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ASPR TRACIE: Module 3C - Preparing for the Worst, Responding at Your Best, and Continuing On

Alternative Text for Time-Based Media

The following is a text alternative description for Preparing for the Worst, Responding at Your Best, and Continuing On video.

[The video begins with the HHS logo appearing with the caption 'ASPR Saving lives, Protecting Americans']


Narrator:  Welcome to “Preparing for the Worst, Responding at Your Best, and Continuing On.” This webinar is part of a series of modules sponsored by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, ASPR’s Technical Resources, Assistance Center, and Information Exchange, or TRACIE.

ASPR TRACIE works closely with healthcare facilities, coalitions, ASPR Recovery staff, and HPP partners across the country and has repeatedly heard from disaster affected communities that disaster behavioral health recovery has been challenging for the healthcare providers involved in recent natural disasters and no-notice events.

Each of the modules we’ve developed includes a micro-learning module and a longer webinar.

The three topics are:

  1. Addressing Compassion Fatigue and Behavioral Health Needs for Healthcare Providers
  2. Organizational Behavioral Health and Wellness for Executive Level Healthcare Facility Staff, and
  3. Healthcare Provider Cognitive Strengthening Preparedness Program



Descriptive Text:       
ASPR TRACIE was developed as a healthcare emergency preparedness information gateway to address the need for the following:

  • Enhanced technical assistance
  • A comprehensive, one-stop, national knowledge center for healthcare system preparedness
  • Multiple ways to efficiently share and receive information between various entities, including peer-to-peer
  • A way to leverage and better integrate support (serving as a force multiplier)

Narrator: ASPR TRACIE launched on September 30th, 2015. The development and functionality of ASPR TRACIE are collaborative, involving multiple HHS Operating Divisions and other federal government departments and agencies; local, state, and regional government agencies; national associations; nonprofit organizations; and private sector partners.

TRACIE is comprised of three domains: Technical Resources, which houses our Resource Library and subject matter expert-reviewed Topic Collections, the Assistance Center, where users can receive personalized support and responses to requests for information and technical assistance, and the Information Exchange, an area for password-protected discussion among vetted users in near real-time.

ASPR TRACIE has also developed several resources specific to disaster behavioral health; these are housed in our Select Disaster Behavioral Health Resources page.

Now, I’ll turn it over to Dr. April Naturale, who developed and will lead all of these modules.


April: Hi and thank you for joining us today. My name is Dr. April Naturale and I am a traumatic stress specialist who provides disaster and emergency preparedness and response consultation to responders and community members.

Today, I’ll be discussing how you can prepare for the worst, respond at your best, and continue on after a disaster or traumatic incident.

After the webinar, you will be able to identify the three types of automatic reactions to high stress and life threatening events; identify at least two skills needed to prepare for working in a mass casualty or infectious disease response; and describe three actions you can engage in to reduce response stress like an adrenaline rush and to return to normal functioning.

The first part of this webinar will focus on incidents of mass violence.


April: We know that emergency medical staff and other behavioral healthcare practitioners are first responders who are called upon to save lives and provide crisis intervention in the aftermath of mass violence incidents. These include shootings, bombings, and other crimes with multiple injuries and fatalities.


April: The Congressional Research Service defines mass shooting as ‘’Incidents where more than four people are killed with a firearm during one event,” and “in one or more locations in close proximity.” While the definitions and case counts vary slightly, these incidents have been and continue to be on the rise in the U.S.

What is as important is that the weapons and ammunition being used in these incidents can inflict higher numbers and more serious injuries.  This was very clear in the Las Vegas Route 91 Harvest Festival Shooting in October of 2017, the Department of Justice recorded approximately 600 injuries in addition to the 58 deaths.


April: The need to attend to a high number of victims at one time by a wide variety of medical and behavioral healthcare responders, practitioners, and other staff from the closest treatment facilities creates tremendous pressure and a sense of responsibility for the lives of the victims. We often forget just how many people contribute to a successful response, from dispatch to discharge.

