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Stress Management for Emergency Responders - Introduction

[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC - safer, healthier people.

Hi. I’m Dr. Leslie Snider with the Antares Foundation. This is the second in a series of four programs on stress management for individuals, teams, and agencies working in emergency and humanitarian aid settings.

This program is geared for you as an emergency responder, humanitarian aid worker, or individual providing technical assistance in these settings. In this program we will explore:

• What is unique about stress for emergency responders;

• What it means to be "emotionally fit" for your mission;

• Stress management strategies you can put in place at all phases of your mission;

• What you need to know if critical incidents happen; and

• What you can expect from your agency.

Let's begin by talking about what "stress" and "stress management" means for responders. Stress is an inevitable part of emergency and humanitarian aid work. Some say, "If you go out in the rain, you should expect to get wet." But let's think about that in terms of the realities of this work.

Emergency and humanitarian aid work have unique stresses and dangers. These can include working in a potentially hazardous environment, heightened responsibility for vulnerable people, exposure to atrocity and suffering, unpredictability, and separation from friends and family and usual supports. These unique stresses and dangers can have serious consequences for responders. Studies show that one-third or more of returned responders have clinically significant signs of emotional distress. That means that their distress interferes with their life and work and may be severe enough to warrant professional help.

It's important for us to remember that stress is a part of life and most certainly of emergency and humanitarian aid work. It is normal for us to feel its effects. Stress is the response of the body and mind to a physical or emotional challenge and occurs when the demands from the outside world or yourself are out of balance with the resources you need to cope. Not everyone experiences and responds to stress in the same way. Two people encountering the same stressful situation may perceive it differently and have different reactions to it. Also, sources of stress vary in different contexts. Each emergency setting is unique with different stressors based on the environment and nature of the emergency, your role in the mission, your team, or your work environment.

We can consider three types of stress:

• Day to day stress refers to baseline stress caused by various sources of tension in our lives (personal, family, or social) and may be increased by changes in our environment, such as the change in routines when responders get to the field, working with new people, and managing new information.

• Cumulative stress, or strain, results from an accumulation of various stresses inherent in the job.

• Critical incident stress, or shock, can result if responders are exposed to extreme or traumatic events.

So, what do we mean by stress management? In emergency and humanitarian aid work, stress management entails preventing or reducing the intensity, frequency, or duration of stressors we may be exposed to; reducing our vulnerability, and increasing our resilience; improving our ability to monitor our stress and cope in healthy ways; and taking steps to prevent the long-term effects of stress.

So, we are really talking about more than just "managing" stress when it comes up. Rather, stress management means making sure that we, as individual responders, are in the best possible condition for the demands of the job. That we are "physically" and "emotionally" fit for our mission.

Preventing, managing, and reducing stress, and ensuring a successful mission, is the responsibility of everyone involved. You, your team, and your agency are inter-dependent. You have responsibilities to each other in good stress management and operational practices. Everyone must do their part.

Strategies for stress management are most effective when put in place for all phases of your mission: pre-deployment, in the field, and at the end of your assignment. Effective stress management also requires measures that are routine, pro-active, and responsive.

We will explore ways that you can be pro-active in managing your own stress, routine measures that you can put in place to cope and function at your best, and how you can monitor your stress level and respond if and when the situation is particularly difficult.

Take a moment to consider how you experience stress. The first step in learning how to manage your own stress is knowing yourself. What kinds of things are stressful for you as a person? How do you feel and manifest stress? And what things help you to cope?

Taking the time to prepare a plan for self-care in the field is important before you go on your mission. There will be many demands on you during the emergency and less time to think about self-care. Putting in place a strategy now will help you to recognize stress and do something about it more quickly when you're in the field.

What are potential sources of stress for emergency responders and humanitarian aid workers? If you are new to the field, it’s important to anticipate what kinds of stressors you may encounter. Experienced responders can look back upon stresses they faced in the past, but each emergency setting is different.

Sources of stress may include dangers and hardships in the emergency context, pressures in the work environment, the often complex role of emergency responders and humanitarian aid workers, personal stress factors, and family factors.

