Stressful events are not always what you expect them to be. They can be different for different people depending on personalities and situations. However we can probably agree that most people would experience the following situations as a stressful event:
- Medical or psychiatric emergency
- A major loss, physical or emotional
- Threat to life or limb
- Conflict, violence
- Any situation that causes intense emotions of fear, anger or sadness.
A stressful event triggers strong emotions and results in hyperarousal. A person is in a hyper-aroused state is extremely sensitive to both internal and external stimuli. This often results in an over-reaction to personal thoughts and to behavior or comments of others. Hyperarousal is a natural response to stress and causes significant anxiety. It makes communication extremely difficult, and often compromises the ability to listen and understand and to make decisions.
What to Do First
First things first! If the person's life is not in imminent danger, do a quick evaluation of the patient's mental state. This will help you decide how to deal with them most effectively. This can actually be done in the first minutes during the course of your contact with the person. Assess the following:
- Appearance: Is the patient "appropriately" dressed for weather and circumstances. Is the patient steady on his feet? Does he have an odor (alcohol)?
- Mood: Is the patient sad, irritable or angry, frightened or not showing any emotions?
- Speech: Does the patient speak English? Does he make sense? Is speech slurred or distorted in any way? (Remember to consider hearing impairment and developmental delay.)
- Thoughts: A person's thoughts are evaluated by what he says. Is he logical? Is he able to stay on topic or jumping from topic to topic? Is he expressing psychotic or delusional thinking?
- Relationship with you: How is the patient reacting to you? Is he hostile and uncooperative or friendly and cooperative? Is he secretive and withholding or open and honest? Do you feel threatened or helpless? Trust your "gut" instinct.
- Suicide/homicide statements: Is the patient making direct or indirect threats to self or others?
Remember the most immediate concern is safety: safety of the rescuer, bystanders and the patient. If your assessment is that the patient is under the influence of drugs, alcohol or is psychotic, these are special situations and beyond the scope of this article. Although the following interventions can be helpful in these situations, they may need to be modified.
In order to deal with and calm persons who are experiencing extreme stress, some basic principles need to be followed.
First the helper must recognize and evaluate the level of stress the person is experiencing. Sometimes this can be difficult and it may not always be obvious by observation alone. A person who is crying may actually be managing emotions well, as this is a healthy response to a loss. However, this person is often the one who is identified as most needing intervention. Whereas someone who is without affect (facial expression) or extremely intellectual (talking about an obvious trauma without mention or expression of feelings, assuring you that he/she is ok), may actually be quite stressed.
Look at the person's behavior, not just what the person says. Is the person making sense when he talks? Is he over-talking or speaking very little? If someone knows the patient, it is always helpful to find out if the current behavior is the person's usual presentation. Is the person protesting too much saying things like: "No big deal, I'm fine, take care of others who need it more." Is the person talking about everything except the problem/incident? Persons who exhibit such symptom may be in denial.
Dealing With Denial
Remember denial is an effective coping mechanism for the short term. The trick for the healthcare provider is to understand it, not to see it as an authentic reaction, to provide support, to watch, and to discourage making important decisions.