Descriptive Text: Responders to Mass Violence Incidents include:

  • Dispatch
  • Law Enforcement
  • Fire/EMS
  • Emergency department staff
  • OR, Critical care, and other hospital staff
    • Radiology
    • Emergency Management
    • Environmental services
    • Pharmacies
    • Blood Banks
    • Housekeeping
    • Surgery
    • Anesthesia
    • Security
    • Admin.



April: Consider this, when a 19 year old former student from Parkland opened fire with an AR 15 style rifle, the only armed person at the scene - a 56 year old school resource officer - did absolutely nothing to mitigate the carnage, that’s what prosecutors reported. There was no time to save the 11 people murdered on the ground floor, but authorities say that killings on the third floor were preventable. Instead, the resource officer retreated from the gunfire and hid for 48 minutes. Another officer, who hid behind his car when he arrived on the scene, was fired from his job, but not charged with any crime. One of the victim’s mothers said that her son would be alive today if the resource officer had taken action. She called him a coward.

We don’t know whether the resource officer felt unprepared to take action against the school shooter or if his freeze instinct kicked in and he was unable to move himself out of it.  Maybe he did not know what stopped him either. But the reference to being a coward may not be accurate. It may have been an inability to move out of the limbic or instinctual brain’s fear response and into the thinking brain that would have allowed him to determine a course of action. 

This webinar will address ways to help yourself move out of an instinctual response and into the thinking brain again, so you can act as you need to in order to do your job well. 

Let’s look at these instinctual responses so we can understand what happens, know what to expect and learn how to change our reactions when the initial responses are not helpful.


April: In the previous webinars in this series, we have talked about how in a life threatening or severely stressful situation, the doing part of the brain takes over from the thinking part. That is, instinct, and specifically your instinct to live, to survive, kicks in. Human beings, like any animal, are able to do just about anything to protect themselves or those they love. Maybe you’ve heard of the acute stress response syndrome, that is the fight, flee, or freeze responses that humans experience when faced with a serious threat to themselves or those they love. 
Each of us responds in one of these ways. The problem is, we don’t know how we will respond and our responses can change each time we’re faced with the threat or fear of traumatic stress.  As a result, we have to prepare for each of these responses because as emergency medical and behavioral healthcare staff, none of these instinctual responses, fighting, running, or freezing, is likely to be the entirety of the response that we need in order to effectively do our jobs.


April: It is important to remember that there are some good aspects to the stress response. This is seen in the fight response, the most common being that most people will automatically put up their hands to defend themselves or push or punch someone back if they’re physically being attacking.  This is self defense and usually a good thing in terms of protecting oneself.

Fighting is not an uncommon response in victims who are in shock or fear and pain. They often don’t know what’s happening and may be going in and out of consciousness, thus awakening during treatment, potentially creating surprise and a fight response to medical caregivers, something very important for treatment providers to be aware of and prepared for in working in emergency and trauma response situations. If you see patients or clients arguing and getting into verbal altercations with you or your coworkers, it’s likely a fear response and the person needs emotional support.

It’s possible that emergency care staff will be very tense from a terribly busy shift, holding themselves tightly, clenching their jaw, and maybe even pushing back on patients or clients who hit and being more aggressive in restraining or intervening activities than is necessary. It’s just as important to recognize this stress in yourselves and your coworkers as health and behavioral health providers, so that you can actually respond in a way that calms patients and clients, and so that you can support each other.


April: Fleeing, or running out of the way of danger is a good thing when the circumstances occur, like a car coming at you, or a fire breaking out or a shooter in your environment. Running to safety is self protective.

First responders actually practice running into danger in their drills. For example, firefighters learn to suppress their instinct to run away, and instead are taught when and where they can try and make their way into a burning area to rescue people or to bring the necessary equipment to extinguish the fire.

