Month: August 2016

Dark Humor

It’s no secret that many of us engage in, and possibly rely on, dark humor to get through tough days. I find myself frequently reassuring responders that there’s nothing wrong with the black, sick jokes, as long as we keep them among ourselves.

A few years ago I got a taste of how they feel to the public when I arrived at an accident that a close friend was directly involved in. My friend was feeling responsible for serious injuries to the victim. I identified myself as a critical incident responder and asked a police officer how the victim was doing. He gave me a very grim look, twirled his finger and said, “Circling the drain.” He waited a beat for my reaction, then smiled and said, “Just kidding. He seemed to be okay when they transported him.” For a moment, my heart had sunk, wondering if the victim was going to die (he didn’t, but his injuries were critical). When I realized the cop was joking, I felt a moment of anger, but reminded myself that dark humor is a coping mechanism. I doubt most ordinary people would feel anything but angry at the apparent insensitivity. Go ahead and make the sick jokes, but don’t laugh out loud on the scene of a tragedy – even if all you are doing is directing traffic.

Here are a few good pages about the psychology of dark humor.

 

It’s Good to be Bad: The Psychological Benefit of Dark Humor – Contains really sick jokes, if that’s what you are after.

Humor as Weapon, Shield and Psychological Salve – Includes discussion of the Nazis’ fear of humor. Possibly quite timely in the current U.S. political season.

Awfully Funny – A deeper dive, with research references.

 

 

 

Psychological First Aid and CISM – Clearing the Confusion

(For publication in the California Peer Support Association newsletter.)

Copying this article is permitted: Psychological First Aid – Clearing Confusion (PDF)

The name “psychological first aid” (PFA) has become a source of great confusion and controversy in emergency services. For 60 years, it has been a generic term for offering immediate support to people impacted by highly emotional events. Multiple PFA protocols have been developed, refined and studied for decades.

Confusion about PFA escalated 10 years ago, when the National Child Traumatic Stress Network (NCTSN) published a new PFA protocol, developed with the National Center for PTSD, and touted it as a “replacement” for Critical Incident Stress Management (CISM).

However, PFA has long been a component of CISM, so calling it a replacement is like saying a finger is a replacement for a hand, says Dr. George Everly, a Johns Hopkins psychologist and co-founder of the International Critical Incident Stress Foundation (ICISF), which establishes CISM standards. Everly has pioneered development and evaluation of both CISM and PFA protocols. He was a primary creator of the PFA protocol taught in CISM, the SAFER-R model.

Unfortunately, PFA confusion has led various organizations and agencies to recommend the NCTSN protocol as a “CISM replacement.” For example, a recent U.S. Department of Justice report, Preparing for the Unimaginable, which reviewed Sandy Hook and other mass casualty incidents, recommended NCTSN PFA as a “replacement” for CISM for law enforcement.

Concern over just one CISM component – debriefing – is at the root of the PFA muddle. The debriefing controversy began about 20 years ago when a small number of inconclusive studies of non-CISM debriefing techniques (none of which involved responders) were misinterpreted as suggesting that re-telling a traumatic story during debriefings could cause harm. However, over 35 years, no study has ever showed harm when ICISF protocols are used by trained people. Although much more research into the effectiveness of debriefings and other interventions is needed and welcome, the criticisms of CISM suggesting harm have been discredited.

Get trained, follow the ICISF protocols and rest assured that you are not going to do damage.

PFA’s Confusing Multiple Meanings

The existence of multiple PFA protocols has led to careless misrepresentation of support for the NCTSN protocol. For example, an Everly paper has been misquoted by multiple authors as saying NCTSN PFA is a “best practice” for first responders. However, the paper was actually about the Johns Hopkins RAPID-PFA protocol. (Everly et al., 2006). Reviewers should have noticed that the paper was written before NCTSN PFA was developed! In many other papers, the specific PFA protocol is not identified, casting doubt on whether NCTSN’s was used.

The NCTSN protocol was not developed with responders in mind. “[NCTSN] PFA is basic ‘grassroots’ psychological support provided for family, friends, neighbors and colleagues by members of the general population” (Barbanel and Sternberg, 2005). It was developed for children, schools and communities. The research literature reports that it has been used by faith communities to support their members in disasters, on school campuses, by community mental health, with disaster survivors, Syrian refugees, Greek refugees and domestic violence survivors. Applying it to responders has been an afterthought.

There has been one study of the NCTSN protocol in public safety. In Hong Kong, 900 responders were trained in the protocol in 2012. Early results were positive. (Chan, 2012,)

The NCTSN Protocol is for Individuals, Not Teams

The NCTSN PFA protocol only addresses interventions with individuals. There is no associated group process that would apply to responders, who have a strong sense of group cohesion and typically share trauma as a team. Applying it to a group is a round peg in a square hole.

The NCTSN Protocol’s Effectiveness Remains Unproven

The NCTSN protocol’s creators call it “evidence informed,” which means that it is based on research that identified potential, rather than actual benefits. Multiple expert reviewers say that there is almost no evidence for its effectiveness and further study is needed.

