Straight Talk About Stress
Mike McEvoy, PhD, NRP, RN, CCRN
www.mikemcevoy.com
Disclosures
• None
• I don’t know how to play golf or ski
I am not a hunter
Author:
Overview
•
•
•
•
Is stress what we think it is?
How well do we handle stress?
Maximizing your stress skills
Personality traits of emergency
responders
• The myth of CISD
• Best practices for organizations and
mental health providers
Define Stress
A response to a demand
for change
BOTH:
• Physical
• Psychological
A response to a
demand for change
• Different for different people
Arousal Score
Study of Arousal Level for Sky Divers
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14
Jump Sequence
Experienced
Novice
A response to a demand
for change
• Stress is not
the event but
our reaction
to it
Life Events
Death of spouse
Jail term
20% pay cut
Fired from job
Death of friend
Traffic ticket
Car accident
Life Events
Divorce
Marriage
New home
Retirement
New baby
Vacation
Christmas
Life Events
Divorce
=
Marriage =
New home =
Retirement=
New baby =
Vacation =
Christmas =
Death of spouse
Jail term
20% pay cut
Fired from job
Death of friend
Traffic ticket
Car accident
Emergency Services
You deal with stress
every day
Emergency Services
• Stressful
occupation
• Expect to see
others in trouble
• Routinely
manage crises
You deal with stress
every day
SO… are you
able to deal
with any level
of stress in
your own
life?
EMS Stress
• Is stress in
EMS different
than in other
professions?
Fire and EMS Service Stress
• FEMA funded 3year, 5-state study
of CISD,
firefighters’
disposition, and
stress reactions.
• Included
personnel from
Murrah building
bombing in OKC.
Fire and EMS Service Stress
• Social support
structure of fire
service is
protective
• Firefighters are
quite resilient
• Firefighter social
support comes
first from family,
then from friends
and coworkers
Fire and EMS Service Stress
• The majority of firefighters would seek
professional support from clergy
(40.9%) over professional counselors
(7.4%)
• Firefighters tend to have positive views
about the world despite continued
exposure to traumatic events
“John Wayne Syndrome”
“John Wayne Syndrome”
“You ain’t
hurt unless
there’s a
bone stickin’
out”
Impact of Major Stressors
Pathological Stress
• Acute Stress Disorder (ASD):
– Symptoms experienced during or
immediately after the trauma, last for at
least 2 days, and resolve within 4 weeks.
• Post-Traumatic Stress Disorder (PTSD):
– Symptoms begin within the first 3 months
after the event, may last months to years.
– Lifetime incidence: 7.8%
– Population prevalence ~ 0.8%
– Lower incidence in emergency responders
ASD and PTSD
1. Reliving the
event
2. Emotional
anesthesia
3. Persistent
anxiety
Pathological Stress
• NYC below 110th street after 9/11:
– Overall PTSD at 7.5% four weeks after
attack.
– Higher (~20%) closest to WTC site.
– Resolved to 1.7% by four months following.
– Further resolved to 0.6% by six months.
» Galea et al. (2002, 2003)
Stress Prevention
• If you can
handle the
daily grind,
you can
handle the big
event
Stress Prevention
• Stress can not be treated after exposure
• Emergency personnel must have good
stress management skills
• Most stress in emergency services is
not from major events, but day-to-day
job hassles:
–
–
–
–
–
Pay
Equipment
Dealing with the public
Administrative hassles
Work hours
Do you know a
“Happy Person”?
Happy People Choose
to be Happy
Miserable People Choose
to be Miserable
Most of us are
somewhere in between
Many of us would like to
be happier
Your Personal Stress
Management Program
Three realms of experience
where demands/perception of
demands can cause stress:
• Body
• Mind
• Interactions with others
Stress Management
Tips for Emergency Responders
1. Condition your body and mind
Stress Management
Tips for Emergency Responders
2. Listen to your
inner voice
Stress Management
Tips for Emergency Responders
3. Never stop growing and learning
Stress Management
Tips for Emergency Responders
3. Never stop growing and learning
Stress Management
Tips for Emergency Responders
4. Be positive
Stress Management
Tips for Emergency Responders
5. Have a life outside emergency
services
Stress Management
• Emergency
Services personnel
are resilient
• Use techniques that
promote resilience
• People cope
differently
• Maintain as much
control as possible
Stress Prevention
•
•
•
•
•
Well run incidents
Well managed organizations
Well prepared providers
Well conditioned personnel
Well grounded lives
Straight Talk About Stress
Mike McEvoy, PhD, NRP, RN, CCRN
www.mikemcevoy.com
Additional Information…
Other Crisis Oriented
Occupations:
One Critical
Difference:
One Critical
Difference:
Brotherhood
You deal with stress
every day
SO… are you
able to deal
with any level
of stress in
your own
life?
Not Always - Personality traits
that make a
good EMT also
increase stress!
“Am I different?”
One Word: Adrenaline
• 90% of population lack traits
needed to perform well as an
emergency responder
• Emergency responders are
“Adrenaline Junkies”
• Average citizens
are not
The “Adrenaline Junkie”
• Control oriented
The “Adrenaline Junkie”
• Attentive to detail
The “Adrenaline Junkie”
• Traditional
The “Adrenaline Junkie”
• Strong role identity
The “Adrenaline Junkie”
• Action oriented
The “Adrenaline Junkie”
• Risk takers
The “Adrenaline Junkie”
• Highly dedicated
The “Adrenaline Junkie”
• Family oriented
The “Adrenaline Junkie”
• High expectations
The “Adrenaline Junkie”
• Strongly rescue
oriented
“Adrenaline Junkie” Issues
•
•
•
•
•
•
•
•
•
•
Control oriented
Attentive to detail
Traditional
Strong role identity
Action oriented
Risk takers
Highly dedicated
Family oriented
High expectations
Strongly rescue oriented
The challenge of being
Control Oriented
• You might be a difficult person!