Take a moment to think about or write down three potential sources of stress for you. Consider the different sources of stress that can come from the environment or your work, as well as from your personal life. How do you feel the effects of stress? How does it affect your health, your relationships, and your work, for example?

We can feel the effects of stress in different ways: physical, emotional, mental, spiritual, behavioral, and interpersonal. Let's look at each of these.

Physical signs of stress may include:

• Chronic fatigue – feeling tired all the time, having low energy.

• Aches and pains, such as, headaches, muscle tension or stomach aches.

• Sleep problems – being unable to fall asleep or stay asleep, waking up early before the alarm, or sleeping too much.

• Appetite changes – you may be in a country or area with unfamiliar food or exposed to food or water-borne illnesses. These can certainly affect your appetite! But stress alone can also affect your appetite. Some people tend to eat more and gain weight while others lose weight.

• Pounding heart, shaking or trembling, and sweating may be signs of stress and anxiety.

Mental signs of stress include difficulty concentrating or keeping your focus; difficulty making decisions; ambivalence; memory problems or forgetfulness; obsessive thinking, such as going over and over something in your mind; and feeling pessimistic and cynical – about your work, the situation, or things in general.

Emotional signs of stress may include feelings of sadness and depression; crying easily; anxiety and worry; feelings of hopelessness and helplessness; and feeling as though your emotions go up and down, in other words, that they are "labile."

Stress may also manifest in spiritual ways, such as losing faith in mankind or the goodness of people, losing faith in God, feeling life is pointless, or a general loss of beliefs and values.

A dangerous sign of stress is engaging in unhealthy or risky behaviors:

• Emergency responders may fall into poor eating habits as they are often eating on the go, consuming lots of coffee or junk food, or skipping meals altogether.

• Poor sleeping habits and lack of exercise also affect your health, your mood, and your functioning.

• Putting oneself in danger or taking unnecessary risks are other tendencies of emergency responders. When working in hazardous areas, some responders tend to ignore their own safety needs and may do risky things in the field that they normally wouldn't do at home - like not wearing seat belts, driving recklessly, or needlessly going into dangerous areas.

• Risky sex is another danger. Of course, there is the potential for HIV and other sexually transmitted diseases. Also, it can complicate working relationships with colleagues or others. It's important to remember that it is unethical for emergency responders to have relationships with beneficiaries who depend on the aid they provide.

• Alcohol abuse is often a common problem among responders, as well as illicit or prescription drug abuse. Substance abuse impairs judgment, often puts responders, their co-workers, and others in danger, and may exacerbate depression or anxiety. Remember that alcohol is a depressant and can affect your natural sleep cycle.

Stress also affects our relationships and how we interact with people. Some responders may withdraw from friends, colleagues, and family, and isolate themselves. We may direct anger and irritability, due to stress, onto others around us. Conflicts can erupt at work or in our personal lives.

There are certain pitfalls that we as emergency and humanitarian aid workers need to be attentive to as we go about our work. These are signs that stress may be getting the better of us. One is either emotionally distancing or over-identifying with the survivors of the emergency. We may start to see beneficiaries as "ideal victims" or become emotionally drawn into the situation. Conversely, we may perceive beneficiaries as manipulative and untrustworthy. A certain amount of distance is healthy, and helps us to keep functioning in desperate circumstances. However, if experiences or emotions are always shoved down and not dealt with, it may cause hazardous emotional material and problems longer-term.

Black and white thinking is another pitfall. Some responders tend to simplify complex situations or ethical dilemmas so they can perceive their role with clear moral boundaries. Adrenaline high or addiction to danger can lead to risky and unhealthy behaviors. Working long hours without rest or not taking our scheduled R&R or break from the emergency is also a warning sign. Although emergencies present us with overwhelming needs, responders who work 24/7 without rest often burn out and are less effective on the job. And, lastly, we may have unrealistic expectations of ourselves and what is humanly possible to achieve in the situation.

Some people who work in emergency response and humanitarian aid have a certain type of personality. You may have heard the term "disaster cowboys" before. This term refers to responders who love the thrill of working in dangerous settings, are often action-oriented, and highly dedicated. Although many of these attributes are useful for emergency work, they can also lead the responder into some of the pitfalls we discussed.

