• Necessary supplies and communication tools should
  be readily available.
• 2. Define a clear purpose and goals.
• 3. Define clear intervention goals and strategies
• appropriate to the assignment setting.
• 4. Define roles by function.

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• 5. Orient and train staff with written role
  descriptions for each assignment setting.
• 6. When the setting is under the jurisdiction of
  another agency, inform workers of each agencys
  role, contact person, and expectation.
• 7. Nurture team support.
• 8. Create a buddy system for support and
  monitoring.
• 9. Promote a positive atmosphere of support and
  tolerance with frequent praise.

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• 10. Develop a plan for stress management
• Assess workers functioning regularly.
• Rotate workers among low-, mid-, and high-stress
  tasks.
• Encourage breaks and time away from assignment.
• Educate about signs and symptoms of worker stress
  and coping strategies.
• Provide individual and group defusing and
  debriefing.

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• Develop an exit plan for workers leaving the
  operation, including a debriefing, reentry
  information, opportunity to critique, and formal
  recognition for service.

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Individual approaches for stress prevention and
management

• 1. Manage workload.
• Set priority levels for tasks with a realistic
  work plan.
• Delegate existing workloads so workers are not
  attempting disaster response in addition to their
  usual job.
• 2. Balance lifestyle.
• Get physical exercise, and stretch muscles when
  possible.
• Eat healthy.

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• Get adequate sleep and rest.
• Maintain contact and connections with family and
  friends.
• 3. Apply stress reduction techniques.
• Reduce physical tension by activities such as
  taking deep breaths, meditating, and walking
  mindfully.
• Use time off for exercise, reading, listening for
  music, taking a bath, talking to family, or
  getting a special meal.

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• Talk about emotions and reactions with coworkers
  during appropriate times.
• 4. Practice self awarenessgt
• Learn to recognize and heed early warning signs
  for stress reaction.
• Accept that you may need help to assess
  problematic stress reactions.
• Avoid overly identifying with survivors and
  victims grief and trauma, which may interfere
  with discussing painful material.

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• Understand differences between professional
  helping relationships and friendships.
• Examine personal prejudices and cultural
  stereotypes.
• Be mindful that vicarious traumatization or
  compassion fatigue may develop.
• Recognize when personal disaster experience or
  loss interferes with effectiveness.

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Normal reactions to a traumatic event

• No one who responds to a traumatic event is
  untouched by it.
• Profound sadness, grief, and anger are normal
  reactions to an abnormal event.
• You may not want to leave the scene until the
  work is finished.
• You likely will try to override stress and
  fatigue with dedication and commitment.
• You may deny the need for rest and recovery time.

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Signs that you may need stress management
assistance

• Disorientation or confusion, and difficulty
  communicating thoughts.
• Difficulty remembering instructions and remaining
  focused.
• Difficulty maintaining balance
• Becoming easily frustrated and increasingly
  irritable.
• Inability to engage in problem solving and making
  decisions.
• Unnecessary risk taking.

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• Physical symptoms of stress including tremors,
  headaches and nausea.
• Loss of objectivity.
• Inability to relax off duty.
• Refusal to follow orders or leave the scene.
• Increased use of drugs or alcohol.
• Unusual clumsiness.
• Problems sleeping.

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Ways to manage stress

• Limit on-duty-work hours to no more than 12 hours
  per day.
• Rotate work from high-stress to lower stress
  functions.
• Rotate work from the scene to routine assignments
  as practicable.
• Use employee assistance programs as needed.
• Drink plenty of water and eat healthy.
• Take frequent, brief breaks from the scene.

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• Talk about your emotions to process what you have
  seen and done.
• Stay in touch with your family and friends.
• Participate in memorials and rituals.
• Pair up with another responder so that you may
  monitor one anothers stress.

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DISASTER COUNSELING

• Disaster counseling involves both listening and
  guiding.
• Survivors typically benefit from both talking
  about their disaster experiences and being
  assisted with problem-solving and referral to
  resources.