Some staff who are unprepared for a situation where they may need to respond to a life threatening or emergency event may leave the scene as part of a flee response, not even having a destination, but finding themselves wandering. Others may try to find a valid excuse to flee, convincing themselves they’re needed elsewhere or they have to go to get supplies, unaware that they are actually fleeing.  They might remain in denial about the need to return and become distracted with other activity, or they might suddenly become aware that they are unable to reenter the emergency environment, actually moving from fleeing into a freeze response.


April: In the freeze response, the brain has decided correctly or not, that staying exactly where you are and not moving at all if possible, is the safest thing to do to stay alive.  Many people describe holding their breath or feeling frozen or stiff. Some people experience this when in the presence of law enforcement or other armed forces, they’re afraid to move. The freeze response has kicked in.

And again, even if there is no real threat, our own thoughts can create the perception of threat and thus initiate the freeze response.

Overall, there is no empirical evidence that can tell us who will experience a freeze, fight, or flight response other than that freezing is more associated with a sense of panic and anxiety to an event.
It’s important to know that this is a possible response, and next I’ll share some ways that you as an emergency medical or behavioral health provider might prepare for and decrease a freeze or other unhelpful instinctual response and move you into thinking in a way that allows you to do your job. 


April: The next thing we are going to cover is the three phases of responding to traumatic stress and identify what skills we need to learn by phase to be able to respond most effectively.

  • Phase 1 is the Pre-Event or Learning Phase. Here we look at how to increase our self awareness and proactive skills. We ask the question, “What do I need to know in order to learn how to better respond? What skills will help me?”
  • Phase 2 is the Action Phase. This is the time when you need to move, to think and react, to take action that will help others.  This involves recognizing which of the three reactions that we already discussed, fight, flee, or freeze, you are experiencing and then implementing the skills you’ve learned to maximize your helpful response. Here you need to identify and acknowledge your immediate, unconscious reactions.  Then learn to shift the reaction to the  most useful responses needed to functioning. This is done by shifting your thinking.
  • In Phase 3, the emergency is over and the work is done. Your body’s still reeling, so you need to determine what you need to do to come down from the adrenaline rush, the overload of stress hormones that your body no longer needs at that time and get back to feeling and acting normally. 

I’ll discuss the first two phases, and then take us through two scenarios next so you can see how they apply. Then, I’ll share how to manage Phase 3.


April: As we’ve stated in the early webinars that make up this series, checking in with yourself on a regular basis is extremely helpful. Remind yourself that you have to do the training you need to care for a surge of patients and clients. There are safety systems in place designed to protect you and your patients and clients. And you have a team of skilled colleagues working with you. Practicing the use of the tools and techniques highlighted in the earlier webinars in this series, you can be more mentally prepared to work in a high-stress environment like a mass casualty incident or public health emergency. We’ll talk about this more next.


April: Phase 1 is the Pre-Event or Learning Phase. Here we look at how to increase our self awareness and proactive skills to enable us to respond as well as possible in an emergency or a disaster. We try to figure out what we as individuals need to know in general and specifically about ourselves to maximize our useful responses.  Here we determine what skills can help.

First, I’ll talk about variables that can influence your reaction to a situation. Then I’ll show you two pre-event training techniques: grounding and a breathing exercise. Grounding can help bring someone’s thinking back into the immediate environment and get them to focus on the here and now. Breathing can also help to get the thinking brain working again, and we will look at a simple breathing technique that is quick to learn and easy to remember.


April: So let’s look at what we need to know as part of our pre-event learning.

There are three types of influential variables that can affect your stress response. The first is situational.

In large scale incidents and public health emergencies with a significant number of deaths, exposure to gruesome injuries or illness may evoke a range of feelings in healthcare and emergency response staff. Burns over a large percentage of the body, bullets ripping through large areas of soft tissue, dismemberment, extreme loss of bodily fluids, blood, bodies exposed to water and extreme temperatures can make you feel vulnerable, worried for your loved ones, powerless, and even ineffective and overwhelmed by the work.

