 |
This Web site is a component of the SAMHSA Health Information Network. |
|
Training Manual
for Mental Health and Human Service Workers
in Major Disasters
SECTION 4
Stress Prevention and Management
Disaster mental health work is inevitably stressful at times. The long
hours, breadth of survivors' needs and demands, ambiguous roles, and exposure to human suffering can affect even the most experienced mental health professional. The first "key concept" of disaster mental health states, "No one who sees a disaster is untouched by it." This combination of witnessing the disaster's destruction, working in an often chaotic environment, and having only limited resources available results in potentially stressful conditions.
These conditions require that planners and administrators integrate a comprehensive stress prevention and management plan into their mental health recovery programs. Too often, staff stress is addressed as an afterthought. Programs focus their efforts on survivors' "normal" reactions to traumatic events, and do not address the very same psychological processes that occur in staff as well. While disaster mental health work is personally rewarding and challenging, it also has the potential for affecting workers in adverse ways.
Preventive stress management focuses on two critical contexts: the organization and the individual (Quick et al., 1997). A disaster mental health program's organizational plan may initially be unclear or inadequate due to the rapid mobilization to address survivor needs. However, it is important that a functional plan and structure be developed quickly. Each worker providing services will be affected uniquely depending on his or her professional experience, personal history, and vulnerabilities. A pro-active approach for workers that teaches and encourages personal stress reduction strategies is essential. Adopting a preventive perspective allows programs to anticipate stressors and shape crises rather than simply reacting to them after they occur.
Organizational Context
Having an organizational structure and plan that builds in stress prevention can mitigate potential stress overload for staff. While these efforts may be time-consuming on the front end, the long-term benefits of reduced employee turnover and avoidance of thorny personnel issues, as well as increased productivity and program cohesion are well worth the efforts. The following five dimensions reflect necessary areas to address when designing a strong program that prioritizes organizational health:
Effective management structure and leadership
Clear purposes and goals
Functionally defined roles
Team support
Plan for stress management
Individual Context
Psychologically healthy and well-balanced individuals are best equipped to implement and maintain an effective disaster mental health recovery program. Programs can build in supports and interventions to ensure that the majority of their staff will be functioning in the "healthy and balanced" range. As community needs change over time, so will workers' stress management intervention needs. Listed below are four skill building areas to address when designing the staff stress management component of a program:
Management of workload
Balanced lifestyle
Strategies for stress reduction
Self awareness
Stress Prevention and Management Methods
The following charts present suggestions for organizational and individual stress prevention for immediate and long-term response time frames. Suggestions for the immediate response phase may be applicable for the long-term response phase as well. Approaches for eliminating and minimizing stressors and stress reactions are included. Since each disaster and mental health response has different elements, program planners will need to tailor the following to their own locale, resources, and disaster.
Organizational Approaches for Stress Prevention and Management
Dimension
Immediate Response
Long-term Response
EFFECTIVE MANAGEMENT STRUCTURE & LEADERSHIP
- Clear chain of command and reporting relationships
- Available and accessible clinical supervisor
- Disaster orientation provided for all workers
- Shifts no longer than twelve hours with twelve hours off
- Briefings provided at beginning of shifts as workers exit and enter the operation
- Necessary supplies available (e.g., paper, forms, pens, educational materials)
- Communication tools available (e.g., cell phones, radios)
- Full-time disaster-trained supervisors and program director with demonstrated management and supervisory skills
- Clear and functional organizational structure
- Program direction and accomplishments reviewed and modified as needed
CLEAR PURPOSE & GOALS
- Clearly defined intervention goals and strategies appropriate to assignment setting (e.g., crisis intervention, debriefing)
- Community needs, focus and scope of program defined
- Periodic assessment of organizational health and service targets and strategies
- CMHS Program Guidance guidelines integrated into service priorities
- Staff trained and supervised to define limits, make referrals
- Feedback provided to staff on program accomplishments, numbers of contacts etc.
FUNCTIONALLY DEFINED ROLES
- Staff oriented and trained with written role descriptions for each assignment setting
- When setting is under the jurisdiction of another agency (e.g., Red Cross, FEMA), staff informed of their role, contact people, and expectations
- Job descriptions and expectations for all positions
- Participating disaster recovery agencies' roles understood and working relationships with key agency contacts maintained
TEAM SUPPORT
- Buddy system for support and monitoring stress reactions
- Positive atmosphere of support and tolerance with "good job" said often
- Team approach that avoids a program design with isolated workers from separate agencies
- Informal case consultation, problem solving and resource sharing
- Regular, effective meetings with productive agendas, personal sharing, and creative program development
- Clinical consultation and supervision
- In-service training appropriate to current recovery issues provided
Organizational Approaches for Stress Prevention and Management (Contin.)
