ASPR TRACIE: Module 3B - Cognitive Tools for Mitigating Compassion Fatigue and Secondary Traumatic Stress

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[The video begins with the HHS logo appearing. Descriptive Text for the Title Slide: Logo for the US Department of Health and Human Services. ASPR Saving lives, Protecting Americans.]

SLIDE 1

Narrator: Welcome to “Cognitive Tools for Mitigating Compassion Fatigue and Secondary Traumatic Stress.” 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, or 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 preview 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

 

SLIDE 2

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.

SLIDE 3

April: Thank you and welcome to this third segment in our series. The goals of this webinar are to move participants to a more comprehensive identification and understanding of the types of tools that can help to mitigate compassion fatigue and secondary traumatic stress. Here you have the opportunity to learn how to use some of these tools as well as consider the types of interventions that you might want to pursue further, especially if you have some more serious distress signs and symptoms that are bothering you. 

Our overall goal is to help emergency medical and behavioral healthcare professionals to avoid developing the types of distress that can negatively affect your functioning both on a personal and professional level, and those that decrease your overall sense of wellness, in addition to that of the organization that you work with.

SLIDE 4

April: We will get to these goals by discussing how to address the negative behavioral health effects of compassion fatigue and secondary traumatic stress, vicarious trauma and burnout.   We expect that after participating in this webinar you will be able to apply cognitive based tools and strategies to avoid and address these types of work place related stress.

SLIDE 5

April: One of the major stressors that we have in the emergency healthcare professions is that everything we do is of importance. We have to have a near 100% error free record of performance. And this work has meaning not only to ourselves, but every patient, client and family member we come in contact with. This makes it very difficult to think of rearranging our schedules to make sure we have breaks and to take care of ourselves as a priority.  Our every day and entire caseloads consists of one trauma case after another. The environment we work within presents continuous exposure to other’s pain, grief and distress. There are long periods of time when we just cannot get away from it. While we have this meaningful and purposeful work in our lives, it can also become overwhelming.

This webinar will look at addressing this concern in practical, realistic and effective ways.

SLIDE 6

April: The word trauma is derived from the Greek word for wound, so it makes sense that those in the healthcare industry refer to it in the physical sense. In this webinar series, we’ve been referring to trauma and traumatic stress primarily in the emotional or behavioral health sense. The Substance Abuse and Mental Health Services Administration, or SAMHSA, notes that more than half of men and women report exposure to at least one traumatic event in their life time and 90 percent of clients in public behavioral healthcare settings have experienced some type of trauma.

SLIDE 7

April: Here, I’ll provide a very brief review of the terms used in the field to ensure that everyone is on the same page. You can find out more about compassion fatigue, secondary traumatic stress, vicarious trauma, and burnout in healthcare professionals in the previous webinars that make up this series.

Compassion fatigue is a combination of work related distress symptoms that culminates as a result of working continuously with patients and clients who are traumatized, physically, cognitively and emotionally.  It’s characterized by a sense of work related exhaustion with some signs of depression, feeling overwhelmed, and it’s usually very evident to the worker themselves and their colleagues.  It’s also often accompanied by a feeling of not being able to make the situation any better, a sense of helplessness, a lack of control, which is a significant sign of a problem.  This is often exhibited as cynicism, especially in healthcare professionals who work in crisis situations and see the same problems in the workplace repeating over and over again, whether it’s insurance related obstructions, or staff shortages or repeat patients who don’t follow medical advice. At its worst, compassion fatigue can cause staff to disconnect and block their feelings for patients or clients, almost becoming indifferent to the pain and suffering.

And healthcare settings certainly are not immune from the epidemic of substance misuse that we’re seeing all across the country with alcohol, opioids and other mind altering substances, especially in those settings where it’s easier access to medications and prescriptions.

SLIDE 8

April: Secondary traumatic stress can have some of same symptoms of compassion fatigue, but can also develop into a more serious disorder. STS is most prominently identified as the healthcare worker having the same distress symptoms as their patients and clients, including depression and anxiety and more commonly, posttraumatic stress disorder or PTSD. The cause of STS is the exposure to the traumatic material of clients and patients.  This makes sense as exposure is the most significant indicator in the risk of developing mental health disorders after a traumatic event. STS is actually included as part of the PTSD description in the Diagnostic and Statistics Manual of Mental Health. And it can develop over time, like compassion fatigue, but it can also occur after just one exposure to very disturbing material such as massive amounts of blood, dismemberment or other severe injuries especially involving infants and children.

