Stress Management for Emergency Responders - Introduction
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Hi. I'm Dr. Leslie Snider with the Antares Foundation. This is the third 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 a team leader or supervisor.
In this program, we will explore how you can help your team and yourself to manage stress and function at your best. We will explore the following topics:
• Unique stresses for emergency responders,
• What we mean by “stress management”,
• Strategies to assist your team at all phases of your mission, and
• What you need to know if critical incidents happen.
First, as a team leader, why should you care about "stress management”? After all, 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." Also, responders sometimes feel they don’t have the luxury of thinking of their own needs when there is so much suffering around them. But let's think for a moment about the realities of this work.
As a team leader, you have important responsibilities: to ensure a successful mission and the safety and well-being of those under your supervision. You should care about stress management because first of all, the stresses and dangers of emergency and humanitarian aid work are unique. Second, our programs are only as good as the people who deliver them. The well-being of your team is paramount to the success of your mission. Third, the well-being of your team means reducing their exposure to risk. Stress management is risk reduction, and will help you and your team to cope effectively with the demands of the job.
Let's look at the unique stresses of emergency and humanitarian aid work. These can include working in a potentially hazardous environment; heightened responsibility for vulnerable people; needing to make life and death decisions in the midst of chaos; exposure to atrocity and suffering; unpredictability; difficult living conditions; and separation from friends, family and usual supports.
Team dynamics can make or break a mission. Emergency response teams may be thrown together at a moment’s notice, with individuals who have never worked together before. Personality conflicts may erupt, as tensions in the field run high. Organizational factors are often cited as the most significant source of stress for responders, including inadequate information, communication systems, logistical support or equipment, unclear job descriptions or changing roles, and unclear lines of authority, causing conflicts between the field and headquarters.
We must also be aware of the potential for danger. The humanitarian sector is no longer protected space – responders find themselves providing aid in increasingly insecure settings. Since 1997, the number of major acts of violence committed against aid workers has nearly doubled. As respect for their work and life decreases, studies show that most aid workers are deliberately targeted for political and/or economic purposes, rather than randomly being exposed to violence.
Although you may believe the expression, "If you can’t stand the heat, get out of the kitchen," these unique stresses and dangers have serious consequences. Studies show that one-third or more of returned responders have clinically significant signs of emotional distress. For example, in one study of returned responders, 20 percent reported high levels of emotional exhaustion, 30 percent moderate to high levels of depression, and 46 percent significant symptoms of post-traumatic stress disorder.
How do we define stress? Stress is the response of the body and mind to a physical or emotional challenge, and occurs when the demands of the outside world or yourself are out of balance with the resources you feel you need to cope. Remember, stress is a part of life, and most certainly a part of this work; it’s normal for you and your team to feel its effects. No two people experience and respond to stress in the same way. Two of your team members encountering the same stress may have very different perceptions of it and reactions to it. And sources of stress vary in different emergency contexts, based on the nature of the emergency, your role, your team, and many other factors.
We will consider three types of stress:
• Day-to-day stress is 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, shock, can result if responders are exposed to extreme or "stress management"? In emergency and humanitarian aid work, this entails preventing or reducing the intensity, frequency, or duration of stressors you and your team may be exposed to; reducing vulnerability and increasing resilience; improving monitoring of stress and healthy coping; 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, it means making sure that you and your team are in the best possible condition for the demands of the job. That you are physically and emotionally fit for your mission.
Preventing, managing, and reducing stress is the responsibility of everyone involved. You, your team members, and the agency are inter-dependent. Everyone must do their part to ensure good stress management and operational practices.
The rule of thumb for you as team leader is first, take care of yourself and manage your own stress. Then, take care of your team, so that you can all be in good condition to take care of the people you are there to serve.
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. We will explore ways that you can be pro-active in managing your own stress and assisting your team, routine measures you can put in place, and how you can monitor and respond to high stress levels within yourself and your team.
Let's focus first on you. As a team leader, you set an example for others. Your ability to recognize and manage your stress is essential not only for your own health, but also in modeling healthy coping for your team. Taking out your stress in unhealthy ways will affect your team and the mission.
First, know yourself. What kinds of things are stressful for you? How do you feel and manifest stress? Are there any current stresses in your life, such as health, work, or family problems that may impact your reserves for coping on this deployment? How does stress affect your health, relationships, and work?