Dimension
Immediate Response
Long-term Response
PLAN FOR STRESS MANAGEMENT
- Workers' functioning assessed regularly
- Workers rotated between low, mid, and high stress tasks
- Breaks and time away from assignment encouraged
- Education about signs and symptoms of worker stress and coping strategies
- Individual and group defusing and debriefing provided
- Exit plan for workers leaving the operation: debriefing, reentry information, opportunity to critique, and formal recognition for service
- Education about long-term stresses of disaster work and the importance of ongoing stress management
- Program checklist including organizational and individual approaches and implementation plan
- Plan for regular stress interventions at work and meetings (see next chart)
- Extensive program phase down plan: timelines, debriefing, critique, formal recognition, celebration, and assistance with job searches
Individual Approaches for Stress Prevention and Management
Dimension
Immediate Response
Long-term Response
MANAGEMENT OF WORKLOAD
- Task priority levels set with a realistic work plan
- Existing workload delegated so workers not attempting disaster response and usual job
- Planning, time management, and avoidance of work overload (e.g., "work smarter, not harder")
- Periodic review of program goals and activities to meet stated goals
- Periodic review to determine feasibility of program scope with human resources
available
BALANCED LIFESTYLE
- Physical exercise and muscle stretching when possible
- Nutritional eating, avoiding excessive junk food, caffeine, alcohol, or tobacco
- Adequate sleep and rest, especially on longer assignments
- Contact and connection maintained with primary social supports
- Family and social connections maintained away from program
- Exercise, recreational activities, hobbies, or spiritual pursuits maintained (or begun)
- Healthy nutritional habits pursued
- Overinvestment in work discouraged
Individual Approaches for Stress Prevention and Management (Contin.)
Dimension
Immediate Response
Long-term Response
STRESS REDUCTION STRATEGIES
- Reducing physical tension by taking deep breaths, calming self through meditation, walking mindfully
- Using time off for exercise, reading, listening to music, taking a bath, talking to family, getting a special meal to recharge batteries
- Talking about emotions and reactions with coworkers during appropriate times
- Cognitive strategies (e.g., constructive self talk, restructuring distortions)
- Relaxation techniques (e.g., yoga, meditation, guided imagery)
- Pacing self between low and high stress activities, and between providing services alone and with support
- Talking with coworkers, friends, family, pastor, or counselor about emotions and reactions
SELF-AWARENESS
- Early warning signs for stress reactions recognized and heeded (see following section)
- Acceptance that one may not be able to self-assess problematic stress reactions
- Over identification with survivors' grief and trauma may result in avoiding discussing painful material
- Vicarious traumatization or compassion fatigue may result from repeated empathic engagement (Figley, 1995; Pearlman, 1995)
- Exploration of motivations for helping (e.g., personal gratification, knowing when "helping" is not being helpful)
- Understanding differences between professional helping relationships and friendships
- Examination of personal prejudices and cultural stereotypes
- Recognition of discomfort with despair, hopelessness, and excessive anxiety that interfere with capacity to "be" with clients
- Recognition of over identification with survivors' frustration, anger, and hopelessness resulting in loss of perspective and role
- Recognition of when own disaster experience or losses interfere with effectiveness
- Involvement in opportunities for self exploration and addressing emotions evoked by disaster work
Signs and Symptoms of Worker Stress
Thus far, the focus of this section has been to describe methods for preventing and mitigating staff distress in a disaster mental health recovery program. The signs and symptoms of worker stress are also important to discuss, as early recognition and intervention are optimal. Educating supervisors and staff about signs of stress enables them to be on the lookout and to take appropriate steps. When programs emphasize stress recognition and reduction, norms are established that validate early intervention rather than reinforcing the more common (even though we know better) "worker distress is a sign of weakness" perspective.