– Prefer to be in charge
– Independent thinker
– Do not take direction well
– Difficult to supervise
High Expectations
=
Perfectionism
• Negative self talk.
(poor self esteem)
• Negative beliefs about others.
(quick to criticize)
CONTAGIOUS
NEGATIVE
POSITIVE
Person + Person + Person +
Person + Person = Team
It’s all up to you.
POSITIVE
• Attitude
– Appearance, tone, demeanor
• Respect
– Words, actions
• Motivation
– Praise, celebration, enthusiasm
• Value
– Person + Person + Person +
• Mistakes
– Forgive people for being human
LEADERS
POSITIVE
1. Know your strengths & weaknesses
2. Have a sense of humor
3. Believe the future will be better than
the past
4. Respect your power
5. Build and maintain relationships
6. Be a team player
7. Help others develop their abilities
What About CISD?
• Created by Jeff Mitchell at UMB 1980’s
• Became defacto response to “Critical
Incidents”
• Premised on preventing
emergency responder
attrition from stress
• Paucity of research on
effectiveness
Cochrane Collaboration
• Worldwide network of centers, based in
England
• Launched 1995
• Definitive source for evidence based
practice
• Quarterly publication, several
separate databases, position
papers define best practices
CISD – Summary of Scientific
Literature (Peer Reviewed)
•
•
•
•
Mitchell model
CISD (not CISM)
Emergency Services
(vs. general population)
Cochrane Library Database (last
CISD revision 14 Nov 2005, last
substantiative update Dec 2001)
CISD - Conclusions
1. Value neutral to negative
2. Not effective compared to all forms of
debriefing and no debriefing at all
3. While perceived as helpful, rescuer
satisfaction ≠ effectiveness
4. Some evidence of harm to certain
individuals, often iatrogenic
CISD – General Population
Unsafe!
•
•
•
•
•
Adds to trauma
Complicates recovery
Should not be used
Now banned in most countries
US Institute of Mental Health and
World Health Organization both
recommend AGAINST it
CISD – Emergency Services
• Not appropriate for 60% of police,
fire, EMS personnel
• 85% talk about critical incidents
afterwards (colleagues and peers
preferred)
• 15% prefer not to talk at all
CISD – Iatrogenic Harm
(Worsening anxiety, depression, PTSD)
• Mandatory attendance
• Discussion of event (relive emotional
trauma) – MH error
• “Mixing” groups
– Peripheral personnel with those directly
involved in the incident
– People lost loved one with people whose
loved one survived
You know who we
haven’t heard from
yet, is John.
CISD Harm – Risk Factors
• Repeated or accumulated severe
unresolved stressors
• Lack of social supports
• Injury
• Preexisting psychological problems
• Traumatic bereavement
• Strong negative beliefs about meanings
of normal stress reactions
• People who most seek CISD show poorer
long term outcomes
CISD – What Now?
• OK - you
made your
point. What
should we be
doing instead?
PFA – Psychological First Aid
Three basics of psychic resilience
hardwired into our biological
makeup:
1. Recreate a sense of safety
2. Establish meaningful social
connections
3. Reestablish a sense of efficacy
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)
• Not new: premised on military “buddy
care”
• Evidence connects physiological arousal
with later PTSD development
General Principles of PFA
The most urgent task is to
focus on restoring emotional
equilibrium
Recreate sense of safety
• Immediate physical needs
– Bathroom, food, fluids, breaks, clothing
changes, sleep, time off…
• Protect from onlookers & media
• Determine if formal or informal help is
required (MH)
Meaningful social connection
• Help connect with family, friends,
children, significant others
– Talking in homogenous groups (ie: firefighters vs.
heterogeneous strangers)
• Provide information on normal signs
and symptoms including suggestions for
what to do
• Educate significant others on s/s and
how they can help
Reestablish sense of efficacy
• Recognition for job well done
• Encourage normal routines & roles
• Discuss self care strategies to reduce
anxiety
– Exercise, rest, relaxation
• Encourage people to support and assist
others
• Identify resources that promote effective
coping
• Accurate, simple information about plans,
schedules, events
• MH follow-up assessment @ 3 months
PFA
• Protect
• Direct
• Connect
Protect
• From further physical or emotional harm,
including gruesome or graphic sights and
sounds
• Dignity and privacy
• From media intrusion or curious wellwishers
• From danger to self or others
Direct
• Toward quiet, safe areas
• With calm, compassionate but
authoritative tone
• Any available personnel to appropriate
tasks and to offer support to co-workers
Connect
• With mental health resources
• Individuals and families with 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
Stress Prevention
•
•
•
•
•
Well run incidents
Well managed organizations
Well prepared providers
Well conditioned personnel
Well grounded lives
Summary
•
•
•
•
•
People are resilient
Friends are important
Conversation helps
Time is a great healer
Look out for others
while you look out for
yourself
- Gist, et al., The origins and natural history of debriefing, 1998.
The End
The
Beginning
•
Thank you!
www.mikemcevoy.com