Stress can affect us physically, emotionally, mentally, spiritually, and interpersonally. Prepare a plan for self-care before your mission and the demands of the job take over. Putting in place a strategy now will help you to recognize stress and do something about it more quickly in the field. You may need to adapt some of the things you normally do to cope and stay healthy for the emergency environment.
How can you assist your team in good stress management practices at all phases of the mission? These strategies are based upon the eight key principles developed by the Antares Foundation. They are designed to ensure that you can support your team and be supported by your agency, with comprehensive and well-functioning systems.
We'll start with the pre-deployment phase. There are many things you, your team, and the agency can do to ensure you are well-prepared for your mission. Adequate preparation will get you all off to a strong start, reduce anxiety, and improve the way you work together. We will consider the following three points in the slides that follow - know your agency, know your team, and know your job and mission.
First, know your agency. Familiarize yourself with agency policies and procedures for field operations, safety and security, and stress management. Know what the agency expects from you and what support you can expect from the agency.
• Who do you report to?
• What is the chain of command?
• What are your responsibilities as team leader?
• What logistical and operational support will the agency provide?
Learn the safety and security protocols for your agency. These may include curfews, buddy systems, restricted movement at night or into dangerous areas, or even security escorts. Be sure you have adequate information, security updates, and equipment for team safety. Also, learn the criteria and procedures for evacuation of your staff, when necessary. In terms of stress management, your agency may have information and protocols for general stress management, as well as crisis support.
Learn the protocols or guidelines for adequate field living and working conditions, such as work hours, leave time, and basic comforts. What confidential, emotional support is available from the agency and how can you and your team members access it?
Next, as much as possible, know your team. Experienced responders and individuals new to the field may require different kinds of information to prepare and different levels of support on the ground. If possible, meet and introduce team members to each other prior to the mission, and welcome new team members in the field.
Some key qualities that you or your agency may have considered in selecting your field team are technical expertise, prior emergency experience, good teamwork, flexibility and maturity, professionalism, mastery of past stressful experiences, and the ability to cope under pressure. Likewise, the agency probably selected you for these qualities and others. Effective team leaders also have good management skills, attend to the safety well-being of the team, can foster team cohesion and engage team members in working together to solve problems. They promptly and fairly manage interpersonal conflicts among the team so that they don't adversely affect the mission. They are sensitive to culture and gender issues and model appropriate behavior and good self-care for the team. It also helps to have a good sense of humor.
Finally, know your job and mission. This involves preparation and training for you and your team members in stress management and operational issues prior to your assignment. Information is power and protects responders because they know what to anticipate in the field, have clear direction, and have given thought to how to respond to the stressors they encounter.
Pre-deployment training should ideally be provided for the pool of responders before a crisis occurs, so they are ready to deploy whenever they are called upon. In addition to general training in agency operations, safety, field conditions, and stress management, training in specific topics may be added for a particular mission.
Preparation also includes briefing you and your team for the mission, both in operational and personal terms. An operational briefing orients you and your team members to the context, such as the nature of the emergency; the security situation; climate; and the social, cultural and political setting. For example, what are norms for behavior and dress? Are there certain gender or cultural considerations? Will you need any special clothing or equipment?
An operational briefing also provides information about the mission, what the agency is trying to accomplish, and each team member’s role. Emergency situations evolve rapidly and tasks may change on the ground. Flexibility is important, but at the outset, everyone should have a basic understanding of their job.
Another type of briefing is a personal, or psychological, briefing. This prepares you and your team for potential stresses of the job, reviews good coping strategies learned in training, and provides information about available agency supports. It also provides the opportunity to reflect on your personal readiness for the mission. Ultimately, everyone must assess their ability to cope with the demands of a mission at this time in their life.
Let's move now to the "in the field" phase. As team leader, you play a critical role in monitoring stress among your team members as the mission progresses and helping them to cope in healthy ways. First and foremost, monitor your own stress and put in place your plan. Help yourself first so you can effectively help others.
We mentioned the various ways stress can manifest for responders. You may start to notice conflicts among team members, irritability, or a disregard for others’ feelings. Perhaps someone on the team is isolating from the others. Be alert to these signs of stress in your team and encourage team members to monitor their stress and its impacts on others.