SLIDE 9

April: Vicarious Traumatization is similar to CF and often includes some signs of STS, but an important difference is that it seems to negatively change one’s view of the world, belief systems, and perception of personal safety. So for example, if you’re caring for a child who has been abused, you might have the experience of feeling very sad, even depressed, and unable to sleep at night without visions of the abuse flashing before your mind’s eye and you additionally feel unsafe in your own environment, regardless of the actual situation of being in a safe living space.

Another difference between vicarious trauma and STS is that vicarious trauma occurs over time with repeated exposure to patient trauma, whereas STS can occur with even just one exposure to another’s trauma material.

SLIDE 10

April:   Burnout manifests differently than the other distress conditions and is often expressed in ways that are almost opposite from the others. Instead of an intense feeling of not being able to help or sad at not being able to do so, burnout is a condition that creates a void - a lack of feeling or empathy towards patients, clients and their families, an indifference, a disinterest in the work altogether.

The causes of burnout are less connected to the work of caring for patients and clients and attending to their families. The problems reported by healthcare staff include the reams of paperwork after patient care, or time constraints that don’t allow them to spend as much time with patients and clients as they feel is necessary. They also cite administrative problems like not having a helpful supervisor, or not agreeing with some of the organization’s policies, maybe not getting along with peers or other workplace challenges that interrupt the work.

Many people use these terms interchangeably but you can see here that to address burnout, you would have to look at the issues that are causing this concern and see what changes are realistic.  You might have some serious considerations to make, like asking for a transfer to another department or a different supervisor, or maybe even working at a different agency.

SLIDE 11

April: In the previous webinars we have discussed in detail the types of tools that can be used to help avoid or mitigate the development of the work related distressing conditions we’ve just reviewed: compassion fatigue and secondary traumatic stress, vicarious trauma and burnout.  A number of the tools that we use to help avoid the development of these issues seem so simple that many people actually tune them out when we start talking about them.

This is especially true for health and mental healthcare professionals who understand how the body is affected by stress, fatigue and trauma. But we do explain specifically how to implement these tools which is often the hardest part of mitigation.

The plain truth is that none of these tools work if you don’t use them. And that they work best when you use as many of them as possible.

So hang in there with us and learn how to take the package and apply it to your life in a practical way, a way that even a busy healthcare professional can use.

Basically, we are hoping you develop a different attitude as you learn even more knowledge and hone your self care skills. That’s what we’re looking to accomplish today

SLIDE 12

April: Let’s look at how you are doing after learning in the last couple of webinars about self care with a short exercise. Even if this is your first webinar in the series, you can join in. You just need paper and pen.

First, list the last time you engaged in physical exercise. What was the day, the date?

Then list the last time you called or spoke to a friend or loved one for emotional support specifically.

Finally, write down the last time you did something that you consider fun.

Were any of these activities in the past week? 

If you cannot remember the last time you engaged in any of these stress reducing activities, or even if you haven’t engaged in any of them over the past week, then you need to take a serious look at how to better balance your work-life activities.

The best way for busy people to begin to do this is to create a plan and put these activities in your calendar, then of course, to act on them. You can learn more about creating and implementing these plans in our webinar on, “Compassion Fatigue/Secondary Traumatic Stress Identification for Healthcare Providers.” It’s part of this series and we highly recommend you take advantage of the free webinars to learn these specific tools.

SLIDE 13

April: Now we’re going to take that deeper dive into learning cognitive ways to strengthen our resilience, our coping and our ability to manage some of the negative consequences of emergency health and behavioral healthcare work, some of the most difficult work in the world.

Cognitive strengthening refers to a compilation of evidence-informed tools that can support healthcare professionals as they develop ways to cope with the severe stress they encounter in work and the exposure to other people’s trauma material. 

These tools involve cognitive restructuring or reframing, attention diversion, mindfulness-based stress management, adaptive engaging and adaptive affective expression.

SLIDE 14

April: Cognitive strengthening tools are based on the understanding that what we think controls how we feel and how we act or react. How we feel is all about perception. Our perception of things, that is, how we think about things controls our emotions, our reactions.  One of the biggest problems this presents is that we believe what we think, even if it is inaccurate and harmful to us. 

Very often, what we think includes what we call old tapes or messages that we heard repeatedly when we were young. For example, adults in your life may have given the repeated message, “girls are not as smart as boys,” or “boys shouldn’t cry.”  Even though these messages are not true and didn’t feel right to us, we likely believed and internalized them, especially if we heard them over and over again. They have become a tape that replays in our memory. Without thinking about it, we may be believing these messages just because of our exposure to them.