Of course, knowing the number and type of patients or clients, and the severity of illness or injuries as soon as possible will help the response. Why? Because there are things you can do to prepare when you have an idea of the numbers and types of injuries, such as locating additional beds and equipment, and identifying the types of medical specialists and extra numbers of staff who will need to be called in. You can also prepare yourself and your staff for large numbers of pediatric patients, or patients that are well known to providers, such as first responders or even coworkers. Treating these types of patients and clients is often mentioned as one of the more challenging situations by all types of responders.  Being prepared as much as possible is vital to controlling stress responses.

When you ask the right questions and start getting answers, your thinking brain starts working and you focus on the priority activities.  If you get information that you will have six severely injured patients and you know you have at least five available emergency room beds and three on call staff, it’s likely you will be less afraid that you cannot handle the situation and you will respond more calmly, allowing for good judgment and therefore good decision making.

Know that this is some of the most important information to have and to share with the staff who are responding so that all can function at their best.


April: Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experiences including the harmful aftermath of exposure to such events. Events are considered morally injurious if they transgress deeply held moral beliefs and expectations. Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations usually rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about concerns such as equity and fairness, the value of life, and religious traditions or cultural morals.

These can occur in mass casualty incidents and public health emergencies potentially creating extremely challenging working conditions and equally challenging, awful painful decision making processes.

Examples of moral injuries may involve:

  • Contradictory priorities that cause harm to one patient over another.
  • Unintentional errors.
  • Acts that you or one of your peers or leaders commit that is perceived as egregious.
  • And as we mentioned earlier, difficult decisions, especially those that have no clear determination factors.

For example, how do you handle giving one child a vent making that equipment unavailable to another who is also in need and explaining why you’re choosing to do so to the parents?
Or when triaging mass violence patients, how do you know when to administer pain meds to someone you think is dying, although in a normal situation, you’d take more measures to save them? Versus knowing when to treat someone whose chance at survival is minimal, when you are working in a very chaotic non-traditional environment.


April: Moral injuries can result in staff feeling:

  • Shame, which is described as a feeling of being unworthy,
  • and additionally feeling guilt, which is feeling a sense of responsibility or remorse for some behavior.

Shame and guilt are generally combined and some form of the most common responses to traumatic stress in health and behavioral healthcare providers who work in emergency and disaster environments.

Moral injury can also cause isolation, as workers feel they are alone in their transgressions and that no one will understand them or their behaviors. This can lead to long lasting emotional distress, that is, chronic problems that build and can often lead to additional concerns like substance misuse and relationship problems and when combined with depression and hopelessness, create a risk for suicidal behavior.

It’s important to note too, that it’s not unusual for moral injury to come at a much later timeframe after an incident has occurred, causing delayed emotional distress that the healthcare staff then have a difficult time connecting to a particular event. This can impair their ability to understand and then determine how to resolve their feelings.


Descriptive Text for Slide 18:       
Additional influential personal variables include additional common fear responses and a lack of personal trauma treatment.

April: The second type of variables that can influence our stress responses is personal.
We talked about the fight, flee and freeze responses, but there are many more specific signs of emotional distress that we might experience while functioning. We may not fight or flee or freeze at all, and in fact, we may begin doing our job immediately and well.

But we don’t feel well inside, thus we struggle through the work with all kinds of symptoms like nausea, headache, shaking, which is usually just adrenaline trying to move itself out of the body, rapid heartbeat, sweating, teariness or crying, feeling angry, exhaustion - having nothing to do with lack of sleep, forgetfulness or mild confusion, all are examples.  Knowing that these are pretty common reactions to exposure to the victims of trauma can help reduce concerns that you might be developing a mental illness or that there is something else seriously wrong with you. This type of fear and stigma around having a mental illness is as strong in the health and behavioral healthcare professions as it is in the general population.