Signs that stress may be getting out of hand include unhealthy or risky behaviors, such as:
• Poor eating habits, consuming lots of coffee or junk food, or skipping meals altogether;
• Poor sleeping habits, lack of exercise;
• Working 24/7, without rest or leave time;
• Putting themselves in danger or taking unnecessary risks. For example, reckless driving, ignoring safety protocols, or needlessly going into dangerous areas;
• Alcohol abuse, and illicit or prescription drug abuse is also a problem; as well as
• Risky sex.
Team leaders set the expectations for team behavior. Everyone will need to blow off steam. You don’t have to be a Puritan, but you do have to ensure team safety and well-being and responsible behavior toward beneficiaries. It is better to head off unhealthy or risky behaviors before serious problems or injuries result.
If team members need a break, consider organizing something for them - a party, dinner, or a group trip away from the site if possible. Bring DVD's for a movie night, music CDs, books, or playing cards to share. Small things can go a long way in boosting morale and showing you care, not only about getting the job done, but also about the welfare of your team.
How do you know when team members are "burning out"? The daily stresses of emergency work can pile up and cause burnout, if not kept within reasonable limits. 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 is also sometimes referred to as "compassion fatigue" - a loss of drive, sense of meaning and pleasure in our work and ability to help others compassionately.
Other pitfalls for relief workers include emotionally distancing from, or over-identifying with, survivors of the emergency. Burnout also affects team dynamics. Signs are 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 can cause a turnover in valuable staff and more work for you in orienting and training new recruits.
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. Maybe this sounds a bit like you. Although many of these attributes are useful for emergency work, they can lead to some of the dangerous pitfalls we discussed.
The message you send to your team members is important. Do we truly believe this statement made by a team leader in Goma, that "Aid workers shouldn’t have too great a heart. We need professionals." It is natural for responders to have feelings about the suffering around them. The point is to be aware of your health and reactions, so you can remain effective and work from a place of wellness.
Provide ongoing support in the field. Ask your team everyday how they're doing, if they're getting enough rest and taking time to eat. Take a minute to do this at daily staff meetings or briefings. Invite their input so you can stay aware of potential problems. Take time to encourage, acknowledge, and appreciate your team for their hard work. This sends a powerful message about their value to the team and the agency. Encourage everyone to be flexible and tolerant with each other. Encourage healthy habits, such as those listed here. Ensure team members take at least one day off a week. You may need to enforce R&R and leave time for your staff to refresh and renew. In the end, you will have a more effective team.
Be aware of particular stresses for the team, and address practical needs and concerns as quickly as you can. Encourage them to know their limits, and be available and accessible so that team members can come to you if they feel their stress is getting out of hand. Provide access to confidential, professional, emotional support as needed.
It is just as important for you to know your limits and ask for help when you need it. You take on particular responsibilities as a team leader and the job is challenging. Pay attention to your stress and take extra care so you can maximize your health and effectiveness.
We've talked about how you can help your team generally manage stress. As team leader, it's also important for you to know what to do if a critical incident occurs. 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 and 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 trauma" 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 can be immediate, delayed, or cumulative. For most, the effects of traumatic experiences fade over time, with care and patience. But for others the effects are major and can lead to problems down the road. Some responders may experience a reaction months or even years after the event.
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.
If one of your team members had a traumatic experience on a previous deployment or in their life, this may impact the severity of their reaction to a current incident. Although each person reacts differently, some common reactions are avoiding situations or reminders of the event; hyper-arousal – feeling "on alert" - jumpy and being easily startled; re-experiencing the event through dreams, recurring thoughts, or even flashbacks; feeling as if the event was happening again, even though the person is in a safe place.
Common thoughts and fears after a trauma include fear that the event will happen again, fear of going "crazy", wondering “Why did this happen to me?”, blaming oneself for what happened or for the injury of others, wishing they had done something differently, and survivor guilt.
Antares principle six states that the agency will provide staff with specific and culturally-appropriate support in the wake of critical or traumatic incidents and other unusual and unexpected sources of severe stress. As team leader, you will have to provide first-line support for affected team members. There are pro-active, routine, and responsive crisis measures you and your agency can implement.