“The scientific literature on psychological first aid available to date, does not provide any evidence about the effectiveness of PFA interventions. Currently it is impossible to make evidence-based guidelines about which practices in psychosocial support are most effective to help disaster and trauma victims” (Dieltjens et al., 2014,).

“Despite popularity and promotion there remains a dearth of evidence for effectiveness and recent independent reviews of PFA have highlighted this important gap” (Shultz and Forbes, 2014).

“More evidenced-based research is still needed to prove the effectiveness of PFA.” (Zhang, Zhou, and Li, 2015).

The Red Cross, which has endorsed NCTSN PFA training for disaster workers, commissioned an independent review, which also found little evidence. “It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline” (Fox et al., 2012).

CISM is Helpful, not Harmful

The myth that researchers found that CISM is potentially harmful to responders was an odd conclusion of a review of several studies that gave “psychological debriefings” to victims of auto collisions, burns, dog bites and other accidents. In fact, the studies were inconclusive, but even if they actually had demonstrated potential harm, they are irrelevant to CISM and responders.

  • The interventions were inconsistent; ICISF CISM protocols were not followed.
  • No responders were involved – the care receivers were medical patients, victims of burns, accidents, etc.
  • All of the interventions were with individuals, rather than groups.

Another myth is that debriefings (which are just one component of a CISM system) are intended reduce or prevent Post-Traumatic Stress Disorder. Although debriefings may contribute to that goal, they really are intended to help a team “bounce back” from a difficult incident. Their explicit goals are:

  1. Mitigation of the impact of a traumatic event.
  2. Facilitation of the normal recovery processes and a restoration of adaptive functions in psychologically healthy people who are distressed by an unusually disturbing event.
  3. A [debriefing] functions as a screening opportunity to identify group members who might benefit from additional support services or a referral for professional care.

Evidence of many benefits of CISM are documented in the scientific literature. Stress-related symptoms drop, such as depression, anger and anxiety. Alcohol consumption is reduced. Self-esteem and emotional well-being are higher. Recipients are more cooperative with treatment and care. Suicide rates are lower.

None of the scientific evidence could be properly described as making a strong case for CISM, which is undoubtedly one of the reasons for the “controversy” around it. More research is needed.

Isolation is Toxic

Protocols matter, but resistance and resilience to stress – chronic or acute – correlates most strongly to an individual’s social support. Social isolation, like physical isolation, puts people at high risk. So in the end, no matter our approach, demonstrating that we care for each other – that no one has to be alone – is the most important “protocol” of all.

Bibliography

ABPP, Laura Barbanel, EdD, and Robert J. Sternberg PhD. Psychological Interventions in Times of Crisis. Springer Publishing Company, 2005.

Chan, Emily Y. Y. “Preliminary Results of Psychological First Aid Capacity Building Program on Coping Strategies and Mental Health Measures Among Emergency Responders in Disaster: Results of 6-Month Follow-up of a Randomized Controlled Trial.” World Federation of Public Health Associations, 2012. https://wfpha.confex.com/wfpha/2012/webprogram/Paper10006.html.

Dieltjens, Tessa, Inge Moonens, Koen Van Praet, Emmy De Buck, and Philippe Vandekerckhove. “A Systematic Literature Search on Psychological First Aid: Lack of Evidence to Develop Guidelines.” PloS One 9, no. 12 (2014): e114714. doi:10.1371/journal.pone.0114714.

Everly, George S., Suzanne B. Phillips, Dianne Kane, and Daryl Feldman. “Introduction to and Overview of Group Psychological First Aid.” Brief Treatment and Crisis Intervention 6, no. 2 (2006): 130–36. doi:10.1093/brief-treatment/mhj009.

Fox, Jeffrey H., Frederick M. Jr Burkle, Judith Bass, Francesco A. Pia, Jonathan L. Epstein, and David Markenson. “The Effectiveness of Psychological First Aid as a Disaster Intervention Tool: Research Analysis of Peer-Reviewed Literature From 1990-2010.” Disaster Medicine and Public Health Preparedness 6, no. 3 (October 2012): 247–252. doi:10.1001/dmp.2012.39.

Shultz, James M., and David Forbes. “Psychological First Aid.” Disaster Health 2, no. 1 (January 1, 2014): 3–12. doi:10.4161/dish.26006.

Usher, Laura, Stefanie Friedhoff, Sam Victor Cochran, and Anand A. Pandya. Preparing for the Unimaginable: How Chiefs Can Safeguard Officer Mental Health before and after Mass Casualty Events. Washington, DC : Arlington, VA: Office of Community Oriented Policing Services, U.S. Department of Justice ; National Alliance on Mental Illness, 2016.

Zhang, Li, Jiangsong Zhou, and Lingjiang Li. “Crisis Intervention in the Acute Stage after Trauma.” International Journal of Emergency Mental Health and Human Resilience 2015 (January 1, 1970). doi:10.4172/1522-4821.1000299.

Copyright © 2016 Nick Arnett, Stress, Spirit, Science (http://nickarnett.net)

Permission to copy unchanged is authorized.