And as you probably already know, if you have experienced trauma in your own life previous to exposure to the current event, you may re-experience some of the same symptoms that you had at the time of that event.  This may be especially true if you’ve never addressed your emotional response to these prior traumatic events. Current naturally occurring life events such as the recent death of a loved one, a divorce, changing careers or a significant decrease in your socioeconomic status can also negatively influence your responses.


April: The research is very clear that professional variables, including emergency and disaster responses drills, tabletop and field exercises, and engaging with partners in community wide drills are highly effective in helping us prepare emotionally for what to expect and how to keep functioning well as responders. 

Staff with the least amount of knowledge and skills tend to be at higher risk for having negative emotional responses during an emergency that can inhibit their helpful actions. Thus, those who are less educated and staff who lack emergency training should always be paired and monitored by senior and supervisory staff. 

Those with field experience - having worked in a community-wide emergency - tend to perform better with less negative emotional reactions than those who have only theoretical knowledge or no experience with an actual event, which just makes sense. Again, in circumstances where staff have no field experience, joining with those who have worked in the field can increase the effective functioning of those teams.


April: Now you how situational, personal, and professional variables can influence our reactions, I’m going to show you two short exercises that you can learn to use now and in emergency situations to help keep you present and as calm as possible.

Grounding is one that can help you to stabilize yourself and focus on the immediate environment, your own reactions and senses, and your body movement. Learning this before a disaster or other high stress situations can help you respond more effectively. 


April: This grounding exercise calls for you to take several slow breaths. Start with that. Breathing in and breathing out. Breathing in and breathing out.

Next, identify and name three non-distressing things you see in the immediate space where you are, simple things like a chair or a car.

Breathe again slowly, in and out. Then name three non-distressing sounds you can hear, again focus on your immediate environment. If you are inside, maybe it’s the sound of a clock or the hum of an air conditioner. If you’re outside, try to listen for sounds of nature like the rustle of trees or birds singing.

Breathe again slowly, in and out, and now name three non-distressing things that you can feel. Is it the ground under your feet or the chair against your thighs? Maybe even stamp your feet to the floor or open and close your hands around the arm of the chair to connect or ground you to your physical environment.

Breathe in and notice that you are more grounded and present in your environment. Say to yourself, I am right here in this space. I am grounded.


April: Breathing techniques can also help to reduce negative stress and fear responses and get the thinking brain working again. I like to teach box breathing or the 4x4x4x4 model, it’s the same thing, because, in addition to working really well, it’s also really easy to remember.

Breathe in to the count of four. Hold that breath to the count of four. Release the breath to the count of four. And then count to four before beginning again. It creates a box, the box breathing model. Repeat the box breathing three to five times at a clip, or more if you need it,  
and do it as often throughout the day as you feel you need to.  Remember, the box breathing method.

The truth is it doesn’t matter what model you use, learn a model for breathing and use it. Do so on a regular basis.


April: We’ve covered pre-learning in Phase 1. Phase 2 is the Action Phase. This is the time when you need to move, to think and react, to take action that will help others.  This involves recognizing which of the three instinctual reactions you are experiencing and then implementing the skills you have learned to maximize your helpful response. Here you need to identify and acknowledge your immediate, unconscious reactions.  And then learn how to shift the reaction to the most useful responses needed to function.

The first step in moving out of the reaction or instinctive state, the fight, flight or freeze reactions, is to recognize it. Are you standing still and having a hard time moving your feet?  Did you already run or are you looking for someplace to move to, trying to get away from the environment? Are you holding yourself tightly, clenching your fists, yelling at other staff or feeling angry?

After recognizing your reactions, conduct some grounding exercises to help decrease the reaction. Look at the wall and name what you see. Do you see a clock, a picture, a window? State what you see to yourself.  Then name three things you can hear, state them to yourself.
Open and close your mouth to make sure your jaw is not tight. Open and close your hands to make sure your fists are not clenched. 