First, pro-active measures. Know your agencies policies and procedures for team support and safety before a crisis actually occurs, so you can respond rapidly. Attend training in practical supportive measures, such as psychological first aid. As a routine measure, regularly review and update the critical incident field plan. Account for any changes in personnel or structures and train and update all field staff in crisis protocols. Ensure you and your field team have readily accessible contact information for logistical, safety, and emergency medical and psychological support.
Psychological first aid is practical care for impacted staff to ensure their safety, protection, basic material needs, comfort, and access to support. It is not high-level psychological care, so you can provide this in the field, whether or not you have any mental health training.
Steps you can take are:
First, rapidly implement crisis protocols, including informing senior management and arranging for backup or medical evacuation of staff. Safety of your staff is your paramount concern. Ensure impacted staff are safe and out of the immediate vicinity of the incident. Assess any critical injuries and urgent care needs, and evacuate as needed. In consultation with your agency, you may need to inform family or loved ones. Account for all of your team members. Depending on the circumstances, you may want to gather all staff in a central location.
Next, provide comfort – physical and emotional. Give impacted team members the chance to rest and recover. Provide food, water, and a quiet space to recoup. Identify and meet any urgent practical needs, such as normally used medications. If impacted staff are able to discuss the event, gather information. Help them to summarize events clearly and in sequence. Ask questions and clarify. Invite them to discuss any major concerns, but do not push them to talk if they do not want to. Simply listen and comfort. Give them an opportunity to connect with loved ones.
Remember that a critical incident will have an impact on all of your team members, not just those directly involved. It may be helpful to hold a group meeting to give team members a chance to express their concerns, to provide realistic reassurance, and to provide information about loved ones or colleagues, the security situation, and plans. Access to information can greatly help to reduce anxiety among your team.
Next, make arrangements for the next work period. For example, reduce workloads, or transfer responsibilities as necessary. Provide information about common reactions to trauma and coping strategies. Continue to monitor individual support needs over time, and arrange access to professional psychological support as needed or requested.
If you or a team member are exposed to a critical incident remember that 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.
Let's move now to the end phase of the mission. The end of assignment is an important time for you and your team to review the mission experience. We will discuss two types of debriefing – operational debriefing and a personal stress review.
First, the agency may provide a formal "operational debrief" upon return to headquarters to review the work you have done, provide an opportunity to give and receive feedback about the mission, and catalogue lessons learned.
You may want to offer a similar, but less formal, exit interview for your team members leaving the field. This is also a time when you can provide information to returning responders about common stresses of transitioning home and available agency supports. If an outgoing team member has had a particularly stressful deployment or experienced a critical incident, you may want to facilitate a referral for them for follow-up psychological support.
Some agencies may offer you the opportunity for a personal, confidential debrief with a mental health professional. Encourage your team members to make use of this opportunity, even if they had a positive experience on the mission. It is a chance to review successes and challenges for personal growth, and to plan for the return home to "regular life". It is also an opportunity to talk about any stressful experiences and access further support.
Coming home has its own stresses. The transition from the emergency world to regular life can be a bit of a shock. You and your team members 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. Prepare yourself and your team members for this and take time for recovery. Avoid deploying from one crisis to the next, another common pitfall for emergency workers. Encourage your team to process their experience privately or with others, identify and use the supports in their life, and re-establish healthy routines.
Coming home may also be stressful in terms of relationships. Life didn't stop during the deployment and loved ones may have had to cope alone with problems at home. Returning responders may find it hard to talk about their experience and feelings and friends and family may have difficulty understanding what they have gone through. Encourage team members to keep communication open and be patient in reconnecting.
The eighth Antares principle relates to support the agency may provide to responders and their loved ones after their mission. Emergency and humanitarian aid missions can be life-changing. Many agencies have specific information and professional support for you and your family to help in coming home and recovering from any traumatic events.
Encourage your team members to be open to the support your agency provides and be open yourself, as well. 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 you can do as a team leader to shield your team and help everyone to function at their best. You owe it yourself, your team and agency, and the people you serve. Good luck on your mission.
Additional programs in this series provide a more in-depth understanding of stress for emergency responders and practical stress management strategies for individual responders and the agency.
For further information and to download resources such as "Managing Stress in Humanitarian Aid Workers: Guidelines for Good Practice," see the Antares Foundation website - www.antaresfoundation.org.
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