Common Disaster Worker Stress Reactions
Psychological and Emotional
- Feeling heroic, invulnerable, euphoric
- Denial
- Anxiety and fear
- Worry about safety of self and others
- Anger
- Irritability
- Restlessness
- Sadness, grief, depression, moodiness
- Distressing dreams
- Guilt or "survivor guilt"
- Feeling overwhelmed, hopeless
- Feeling isolated, lost, or abandoned
- Apathy
- Identification with survivors
Cognitive
- Memory problems
- Disorientation
- Confusion
- Slowness of thinking and comprehension
- Difficulty calculating, setting priorities, making decisions
- Poor concentration
- Limited attention span
- Loss of objectivity
- Unable to stop thinking about the disaster
- Blaming
Behavioral
- Change in activity
- Decreased efficiency and effectiveness
- Difficulty communicating
- Increased sense of humor
- Outbursts of anger, frequent arguments
- Inability to rest or "letdown"
- Change in eating habits
- Change in sleeping patterns
- Change in patterns of intimacy, sexuality
- Change in job performance
- Periods of crying
- Increased use of alcohol, tobacco, or drugs
- Social withdrawal, silence
- Vigilance about safety or environment
- Avoidance of activities or places that trigger memories
- Proneness to accidents
Physical
- Increased heartbeat, respiration
- Increased blood pressure
- Upset stomach, nausea, diarrhea
- Change in appetite, weight loss or gain
- Sweating or chills
- Tremors (hands, lips)
- Muscle twitching
- "Muffled" hearing
- Tunnel vision
- Feeling uncoordinated
- Headaches
- Soreness in muscles
- Lower back pain
- Feeling a "lump in the throat"
- Exaggerated startle reaction
- Fatigue
- Menstrual cycle changes
- Change in sexual desire
- Decreased resistance to infection
- Flare-up of allergies and arthritis
- Hair loss
(CMHS, 1994)
As with disaster survivors, assessment hinges on the question of "How much 'normal stress reaction' is too much?" Many reactions listed are commonly experienced by disaster workers with limited job effects. However, when a number are experienced simultaneously and intensely, functioning is likely to be impaired. Under these circumstances, the worker should take a break from the disaster assignment for a few hours at first, and then longer if necessary. If normal functioning does not return, then the person needs to discontinue the assignment.
Clinical supervisory support is essential when a disaster worker's personal coping strategies are wearing thin. Counseling support involves exploring the meaning for the worker of the disaster stimuli, prior related experiences and vulnerabilities, and personal coping strategies. Suggestions can be made for stress reduction activities. Usually, stress symptoms will gradually subside when the worker is no longer in the disaster relief environment. However, if this does not occur, then professional mental health assistance is indicated.
Rewards and Joys of Disaster Work
Most staff find helping survivors and their communities following a major disaster to be enormously rewarding. Disaster mental health workers witness both gut wrenching grief and sorrow and the power of the human spirit to survive and carry on. To assist people as they struggle to put their lives back together is fundamentally meaningful. At the close of the long-term mental health recovery programs, staff often describe their participation as the most challenging and personally satisfying of their careers.
References and Recommended Reading
Figley, C. R. (Ed.). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in those that Treat the Traumatized. New York: Brunner/Mazel, 1995.
Mitchell, J. T. & Bray, G. P. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.
Center for Mental Health Services. Field Manual for Mental Health and Human Service Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 90-537. (Rev. ed. in press.)
Center for Mental Health Services. Support and stress management for disaster mental health staff. In: Disaster Response and Recovery: A Handbook for Mental Health Professionals. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 94-3010, 1994.
National Institute of Mental Health. Disaster Work and Mental Health: Prevention and Control of Stress Among Workers. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 87-1422, 1985.
National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers. Washington, D.C.: U.S. Department of Health and Human Services; DHHS Publication No. (ADM) 90-1497, 1987.
Pearlman, L. A. Self care for trauma therapists: Ameliorating vicarious traumatization. In: Stamm, B. H. (Ed.). Secondary Traumatic Stress: Self Care Issues for Clinicians, Researchers, and Educators. Maryland: Sidran, 1995.
Quick, J. C., Quick, J. D., Nelson, D. L., & Hurrell, J. J. Preventive Stress Management in Organizations. Washington, D.C.: American Psychological Association, 1997.
Stamm, B. H. (Ed.). Secondary Traumatic Stress: Self Care Issues for Clinicians, Researchers, and Educators. Maryland: Sidran, 1995.
BACK || TOC ||
NEXT
|
|