Instruct yourself to breathe, this will get the thinking brain working at thinking again. After a few deep breaths, then begin to move in the direction you need to go. Begin to follow the protocols and procedures that you have learned to ready yourself for incoming patients, clients and their family members. Remember too, to speak to colleagues near you, check-in and see if they’re ok.

Next, we’ll take you through two scenarios so we can apply what we’ve learned so far.


April: You work in a hospital and your shift is coming to an end. It’s been a busy but fairly quiet night, and you’re looking forward to going home and getting some rest. You finish working with your last patient, when one of your colleagues approaches you and says they overheard chatter on the radio about a potential mass casualty incident.

Then the call comes in, someone opened fire at the music festival in town. Your hospital is the closest to the event, and within 15 minutes, patients in their late teens and early 20s start showing up. They’re being dropped off by friends, Uber drivers, and police, only a few have been triaged by EMS.
The extent of the wounds is shocking. Blood is everywhere, making triage a challenge. It’s hard to determine who’s injured, who’s more seriously hurt than another versus who’s accompanied a patient and is highly emotionally distressed, but not physically injured.

You see a young woman brought in with a gunshot wound, she was shot in the chest and has a large exit wound.  But you’re being called to take care of several cases with a similar description simultaneously, suddenly there are several patients who are seriously injured and many others are covered in blood.

You begin to feel your heart rate increase and a panicked feeling starts to grip your throat, stopping you from being able to speak. You realize your coworker is speaking to you, but her voice sounds muffled. What’s happening to you?  


April: In preparing for mass violence incidents, it’s of critical importance that you understand your potential reactions to the emergency. Rapid heartbeat, sweating, shallow, rapid breathing, and diminished senses may all be fear responses that can be managed by controlling your thinking. 
The first step in doing this is to identify the first thought you had in the scenario when patients began arriving, bloodied and with serious injuries. Was it “Oh, no, we’re not prepared for this.” Or “We don’t have enough staff to handle this.” Or “I can’t handle this.” Once you identify the thoughts that are distressing you, acknowledge just that. “These thoughts are causing me to feel worse. I need to get a handle on this and control my thinking and my responses.”

As part of your preparedness, think about what messaging you need to tell yourself to get your emotional reactions to settle back to normal.  If you are someone who feels out of control, do you need to tell yourself, “I can take control of this. I know what to do and I am well prepared to do what’s needed.”  I’m using suggested messaging, but you need to take the time to think about what messaging you would create for yourself that will counter the negative thoughts  that you may have in response to an event.  Remember too, always take the time to focus on your breathing and make sure you’re taking in deep breaths and then as importantly, exhaling fully. This will control and slow your rapid heart rate and allow a better oxygen flow through the brain, that will allow you to begin thinking more clearly. This is why we encourage you to practice this before an emergency occurs.

Then determine what you need to know to continue your job. Are you assessing patients and need the status report from the EMS staff? Do you need to hold staff over until the next shift arrives? Identify each of your next action steps. Write them down if your list is more than three things and keep tracking them as needed. 


April: Let’s switch gears and think about a different type of situation. You have been called, in your position as a public health officer trained as a nurse, to help treat a number of pediatric and adult patients reporting feeling ill, all with similar symptoms at a local hospital in your region. There has been talk in the international healthcare community of a new strain of flu circulating, one that has a high fatality rate, that is accompanied by high fever, severe vomiting and diarrhea, and for which there is no known vaccine.

You are well aware of the transmission risks and the need to wear protective equipment as you expect to be engaging directly with the identified patients.


April: Fear and anxiety are the most commonly reported reactions to working with a patient who is suspected of or who is actually diagnosed with a highly infectious disease. This increases when the disease is relatively unknown.