One of the exercises we’ll be learning about here will be focused on using techniques to stop listening to old tapes and learning instead, to create and insert new messages.  Messages that are right for you and helpful to you.  This way, when you do believe what you think, your thoughts will help you to cope and control your reactions.

SLIDE 15

April: And that is just what cognitive restructuring or reframing does.  It helps us address unhelpful thinking. Because if we believe our unhelpful thinking, we’ll hit a dead end immediately and our thinking will add to our distress, making things worse.

Cognitive Reframing, or CR, is a part of cognitive behavioral therapy that can be useful in helping to change how you’re thinking for the better. It’s something that can be taught by an experienced therapist in about 10 to 15 weekly sessions. We are covering a very short simplified version right here.  The first step in learning this tool is to recognize that many of our thoughts are automatic, based on prior experiences and in stressful situations, they are based on the fear response.

CR teaches us to identify what the automatic thoughts are, to instruct ourselves to stop and look at these messages, determine if they are accurate and helpful or not, and then to move on to reframing the thoughts, to literally write down new ways of thinking, more helpful beliefs that lead to a new approach to dealing with the traumatic or stressful situation. Over time and with repeated practice, you can actually change the stress-inducing thoughts that are not helpful, and begin to accept the new thoughts or messages allowing you to feel less stressed and therefore happier.

In this series, we are just introducing some aspects of cognitive reframing that will show you how useful this technique can be. The components that we show you can be helpful, but they don’t comprise the full on treatment. 

SLIDE 16

April: This technique is drawn from cognitive therapy and can help to identify, challenge and alter stress-inducing thought patterns and beliefs. The goal is to enable people to replace stress-inducing thought habits with more accurate and less rigid, therefore less stress-inducing thinking habits. It’s a very powerful therapy technique which has been adapted to help people cope with all manner of stressful events and conditions.

In cognitive restructuring, we identify and write down our disturbing thoughts. This is an important activity, as thoughts are much easier to manipulate and examine when you've clearly identified them and pinned them down writing them on paper.

Additionally, you write down what was happening at the time of the thoughts, when they occurred, and then write down your emotional response to what happened.

Then in restructuring you stop and examine the original thought. Look for patterns of distorted thinking or dysfunctional beliefs. Do certain types of situations always tend to trigger certain negative thought patterns? Are you a black or white thinker when it comes to certain topics? Do you typically experience anger or sadness in response to stress? Think carefully about what sorts of thinking mistakes you might be making, about whether or not your thoughts may have been wrong, or whether you may have unconsciously experienced a cognitive distortion.

SLIDE 17

April: When you’re clear on what you got wrong, look at how to shift your cognition or change your thinking by asking yourself a few questions:

• Are my thoughts on the event accurate?
• What objective evidence or facts are there to support my view?
• What alternative views are out there of the event?
• Am I underestimating my ability to cope with the event?
• What is the worst thing that can happen to me or my family?
• What actions can I take to influence the event?

Write down new ways of thinking or more helpful beliefs, that is, what we call thought insertion that can lead to a new approach to dealing with something that is a disturbing or traumatic event.

After thinking things through for a while, your final task is to restate or rephrase your original beliefs so that they are more accurate and less distorted. This is positive messaging.

With practice, you will be able to start changing the stress-inducing thoughts that are not helpful, and you’ll find yourself feeling less pressured and therefore happier.  It’s like exercise for your thinking brain.

On the next slide, I will take you through a thought stopping exercise. Over time and with repeated practice, cognitive restructuring becomes easier. If you want to learn how to do cognitive restructuring in more detail, we recommend that you work with an experienced cognitive behavioral therapist usually over the course of 10 to 15 sessions.

SLIDE 18

April: It’s really important to create good messaging for yourself. Often, it’s too hard to do this when we are distressed, frightened, tired or in the midst of a trauma. So another really important exercise to engage in would be to create good messaging for yourself ahead of time when there isn’t a traumatic event.  Think about something that really makes you feel upset, afraid, distressed, or angry, any emotions that might stop you from thinking clearly. Do this at a time when you’re not in the midst of a traumatic, stressful event.

Let’s use the example of a near miss while driving. You are in the car moving across an intersection and another car suddenly sweeps across your vision an inch away from your hood leaving you with a rapid heartbeat and anger. Your immediate thought might likely be “I almost got hit. I could have been hurt or killed” or “That driver is an idiot. I should go after them. I want to scream at them.” 