Do we truly believe this statement that, "Aid workers shouldn't have too great a heart. We need professionals." Having feelings about the suffering around you is natural. The point is to be aware of your health and reactions so that you can remain effective and work from a place of wellness.

How do we know when we're burned out on the job? Chronic stress is the most frequent type of stress for responders, given the nature of the job. Small daily stressors often build up and cause strain. Therefore, the steps you take each day to manage stress can have a big impact.

If we are unable to keep chronic stress within reasonable limits, we may experience burnout. Burnout is an emotional state due to long term stress and is characterized by chronic emotional exhaustion, depleted energy, loss of enthusiasm and motivation to work, lowered work efficiency, a diminished sense of personal accomplishment, and pessimism and cynicism.

Burnout in individuals will also affect the functioning of teams in the field. Some of the signs include interpersonal conflicts, scapegoating a member of the team, formation of cliques, difficulty gaining consensus, negative attitudes, and an overall decrease in work output and quality of service.

Burnout is also sometimes referred to as "compassion fatigue." When we are burned out, we may lose our drive, sense of meaning, and pleasure in our work, and ability to help others compassionately.

Consider this quote: "There is a soul weariness that comes with caring, from doing business with the handiwork of fear. Sometimes it lives at the edges of one’s life. At other times, it comes crashing in, with its profound demands for attention, nightmares, strange fears, and generalized hopelessness."

Emergency and humanitarian aid work is demanding, but it is also incredibly rewarding. Knowing what to expect and being deliberate about taking care of yourself will help you to maintain your passion and effectiveness for the job.

Take some time now to think about how you can manage stress better as a responder. There are strategies you can employ before your deployment, while you’re in the field, and also at the end of your mission upon your return home. It’s helpful to be aware of what kind of stresses you may face and to plan ahead for how you will handle them.

Let's start with pre-deployment strategies. Some things to think about before you deploy on your mission are: know yourself and your agency, learn about stress and its impacts, prepare yourself, and know your job and the emergency mission. We’ll talk about each of these points in the slides that follow.

First of all, know yourself. Take a moment to reflect upon your motivations for choosing this work: Why am I doing this work? Why now in my life? What are your expectations for this mission? What do you hope to achieve? Remember to keep reasonable expectations for yourself. Emergency settings are challenging and there are many factors we can’t control.

People choose emergency and humanitarian aid work for a variety of reasons. These can include looking for adventure, feeling called to help others, changing career paths, or sometimes running away from problems or difficulties in your current life.

Knowing your motivation is important, as well as assessing your own physical and emotional readiness for the mission. Is this a particularly stressful time in your life? Do you have health or family concerns that will make this deployment more difficult? You are ultimately responsible for making the decision of your personal readiness for the mission, and choosing if this is an appropriate time in your life to take on the challenge.

Now, let's talk about what works for you. Think about or write down three things you do now or could start doing to help you better manage stress. What will work in the field? You may need to adapt some of the things you usually do to relieve stress for the field context. For example, if you’re a runner, you may not be able to find safe areas for running in the crisis setting or may be restricted by curfews and other security constraints. Try to plan for another way of getting your exercise.

There is often a lack of cultural and leisure activities in the field. If you like to watch movies, bring a couple of DVDs along to play on your computer. Bring some music, reading material, a journal – whatever you enjoy and that helps you to relieve stress.

Next, know your agency. Learn your agency's policies and procedures for safety and security, communication, work and leave time, and staff support, including health care and possible evacuation procedures during and following your deployment. Learn about stress and its consequences – as you are doing now! Attend training or briefing sessions and review information provided by your agency about stress and stress management. If you are new to this work, talk to others who have been to the field and get an accurate picture of what to expect and ideas for coping strategies. Knowledge is power!