Healthcare providers who have been in this situation note an initial fear of acquiring the illness and dying, basically the worst case scenario.

These reactions can cause a fear response with the type of symptoms that make the work even more difficult. For example, fear will increase your heart rate, which causes rapid breathing, which will heat up your mask and respirator and make you feel hot and sweaty and uncomfortable. Fogging up the mask makes it difficult to see, which makes you feel more fearful and you may experience claustrophobia, it becomes a circle.  Additionally, some staff complain about shaking, which is often caused by an increase in adrenaline as a part of the fear response. This too, can make the work more difficult and can make staff members feel less competent, less able do their job properly.

Anxiety can cause you to have obsessive thoughts about getting infected, ripping your suit, or making a medical mistake because you cannot rely on feeling your fingers well, these are just examples. Obsessive thinking can cause us to question our decisions and overall, we can feel less competent. This affects our judgment and again, our confidence in our decision making. Another circular problem. 


April: Since we now know that being prepared helps us to mitigate fear and anxiety responses, let’s go back to our preparedness list and add the specifics for an infectious disease scenario.  

First, have you been fitted for your personal protective equipment?  If not, that is something you should schedule as soon as possible.  Some professionals put off their fittings numerous times thinking it’s not an urgent issue, but it is important to get fitted in a non-emergency time period.  So, do it. Get a sense of what it feels like to have to work continuously in a mask and respirator, gloves and a gown. An apron may also be needed if the patient is actively emitting bodily fluids.  Working like this is awkward at its best.

Healthcare professionals who have to work in protective equipment report feeling that the equipment is restrictive, hot and uncomfortable and these sensations alone can cause you to feel less competent.

Additionally, many staff indicate that their anxiety increases, often with worry about any broken skin areas that they have and fear that the equipment will fail in some way, be ripped during treatment or penetrated by bodily fluids.

Anxiety can increase your heart rate and then your breathing, making it become even more rapid, and creating more heat and more discomfort.

One of the most important things for you to be able to do is to control your thoughts, which in turn will control your fear and your anxiety responses.  Identify what thoughts you’re having. Is it, “I’m not going to be able to do this” or “I’m going to get sick and die.”  Identify your fearful thoughts and then develop another message to directly counter those thoughts. For example, in response to I’m not going to be able to do this, try:

  • I am well prepared to do this work. I know how to do this.
  • I know I have the skills to do this. I just need to focus on that.
  • I’m competent. I know I can do this.

And to control your fear try messaging like:

  • I can control my breathing. Use the box breathing model, in for the count of four, hold it for four, release to the count of four, and wait to the count of four. I will slow my breathing and calm myself.
  • I know what I need to do and I will just do the best I can.  I have all my equipment on and it will protect me.

Also, I can only control what I’m doing right here and now.

  • I’m following the rules and it will be ok.
  • I have done what I need to protect myself. Now I just need to do my job.

Repeat this messaging over and over as long as you need to and go back to it if your symptoms arise again.

If you are highly distressed, ground yourself. Name three things you can see, three things you can hear. Name your coworkers in the room with you.  Feel the ground beneath your feet. Open and close your hands. Open and close your eyes.  Repeat these things as you need to.
These are some examples of ways to calm yourself. In preparation for the work, consider using your own words, your own messaging that you can call on when you need to. Write the messaging down on an index card, keep it in your desk, near your computer, in your wallet or your purse. Look at it on occasion to keep the messaging fresh in your mind and pull it out before working in an emergency, a disaster or other stressful situations.


April: So, congratulations, you made it through Phase 2. Phase 3 is about what happens after the emergency is over and the work is done. Your body is still reeling, and there are things you need to do to come down from the adrenaline rush and get back to normal. 

Knowing what to expect, becoming informed as you are doing this through this webinar, can decrease anxiety significantly, especially for educated health and behavioral healthcare professionals who function well on a cognitive level.  This is referred to as psychoeducation, knowing what kinds of reactions you may experience and recognizing that most of them are common and expected, will dissipate on their own with good coping and good social support.