Each of these thoughts will likely result in increasing your heart rate or making you feel even more afraid or angry, becoming distracted, maybe even not being able to think clearly. If we follow the exercise, then what you want to do is tell yourself, “Stop, think, take a breath.”  And then give yourself a new message. “I’m okay. I did not get hurt. I’m grateful for that.”  It’s so important to write down the new messaging, and it’s extremely helpful to do this, again, before something happens. Think of situations that may generally or even often upset you. Try to identify your harmful thinking that you’re aware of and what new thinking, what new message do you want to replace it with. Write this down.

For healthcare and behavioral health staff who see injury, pain and trauma happen to people every day, some of the messaging might look like, “This didn’t happen to me or to my children or to my family.” Maybe, “My family is safe. I am safe. I can help. That’s the best thing I can do.”   These are just some examples of messaging, but you need to personalize your own messages. Use your own words, words that you are comfortable with and you know will speak to you and your concerns directly.

SLIDE 19

April: Think about what this messaging might really need to be for you. You can go deeper and look at what kinds of thoughts you have on a regular basis that bother you. Are your thoughts really your own or are you replaying old messages from someone else in your life? Maybe from a punishing parent, a grade school bully, a toxic relationship.  In the coming week, take some time for yourself and look at your thoughts. Ask yourself, what thoughts are not your own? Try the thought stopping exercise, replacing those thoughts that are not your own, bringing in new helpful ones that you have created while you are in a safe space and in a thoughtful frame of mind.

Think about how much of your day is conducted out of habit. Which ones aren’t helpful? Are you running in circles that keep you stuck? Allow yourself the thought that you can change these things. You can change old family routines and other habits that may not be helpful to you, and in some cases even cause harm.

SLIDE 20

April: So when you’re having upsetting thoughts, imagine that stop sign and say to yourself “Stop.” Remind yourself to think and then suggest to yourself to breathe.

Then practice your breathing exercise, whether it’s the 3-5-7 or box breathing methods, or any other model that you are comfortable with.  Stop, think, and breathe.

Then move to the positive messaging, the thought insertion part. When you are having upsetting thoughts practice the thought stopping. Imagine seeing the stop sign and saying to yourself, “Stop.”

Then think about what you want to replace the unsettling or disturbing thought with. Create a new message that you will tell yourself that’s helpful to remain stable. For example, “I am safe. My family is okay.”

Insert that new thought into what you have developed for your thinking. Writing it down and practicing stating it to yourself several times a day can be very helpful. Remind yourself that you can become calm by practicing this exercise whenever you’re distressed.

 Additionally, you can imagine a pleasant image, maybe a picture of the family or the dog. Or remember engaging in a pleasant activity as a way of reducing negative or unhelpful thinking. Again, it’s a way to shift your thinking from unhelpful distressing thoughts to more pleasant things that can bring your stress levels down.

SLIDE 21

April: One of the gifts of our human condition is our ability to think. It’s our capacity for self control, our ability to refrain from inappropriate behaviors. This skill helps us interact better with society, care for ourselves, and pursue longer-term goals. Attention diversion is one of the gifts as well. It’s an emotion regulation tool that can be used to cope with very strong emotions that we may experience in a distressing moment and helps to avoid the risk of long-term negative behavioral health consequences.

Attention Diversion is one of our thinking skills that gives us some self control, which in turn allows us to engage better with others, care for ourselves in more productive ways rather than just giving in to instinct, impulses and the need for immediate gratification.

Attention diversion is basically purposeful distraction. It’s anything that you do temporarily to take your attention off of a very strong emotion that’s distressing you. Sometimes, focusing on a strong emotion can make it feel even stronger and more outside of your control. Therefore, by temporarily distracting yourself, you may give the emotion some time to decrease in intensity, making it easier then to manage.

A key part of the above definition of distraction is the word temporarily. Distraction is not about trying to escape or avoid feelings. With distraction, it’s implied that you eventually will return to the feeling you were having, trying to allow yourself then to feel it, address the feeling when it’s less intense. Once that intensity has reduced, you can try and use another skill maybe to manage the emotional response that’s bothersome, such as expressive writing for example.

SLIDE 22

April: Distraction can be a lot of different types of activities. We can suggest more here, but as we have noted before, you need to tailor all of your stress management activities to the type of things that work for you.