Next, get ready. Many emergency and humanitarian aid workers have to deploy on a moment's notice when a crisis occurs. Getting ready and being ready is ideally something that a responder needs to do before an emergency happens. Being ready means being prepared in both practical and psychological terms. You may be away for a brief or extended time, and may need to consider not only preparing yourself, but also your family for your deployment. Plan for paying bills, handling mail and paper delivery, letting loved ones know how to contact you and what to expect. Persons who live alone may have different issues to consider than those who live with a partner or family. Responders with children may want to consider how to prepare them for your absence, and will need to plan for child care responsibilities.

Practical steps to prepare yourself for the mission will likely include medical clearance procedures and immunizations, depending upon your destination. Be sure to have on hand any medicines you routinely take, spare contact lenses or glasses, and a first aid kit. Some responders keep basic supplies, such as travel-size shampoos, ready in case they need to deploy quickly. Being prepared for travel may require you to keep a current, valid passport, and for some countries, you may need to complete paperwork to obtain a visa.

Next, know your job and mission. What is your job description? What is expected of you? Because emergency settings change rapidly, your job description may change on the ground. Flexibility is important, but at the outset, you should have an understanding of the overall mission, your job, your role on the team, who you will report to, and so on.

Finally, where are you going? Before you deploy, learn as much as you can about the emergency context. What type of emergency is it – natural disaster, post-conflict area, disease outbreak? What is the environment like, in terms of climate and terrain? Do you need to prepare for very warm or cold weather? Is this the rainy or dry season?

Find out as much as you can about the security situation. Attend a security briefing. Know what is expected of you, in terms of safety procedures and know what support you can expect from your agency. Learn about the cultural, political, economic, and social environment where the emergency has occurred. Are there certain norms about dress and behavior that you need to be aware of? Are there different expectations for men and women? What is the appropriate greeting in the culture?

Now let's look at strategies for stress management while you're in the field. Here are some things to consider while you are deployed on your mission. We will look at each of these points in turn.

• First, continue to assess and monitor your own stress levels. Pay attention to the signs of stress for you, such as changes in your sleep or appetite, fatigue, being short-tempered, and put in place your strategies to cope in healthy ways.

• Be deliberate in managing stress. Make your plan a routine part of your deployment.

• Know your limits. Remember that going beyond your limits is likely to make you less effective in the long run.

• Ask for help when you need it, both in terms of your task and with personal support whenever necessary. It is your responsibility to seek support to make sure you are in the best possible condition to the job, and not to let stress get out of hand.

As much as possible, try to keep reasonable working hours when you're on a mission, and have at least one day off a week. Also, take your R&R or leave time; it is there for good reason. You will be working in a hardship setting with various new stresses. The job and living conditions do take a toll. It may be hard to leave your work and mission, but it is important that you do, in order to refresh, keep perspective, and stay fit for the job.

Remember the importance of flexibility and tolerance. Your job may change as the situation on the ground changes. There are many things we can't control in emergency settings. You may be asked to do something outside of your job description or particular area of expertise. Flexibility from all team members is key for good teamwork and the success of the mission. The demands of the job also require that everyone practice tolerance and patience with each other.

Here is a list of healthy habits, or what we call "adaptive coping" for you to keep in mind. Some emergency responders tend to live off caffeine and junk food and often eat on the run.

• Do try to eat healthy foods and try not to skip meals.

• Keep a regular schedule, such as regular waking and sleeping hours and work and relaxation time.

• Don't work 24/7!

• Do something everyday to relax and get proper rest and exercise.

• Keep in touch with friends and family back home.

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Finally, be safe and avoid risky behavior, such as drinking too much or putting yourself in danger.

We've talked about ways of managing the day-to-day and cumulative stresses that can pile up during emergency work. It is also important for us to discuss the potential for critical incidents in the field. Critical incidents are extreme or traumatic events outside of the realm of normal, everyday human experience that threaten the life or integrity of the person and cause intense fear or horror. Exposure to critical incidents is a reality of emergency and humanitarian aid work in this day and age. These may include accidents, kidnapping of aid workers, or witnessing or hearing about traumatic events happening to others, which can, in fact, impact the responder as severely as if they had experienced the event themselves.