Relaxing music v. emotional memory

One of the ways we can help cope with high-stress events is to do things that, strange as it might sound, interfere with our brain’s ability to remember the emotions. Music has that power. Psychology researchers at Monash University in Australia took a look at the ability of relaxing music to lower the impact of traumatic events and found a strong correlation between listening to the music and reduced recall of an emotional story.

The research abstract is available here,  with a link to the full article (payment required).

I find myself wondering if we would do well to play relaxing music at the start of every crisis intervention. In any case, it’s probably a good idea to have your own playlist of relaxing music ready to listen to after a critical incident.

 

Grand plans, simplistic solutions and comparison stress shopping

Whether you face long-term or acute stress, whether you work in public safety or elsewhere, you will find in these pages invitations to ways of thinking and acting – attitudes and actions – that lead to wholeness and balance.  I invite you to let go of three bad habits that our culture encourages. Reject grand plans, simplistic solutions and comparison stress shopping.

Grand plans don’t work for grief and trauma. They fail partly because they have an end goal in mind: to “get over” whatever has happened. However, we don’t get over losses and traumas that are life-changing – we figure out how to live with them. Grand plans also fail because it is impossible to plan your reactions.

Instead of planning what you are going to do in the future, healing comes from figuring out how to be in the present as much as possible.

Even if any of us had enough self-knowledge to make such a plan, the rest of the world rarely cooperates. Instead of planning what you are going to do in the future, healing comes from figuring out how to be in the present as much as possible. Just like major physical injuries and illnesses, predicting a fixed path to healing and timing is foolish (which doesn’t mean we don’t want it – of course we do).

Trust that you will know what to do when it is time to do it, if you take the time to listen to your heart. For example, at my house we have several boxes of my father-in-law’s clothing. He died more than a decade ago. When it is time to do something with them, my wife will know. Until then, my job is to patiently wait and set aside the idea that we really could use that storage space for something else.

One of Mother Teresa’s oft-quoted sayings rejects grand plans: “Do small things with great love.”

Simplistic solutions are the cheap answers that often come out as supposedly comforting clichés. After losing a loved one, have you ever been told something like, “She’s in a better place?” That’s a half-truth because the reality of your loved one’s death is missing.

Faith accompanies, rather than erases or cancels, the pain of loss. It doesn’t reduce the pain, it makes it easier to bear.

Faith indeed says she is at peace, but at the same time your senses are telling you, “She’s not here and I miss her!” Faith accompanies, rather than erases or cancels, the pain of loss. It doesn’t reduce the pain, it makes it easier to bear.

When people hear clichés and other simplistic answers they are often left feeling alone and criticized for being weak when they find – as they almost always do – that grief and trauma are never simple. Truly stressful life events are always messy and complicated.

Overly simplistic solutions are pervasive. We see suicidal high school students overloaded with pressure to get into the best colleges and leap to the conclusion that to end the self-destruction we have to figure out how to lower their stress. In the quest for the simple fix, focusing on academic pressure, we ignore what is missing from their lives – most critically, social support – when academic achievement crowds out everything else. They don’t need lower stress (the best schools are also the most challenging), they need us to restore priorities that were abandoned when academic success became the only thing that mattered.

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This kind of black-and-white thinking has also given us political parties that are defined by who and what they are against. In this atmosphere, debate rarely rises above criticism, as if by proving the “other side” is wrong, our problems are solved. Christian churches split over whether or not a particular idea is right or wrong, forget that the only true unity in our faith is the result of a work of ultimate sacrifice by God alone.

We are uncomfortable with ambiguity, so we focus on competition, right and wrong, and accomplishments – winning/being right is the only thing. Sadly, if we stick to that mindset when we experience grief and loss, the world will seem wrong and we feel like losers because we have no other dimensions in which to live. And yes, stress is indeed toxic when we view the world as a place in which our responses are limited to “fight or flight.” When we are stuck there, we have forgotten that we are also deeply wired, spiritually, psychologically, and physiologically, to connect with one another, the divine and the physical world, engaged in the often-holy work of tending and befriending. We are not created to focus only on correcting ourselves and others, we are also made for connecting – with people, the world and the spiritual or divine.

Comparison stress shopping is a name that our crisis intervention team uses to describe a way that people often minimize their own or others’ stress. “It’s so much worse for that person; it’s not so bad for me.” Caregiving professions such as public safety, medicine and teaching are full of people who are in the habit of putting others’ needs ahead of their own. Many of them are accustomed to putting their own emotions on “hold” so that they can take care of those around them.

Deferring or ignoring their own needs is especially common for leaders. For example, every time I ask a school administrator in the midst of crisis the question, “What’s hardest for you right now?” the answer is something like “Making sure my staff is okay.” Ask the teachers and the reply is, “Making sure my students are okay.” Ask a fire captain or police sergeant and the response is similar – they will be focused on taking care of those who report to them, rather than themselves.

Comparison stress shopping is more than just an obstacle to self-care. It isolates those who are struggling, which aggravates their stress. When people honestly express grief, sadness, frustration or other emotions that those around them are also feeling, the others know that they are not alone, which is crucial to living with stress. This is what it means to carry each other’s burdens, as the Bible and other spiritual writings urge us toward.