If you are distressed and need a distraction, try a grounding exercise. You can do this by focusing your attention on your environment. For example, identify all the objects on the walls, or name all the colors in the room. Try to memorize and recall all the objects that you see in a room. Or do something physical like stamp your feet on the floor or touch all the smooth surfaces in the room. Take a moment to write down something you might do to help ground yourself.

Another distraction that works for many people is to count. Try counting backwards from a large number by sevens or some other number. So for example, 856, 849, 842, 835. It takes a lot of concentration, it’s a good distraction.

Take part in fun and challenging games that might require some level of your attention as a distraction, such as a crossword puzzle or Sudoku. These are generally portable games that you can engage in from a smartphone app or from a newspaper posting that you can access during breaks at work.  Or do something more creative like draw, paint, or build a model. Write down what creative or fun activity you might engage in, even it’s just reading a good book or watching a funny movie.
Engaging in social support can be a very helpful distraction, calling or writing a letter to a good friend or a family member. Social supports can be very effective especially when we are in the midst of distressing or traumatic experiences.

Try doing some physical chores: cleaning the house, doing laundry, washing the dishes. As we’ve discussed before, body movement is very helpful so go for a walk, do some stretching.

And consider engaging in skills like mindfulness, by focusing on your breathing. We’ll do this together in the next slide so you can see how it’s done.

SLIDE 23

April: Most people have heard of mindfulness or meditation, but many still think it’s some complex practice that’s too difficult to attempt to use in your daily routine. There are many levels of mindfulness, and the research is telling us that when combined with the use of other evidence-based interventions, mindfulness can boost the positive effects.

Mindfulness is a great cognitive strengthener. And the good news is that although you get better with practice, any level of mindfulness is a good thing in many aspects of everyday life. Mindfulness is simply the state of being conscious or aware of something. It’s a mental state achieved by focusing your awareness on the present moment, while calmly acknowledging and accepting your feelings, thoughts, and bodily sensations just as they are, and no matter what they are.

SLIDE 24

April: When we look again at the change in body functions that are activated by the limbic system when stressful incidents occur, we can see that these changes are visceral, very real, and can highly impact how staff are feeling, thinking and functioning.

Notice the heart beats faster - a very common response - blood vessels constrict, the skin chills, sweats, blood pressure increases, and muscles are tensing.

Mindfulness, especially breathing retraining, can be very helpful. When we breathe, this limbic system starts to shut down and allows thoughts to come back in to work. This allows for more control of our responses, which allows even more thought process, you can see how this is beneficial. It’s essential for health and mental healthcare workers to use the knowledge and these skills rather than the expression of fear responses.

The first webinar in this series provides a basic overview of stress and stress management with some examples for breathing retraining. We encourage you to take advantage of these free learning opportunities from ASPR TRACIE.

SLIDE 25

April: So, there are many different ways to practice mindfulness and a few techniques that can help you develop your mindfulness practice include guided imagery and affirmations, which I will explain next. 

First, let’s just practice a very short, very simple mindfulness exercise.

It’s only about a minute and a half.  If you can, sit in a quiet place, turning off any radio or other distraction. Place your feet solid to the ground, allowing your hands to rest on your lap. Either close your eyes, if you’re comfortable doing so, or just lower your gaze downward.

Then start to pay attention to your breath. Recognizing when you take a breath in and then the relaxation that comes with the exhale. Just think about your breath. Breathing in and then exhaling. Allow any other thoughts that you have to come and go, refocusing on your breath.
As you breathe in imagine all the good will, love and caring thoughts of those who love you now, those from your past, whose love still surrounds you, all entering your body with the breath and relaxing you. Going to any stressful, tight places and releasing the tension as you breath out, sending the tension out with the breath. Breathing in and breathing out. Breathing in and breathing out. And then when you are ready come back into this space, opening your eyes, and still feeling the relaxation.  This was obviously a very short mindfulness exercise, and very simple, but doing this kind of practice every day and increasing the amount of time can change your stress levels significantly, it can change your thinking and your ability to focus significantly. 

Let’s look at some additional ways to practice mindfulness.

SLIDE 26

April: Guided imagery is another tool that can help you to be mindful and reduce stress. It usually involves a narrator taking you through imagining a calming, comfortable scene in your mind and inserting positive messages to allow for and accompany the imagery. Here in this short video, Dr. Bella Ruth Naparstek, who is a behavioral health consultant with the Veteran’s Administration, addresses the issue of PTSD in our veteran population and shares a simple description of guided imagery.