Operational debriefings can also help you return to normal. Meeting with others to discuss how the operations were carried out, what went well, what could be improved, and what lessons were learned can allow staff to put the incident aside and not obsess about it.

While the field used to conduct emotional debriefings, we have shifted the model to informational and resilience focused meetings. These include a review of what to expect in terms of common stress reactions, compassion fatigue and secondary traumatic stress, and teaching effective coping and resilience building. Behavioral health staff can also offer individual crisis support meetings for some of the most highly exposed staff who express wanting it. And all staff should have additional options of accessing their employee assistance program or accepting referrals to traumatic stress specialists if they wish, regardless of whether or not they have symptoms that bother them.

Being with and talking to others who are peers, who’ve had similar experiences, who understand and accept how you feel is one of the most helpful ways to decompress and destress from emergencies and traumatic events. You don’t even need to be talking about the event, but rather being present with each other, supporting whatever mood you’re in, sharing a meal, walking, working out, and basically making sure that you are not isolated.

And the research is also very clear that body movement is effective in moving toxic stress hormones out of your system. It doesn’t have to be heavy duty exercise, in fact, lifting heavy weights should be avoided in the early days while there is still a lot of adrenaline in your system. But walking, stretching, and simply deep breathing numerous times over several times each day is very effective.
And of course, adequate rest, healthy nutrition and relaxing leisure exercises should be built in to every day after an emergency or traumatic event response: read a book, watch a good movie, and get sufficient sleep.

Practice the cognitive messaging skills that we learned earlier and do them at any time when distress symptoms emerge, seek out short term professional treatment if any distress symptoms bother you.


April: If you have followed along with and participated in all of these webinars, you know there’s a range of common stress reactions to emergencies and traumatic experiences. Many health and behavioral healthcare staff report sleep problems and fatigue, or having problems regulating emotions. Some may engage in risky behavior, and others may experience headaches or gastrointestinal issues.

It’s important to remember that emergency and disaster health and behavioral healthcare providers, even the same provider types from the same kinds of settings, who are exposed to the exact same situations can have very different perceptions about and reactions to these traumatic events. Different staff members may focus on very different things, often with very different results. 

In some cases, depending on the type of negative mental health effects, some providers can experience compassion fatigue, secondary traumatic stress, vicarious traumatization, burnout, or even more seriously posttraumatic stress disorder.

In Module 1 of this series, you can learn more about the terms I just listed, including definitions and symptoms. In Module 3, we give you tools for recognizing your cues and managing your negative reactions to stress. Take advantage of these resources that ASPR TRACIE offers, especially for those in the health and behavioral healthcare settings.


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April: There are many resources that can inform you further about acute stress, posttraumatic stress, secondary traumatic stress and compassion fatigue. ASPR TRACIE and SAMHSA DTAC have Educational Fact Sheets, webinars and podcasts that are free and accessible online. Some are for survivors, other are for helpers, some are for parents and other caregivers, check them out.

And for those of you who are interested in the research, the National Center for Posttraumatic Stress Disorder’s website will bring you to the Pilots database which is the most comprehensive collection of literature on these subjects.  These articles are also free and downloadable once you register


April: Thank you for attending this webinar sponsored by ASPR TRACIE. We hope it was an informative one and useful, and that you can use this material to help improve your sense of well being, in addition to improving your confidence in your ability to continue the work that you do in this most important profession.  Our wish for you is to remember your own good will and your heart, so that you can continue to take care of your patients, your clients and yourself in the best ways possible. And we encourage you to access the rest of the videos in this series.

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Contact ASPR TRACIE for additional information:
1-844-5-TRACIE (844-587-2243)


Voiceover: Produced using taxpayer funding by the U.S. Department of Health and Human Services.

[The video ends.]