"Vicarious or secondary traumatization" may occur when responders hear the traumatic stories from survivors of the emergency. Critical incident stress, or shock, can result from exposure to extreme events. Reactions to traumatic stress can be immediate, delayed, or cumulative. For many people, the effects of traumatic experiences fade over time, but for others the effects are major and long-lasting. Some people will experience a delayed reaction to the event, months or even years after the experience.

The way someone reacts to a traumatic event depends upon many factors, including:

• Intensity, duration, or frequency of the trauma;

• Proximity to the event;

• A history of previous traumatic experiences;

• Pre-existing physical and emotional health of the person; and

• Finally, the meaning of the event to the person is also an important factor to how they process their experience and react longer-term.

Although each person will react differently to an event, we will describe here some common reactions to critical incidents.

• Avoidance – Following a trauma, many people avoid situations that may remind them of the event or thinking about what happened to them.

• Hyper-Arousal – Many people find themselves"on alert", feeling jumpy and being easily startled.

• Re-Experiencing – In order to process and understand the experience, some people re-experience the event through dreams, by going over and over details of it in their mind, or sometimes have "flashbacks" – feeling suddenly as though the event was happening again, even though they are now in a safe place.

Remember that after a trauma, the body and mind are in a kind of survival mode and are adapting to this new information and experience. If you are exposed to a critical incident and develop some of these reactions, they will likely fade over time. It is important to take extra care of yourself and be patient with the process of recovery. For some, the reactions do not fade or they get worse over time. They may also experience depression, anxiety, or more serious difficulties in their life and work. Seeking help from a mental health professional may be important, both for those who experience severe symptoms, and also for those who simply want help making sense of the experience.

Now, let's go the end phase of your mission. As you transition from the emergency world back into your regular life, here are some things to expect and think about. At the end of your deployment, take time to review your experience. Most agencies conduct an operational debriefing at the end of mission. This could happen in the field with your supervisor or upon your return to headquarters. This is an opportunity to review the work you have done, examine lessons learned, and to receive from and give feedback to the agency.

Some agencies may offer you the opportunity for a personal, confidential debrief with a mental health professional. Make use of this opportunity, even if you had a positive experience on your deployment. It is a chance to review your successes and challenges for your own personal growth and to plan for the return home to "regular life." If you have had a particularly stressful deployment, this is an opportunity to connect with someone to talk about your experience and access further support.

Coming home has its own stresses. The transition from the emergency world to your regular life can be a bit of a shock. You may be coming from a place of extreme devastation and suffering, back to a world where everything and everyone have continued on, despite what you have just seen and experienced. It's important to be prepared for this, and to take some time for recovery. Take a rest, and try to avoid deploying from one crisis to the next – a common pitfall for emergency workers. Take time to process your experience privately or with others. Some returning responders find it helpful to talk with other returning colleagues who understand the experience.

Identify and use the supports in your life, including loved ones and healthy routines. Coming home may also be stressful, in terms of your relationships. Life at home didn’t stop while you were on deployment. You will need time to catch up with family and friends, and all that happened while you were away. Your family or partner may have had to deal with various problems without your help while you were deployed. They may have difficulty relating to your experiences, and you may find it hard to explain what you have seen and how you feel.

Be aware and prepared for these possibilities. Keep communication open and be patient. Many agencies have specific information and support for family members to help them understand your experience, and may offer professional services to you and your family to ease your transition home.

If you have had a particularly stressful deployment or experienced a critical incident, be open to the support your agency provides. This is for your health and well-being in the long-term.

So they say, "If you go out in the rain, expect to get wet." We say, "If you go out in the rain, take an umbrella." The reality is that emergency and humanitarian aid work is stressful, and incidents do happen. But there is a lot we can do, personally, to shield ourselves and function at our best. We owe it to ourselves, our loved ones, and the people we are serving.

Additional programs in this series discuss a more in-depth understanding of stress for emergency responders and practical stress management strategies for team leaders and agencies. Good luck on your mission.

For further information and to download resources such as "Managing Stress in Humanitarian Aid Workers: Guidelines for Good Practice," visit the Antares Foundation website: www.antaresfoundation.org.

[Announcer]For the most accurate health information, visit www.cdc.gov or call 1-800-CDC-INFO, 24/7.