Bella: We get a lot of questions about guided imagery. So I’m just gonna address some of the things people ask us the most. So, guided imagery is the kind of deliberate, directed daydreaming. It’s a form of meditation. It’s also a form of hypnosis, but it’s more specific, so those other terms are more umbrella-like. And it’s a way of sending appealing messages to the whole being: mind, body, spirit. And in fact, the process of doing guided imagery kind of coheres mind, body and spirit and gets the whole person behind their intention to do whatever it is they want to do.

April: The use of affirmations is a third tool. Affirmations are positive messages or statements that can aid in cognitive strengthening and reframing which allows your mind to overcome negative thinking and to help you think differently in general. The research shows that repeated use of affirmations can calm your nerves, reduce stress and increase confidence especially in the workplace environment. They’re designed for repeated listening. It’s like exercise for your mind.

SLIDE 27

April: As we discussed earlier, creating good messaging can help you reset your thinking.  As with any other tool, skill or new learning, you need to spend some time, tailor the words and the messages so that they speak to you personally. 

Create good messaging when you have a free period of time, when you are not in rush or in a highly stressed situation. Using commercial language for your messaging would work to a certain extent, but the process is really much more effective when you personalize the messages.

So, think about when you might have a period of time to spend on this preparation.

Think about what thoughts you have that are bothersome or maybe harmful to you. A simple example is, “I can’t do this. I’ll never be able to reach this goal.”   Write down the bothersome thought.  Ask yourself, “Is this true?”  More than likely it’s not. Think about how to counter the negative message. What do you want to tell yourself instead? For example, “I can reach this goal. I will reach this goal.” If you are a realist, and think to yourself that you in fact may have difficulty reaching this goal, then create a different thought that will help you make it work.

For example, you might give yourself more time. “I can reach this goal in the next month.” or “I can finish this project if I ask so and so to help with me with that section I’m unsure of.”  These are just examples. What thinking are you engaging in that you would like to reframe? How can you reset your thinking in a way that creates a positive outcome for you?  Write down your harmful thoughts and then write a number of different thoughts that counter it.  Chose the thoughts that you think will be most helpful and write them down on an index card. Carry it with you. Post it on your computer. Allow your mind to be exposed to the new thought as much as possible. Use the new thoughts in your mindfulness practice as well.

SLIDE 28

April: There are many different types of formal treatments that can help people who are experiencing severe distress symptoms and emotional illnesses. One very significant tool that research tells us can help people experiencing stress and distress more than anything else is social connectedness. That is, being with or connecting to people who understand and accept how you feel. Not people who tell you to get yourself together or get over it when you express difficulty dealing with a trauma or grief.  It’s important to engage with people, social events and activities that increase your coping and your confidence that you can manage stressful times. People and activities that support your efforts at building your own resilience, your ability to adapt to difficult or changing situations. 

Engaging can mean many different things, this is especially so when we consider the ways that different age groups communicate, and we’ll talk about that a bit more in the next slide.
Adaptive engaging is especially important in emergency healthcare settings where there is literally no room for putting others down or instilling fear, distress or despair. It’s the responsibility of health and behavioral healthcare professionals to express hope, showing their best selves and treating patients, clients and family members with the same dignity and civility that you expect. Even in the face of imminent death, the need to instill integrity and calm must come from the staff regardless of how tired or distressed they may be feeling. 

Adaptive engaging also means holding your integrity, your dignity and your civility, as well as avoiding toxicity and negative coping behaviors like substance abuse, anger, or violence. Of course we know that anger and violence are unacceptable, so if we find ourselves in situations that we know can impact us with feelings of anger, we need to use some cognitive reframing to change the situation into one that we can cope with in a more helpful way. It would be especially important to create some cognitive messaging and practice using them ahead of these situations so that when they occur in the midst of emergencies, you’re prepared.

Healthcare workers also need to be highly aware of avoiding creating a negative environment for patients, clients and family members like judging people who misuse substances or homeless individuals.

SLIDE 29

April: We hear from patients and clients that they don’t appreciate some of the comments that healthcare providers make in the midst of an emergency situation. As healthcare professionals, we should refrain from using comments that invalidate concerns, such as “don’t worry about it” or “everything will be fine” when talking to patients and our colleagues. You can say other things to maintain an upbeat attitude and still appear authentic. Some examples are, “I’ll do my best to help you. We can do this together.”