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Disaster counseling skills

• Establishing rapport.
• Active listening
• Allow silence
• Attend nonverbally
• Paraphrase
• Reflect feelings
• Allow expression of emotions

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Some dos and don'ts

• Do say
• These are normal reactions to a disaster.
• It is understandable that you feel this way.
• You are not going crazy.
• It wasnt your fault, you did the best you could.
• Things may never be the same, but they will get
  better and you will feel better.

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• Dont say
• It could have been worse.
• You can always get another pet/car/house.
• Its best if you just stay busy.
• I know just how you feel.
• You need to get on with your life.

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COMPASSION FATIGUE

• Compassion fatigue is a state experienced by
  those helping people in distress.
• It is an extreme state of tension and
  preoccupation with the suffering of those being
  helped to the degree that it is traumatizing for
  the helper.
• The helper, in contrast to the person(s) being
  helped, is traumatized or suffers through the
  helpers own efforts to empathize and be
  compassionate.
• Often this leads to poor self care and extreme
  sacrifice in the process of helping.

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• Together, this leads to compassion fatigue and
  symptoms similar to PTSD.
• Helping other individuals requires empathy and
  compassion.
• Caring too much can hurt.
• When caregivers focus on others without
  practicing self-care, destructive behaviors can
  surface.
• Those who are selfless and compassionate have an
  Achilles heel they dont pay enough attention
  to themselves.

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• It is important to set boundaries.
• It is important to strike a balance.

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COMPASSION FATIGUE AWARENESS PROJECT

• Denial is one of the most detrimental symptoms of
  Compassion fatigue and Life Stress.
• It can hinder the ability to assess the level of
  fatigue and stress in your life as well as thwart
  your efforts to begin the healing process.
• Once you realize that you are experiencing
  compassion fatigue, exploring this new awareness
  can lead to insights about your behavior patterns
  and approach to life.

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• A common coping mechanism in care giving is to
  simply stuff your emotions that surface
  repeatedly in your work.
• Eventually, those emotions refuse to be ignored.
• Psychological and physical symptoms develop.
• With support, insightful information, and
  authentic self-care, you can begin to understand
  the complexity of the emotions youve been
  juggling and, most likely suppressing.

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• Most people never take the time to understand how
  their jobs affect them emotionally.
• Give yourself credit for moving forward and
  affecting change.
• Your hard work will pay off.

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Authentic and Sustainable self-care begins with
you

• Be kind to yourself
• Enhance your awareness with education
• Accept where you are on your path at all times
• Understand that those close to you may not be
  there when you need them most
• Exchange information and feelings with people who
  can validate you
• Listen to others that are suffering

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• Clarify your personal boundaries
• Express your needs verbally
• Take positive action to change your environment

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Your continuing journey

• Helping the symptoms of compassion fatigue is a
  personal ongoing inside job.
• Youve been loyal to your self-care plan,
  clarified personal boundaries in both your
  personal and professional life, and now
  understand your negative behaviors and their
  origin.
• As you continue to do the necessary internal
  work, you will reap the benefits.
• Your life will begin to change for the better.

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• In order to move forward on your path to
  wellness, you must continually commit to
  authentic self-care that includes
• Health-building activities such as exercise,
  massage, yoga, meditation
• Eating healthy foods.
• Drinking plenty of water
• Use natural healing products to care for and heal
  your body

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• Practicing the art of self management learn to
  say no
• Developing a healthy support system people who
  contribute to your self esteem, people who listen
  well, people who care.
• Organizing your life so you become proactive as
  opposed to reactive.
• Reserving your life energies for worthy causes.
  Choose your battles.
• Living a balanced life. Sing, dance, sit with
  silence.

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• Francisco I Perez, Ph.D., ABPP
• 6560 Fannin Suite 1810
• Houston, Texas 77030
• 713 790 1225
• fperez3_at_sbcglobal.net