Healthcare professionals also need to avoid imposing toxic positivity such as, “Just think positive thoughts” and “You’ll get over this,” or “Don’t be negative” and the very guilt- inducing comment, “God doesn’t give us more than we can handle,” which implies there must be something wrong with us if we’re not coping.  Instead of these patronizing, unhelpful comments, we can teach patients and clients basic ways to cope with pain and distress.

SLIDE 30

April: Let’s just go back for a minute and look at levels of engagement. How we connect with people can give us more or less supportive feelings and the research is clear that social engagement is one of the best ways to cope with stress.  But just posting on your social media site once in a while may not give you all the good energy that you need.

In-person meetings, both one to one and group meetings, are the best way of engaging. This is because seeing and hearing someone in addition to feeling their presence are what can give us strength and support. We absorb each other’s energy.

You can still get some good energy from seeing and hearing the other person who is providing support through video screens or the telephone, although the energy exchange is obviously not there. But at least facial expression might be on video screens and the tone of voice through the phone can help to convey support.

Hearing another’s voice such can be supportive when the words are spoken, words that you need to hear. So it’s limited in that you cannot see a soft, caring look or feel the energy of the person you’re talking to, but if they’re saying the right things even if it’s just “I care about you” and “I’m here for you” that can be helpful.

Texting feels a little closer than email in connecting, and can demand your attention and works very quickly, but we know that texting, and the next modality emailing, really don’t allow us to get the feeling behind the message. Thus, the reason that emojis are so popular. They allow a show of emotion with having to type a lot of words to describe the feeling. Still, it’s a very limited way to engage. 

Social media messaging is only slightly above social media posting because there really is such a distancing of feeling in each of these means and the research is actually quite mixed on whether these are helpful ways to connect or not.

SLIDE 31

Adaptive affective expression involves identifying and expressing emotions in healthy ways, rather than just exploding with automatic reactions or words that can be harmful to yourself or to others.  Or doing just the opposite, which we tend to be very good at in our culture, which is to go into avoidance and denial. Many of us don’t express our emotions because we are afraid of looking weak or losing control. There’s also still the stigma in our culture that expressing emotion is a sign of mental illness.  We may be concerned about repercussions at work if we state our discontent or complain about a difficult work environment. This may involve a reprimand, a change in roles or a demotion, or even being discharged from the job altogether.  That’s why it’s so important to learn how to identify what’s problematic and where the causes lies. And to be appropriately assertive in expressing concerns, that is to state distressing emotions without inappropriate blaming , displaced rage or unfounded accusations.

Adaptive affective expression also involves recognizing what we call prodromals, which are signs or those things that you start to think or do right before you become distressed or have difficulty controlling your emotions. 

And finally, we all need to recognize that there are people, places and things, even timeframes like birthdays and anniversaries that will remind us of bad feelings or traumatic events, and these reminders can make us feel as badly as we did at the time of the actual event, even though the event may be over for a long time. Knowing that we experience prodromals and triggers, or reminders, can help us prepare and plan things that can help keep our expression of emotion under our conscious control.

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April: A prodromal basically means early signs or symptoms of a problem to come.  They are those things that you start to think or do before you become distressed or have difficulty controlling your emotions.  They cannot be described specifically because they’re different for everyone and they can be any thoughts or behavior.

 I’ll give you an interesting example. I had a patient, a young man with schizophrenia whose illness was generally stabilized with medication. But about every two years or so, he would have an episode of becoming quite psychotic and requiring hospitalization and significant changes in medication.  The last time I saw him, his mother told me she knew he was decompensating and she was able to get him into a hospital before he had trouble at work. When I asked her how she knew, she said she finally recognized his prodromal behavioral, which was so unusual, that she had not been able to identify it before. She said that a couple of days before becoming unstable, he would lean down and touch the saddles in every doorway in the house as he passed through. He did it really quickly and easily, so it didn’t seem problematic, but once she got that he was decompensating she recognized that he had gone through periods of this behavior before each of his previous hospitalizations.

That patient’s illness is a serious one, but the concept of identifying your prodromals, those things that are signs that you’re becoming very stressed is important. Some people describe becoming highly anxious, forgetful, unable to sleep. Others will report that they become really short tempered, impatient, or highly agitated over small issues or even over nothing at all. These are the most common signs of serious stress responses that require immediate attention. 
Your close friends or family members might be able to tell you what behavior they recognize in you that warns them that you’re really stressed and that they should probably avoid adding any more to your plate.  You might want to ask them.  Think about the last time you were highly stressed. This idea of thoughts and behaviors that you had right before you recognized that you were really stressed is important.  This is a piece of information that can help you in mitigating your stress levels.  Do you already know what your prodromals are?   I’ve learned that I start yelling really loudly at my computer when I get really stressed.  I only do it when no one is around, but originally, I had done it when my cat was in the room and he was so frightened that he would run and hide. That was what brought me to recognizing this as a prodromal. Again, think about your thoughts and reactions. Ask those who are close to you if they can help you identify some of those signs. It could help you avoid serious negative stress responses and prompt you to take the actions that you need to help yourself.   

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April: It’s extremely difficult to address distressing thoughts and feelings when we don’t know what they are. If you are the type of person whose go-to response to most things is anger, you are likely having affective expression problems. You don’t even know how you really feel because anger just masks anything else, so you create difficulties in engaging with your coworkers, family members, and maybe even yourself because anger can also keep people at a distance.
A good tool to address expressive problems is that when you are having your usual, automatic reaction stop and listen to yourself. Staying with the anger example, which is a pretty common cover emotion, think about what other emotion or feeling is happening alongside the anger. Is it grief? This is possible if you had a recent loss. Is it fear? Covering fear with anger is another really common response. It’s in our DNA to cover up our vulnerabilities, so this might very likely be a coexisting feeling. Use the thought stopping exercise that we learned earlier. Stop and think about how are you really feeling. Take a couple of breaths and try to put a name to your deep feeling. What’s underlying the top or covering feeling?  What’s the other feeling that has real depth? If you can identify it, you might be able to then tie it to an experience that’s associated with it and create some exercise that will move you through taking the power out of that experience.

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April: Another part of affective expression is to recognize that we all get triggered. That is, we experience negative emotional reactions when we’re reminded of a distressing or traumatic event in our lives. For many people, the trigger makes them feel as badly as they did at the time of the actual event, even if it’s many years later.

A common trigger is the anniversary date of a distressing or traumatic event.  It is usually the strongest at the first anniversary, but victims and survivors of traumatic events, and their family members and even responders report being triggered every anniversary timeframe in some events.

Seeing images of a traumatic event or hearing stories, someone describing the incident, can be a trigger setting off serious distress responses in those both directly and indirectly exposed. Indirectly generally being things like the radio or television news which happens very often in our current social climate.

For some people, triggers can be people and places associated with a highly stressful event. Many share that responding to or caring for patients and clients who experienced similar incidents are triggers for negative mental health responses. For those who have lost a loved one, especially under highly disturbing circumstances like a violent or painful death, their loved one’s birthday can be a trigger for stress. 

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April: Here is a reminder of what can happen if we don’t address the traumatic stress that we’ve encountered in our lives.

• High levels of anxiety, or the need to be extra vigilant at all times.
• Substance misuse.
• Feeling angry, resentful, and engaging in conflict. This is a variable that’s often associated with domestic violence.
• Disturbing uncertainty about the future.
• Prolonged mourning is another effect of unaddressed traumatic stress, as is the
  diminished ability to solve problems.

Many people report feeling isolated or hopeless, and dissociated from others.

You can experience physical health problems as a result of not dealing with traumatic stress, including high blood pressure and digestive issues which are common.

And you may find yourself making lifestyle changes that don’t really match who you are as a person, deep down.

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April: Remember: Reactions to stress are based on our perception of the situation. For example, when we see a car coming towards us and we think it’s right in our path, and will hit us and we’ll die, we may have a stress response.  Even if the perception is false, these thoughts can cause us to have distressing responses. Our previous experiences may also cause us to be fearful of things for no reason. Something that happens may remind us of a previous trauma and thus we’ll have those negative responses.  Fearful thoughts, cause negative emotions, so it follows that we can control those responses cognitively, that is by changing our thinking. The tools in this webinar will help you to manage your stress in your everyday life, your work activities, and during emergencies as well as non-disaster times.

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April: There are many resources that can inform you further about acute stress, posttraumatic stress, compassion fatigue and secondary traumatic stress, they can increase your knowledge and understanding about how these disorders occur and more in-depth means to counter their negative effects. ASPR TRACIE has a wealth of resources on these issues as well as planning, preparedness and response activities for healthcare providers addressing disasters, disease outbreaks, biohazards and more.  For those of you who are researchers, the National Center for Post Traumatic Stress Disorder’s website will bring you to the Pilots database which is the most comprehensive collection of literature on these subjects. These materials are free with Pilots registration.

SLIDE 38

April: Thank you for joining this ASPR TRACIE sponsored webinar.

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

[The video ends.]