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.
Ask general questions such as "Can you tell me what happened?" Encourage elaboration by asking "Then what did you do?" Avoid direct questions about feelings such as "Are you nervous, scared, angry?"
Communication is Key
Communication is difficult, even under the best of circumstances. One of my favorite sayings is credited to Robert McCloskey: "I know you heard what you think I said, but I'm not sure if what you heard is what I meant."
Some important communication concepts include:
- Asking open-ended questions
- Restate or paraphrase
- Encouraging description
- Seek clarification
- Evaluate for use of touch; ask first
- Non-verbal communication is powerful
- Making eye contact
- Monitor your own body position/language
- Reflect the patient's body position, personal space, rate and style of speech
- Use empathy.
A Formula for Empathic Response
Empathy is the accurate understanding of the basic message the patient is trying to communicate (you do not need to understand unconscious or underlying meanings.) It also requires the ability to communicate that understanding to the patient (responding in a tentative manner allows for mistakes). Empathy is the most powerful communication technique and deserves special attention. Effects of accurate empathy include:
- Defuses anger
- Reduces resistance and conflict
- Promotes communication
- Calms fears
- Reduces hopelessness
- Improves relationships
- Increases trust.
Empathic statements are a powerful communication tool and the most effective means of calming emotions. They show the patient you understand how he feels.
Empathy comes more naturally and easily for some people then for others. However, empathic statements can be learned with a simple two-step formula for empathic statements. This may sound contrived, but if you use your own words, use the patient's style and are tentative, the formula will become natural for you. Remember to use the appropriate intensity of words for emotions. Take your cues from the patient, do not overstate or understate. (i.e., nervous instead of frightened, frightened instead of terrified) For patients in patients in denial, be very tentative and use mild emotional words.
Part one of an empathic statement is to name the feeling. Accuracy is critical, so if you are not sure don't guess. The intensity of the word you use depends on the patient's recognition and expression emotions. Second, state the reason for the feeling (if it is obvious and you are sure of it).
Thus the basic formula for an empathic statement is as follows (this is for illustration, do not use these words): 1. You feel _______ 2. because______________.
Name the feeling at the appropriate level of intensity in a tentative manner:
- Could it be that…
- You seem to be…is that right?
- It must have been…
- I would think that…
- I wonder if you…
- It seems that…
Name the reason the patient is experiencing the feeling. Say it in a tentative manner. If you are unsure, stick with part 1 of the empathic statement only. Do not make interpretations! You do not need to do it in order of steps given. Some examples of empathic statements:
- It must have been scary to be in that burning building.
- I would think it would be very frightening to experience an earthquake.
- I can imagine the anger at seeing that child abused.
- You must have been frustrated not being able to help.
- Being caught in a fire must have been terrifying
- Not being able to help is frustrating.
With patients who are delirious, confused, psychotic or under the influence of drugs or alcohol, use simple, calming, communication techniques only. When dealing with persons who cannot or will not communicate:
- Use brief, direct sentences
- Excuse yourself/stop interview if you feel threatened
- Do not hesitate to call for back up or ask person to leave if they are safe/able.
- Physically remove the patient to a safe place if necessary.
Remember emergency workers must deal with their own feelings first in order to best care for patients. Often we work on automatic and don't experience much emotion until the situation is over; then the emotions may flood us. There are times however when the situation may feel overwhelming to us especially when it "hits close to home."
Emotions often experienced by rescuers include:
- Fear (of making mistake, of being hurt, of hurting patient)
- Desire to leave
- Mixed emotions
Some strategies for dealing with your own emotions include:
- Take a few seconds to think, and calm yourself
- Talk to yourself (I can do this, I have done this before, just focus on the job, etc.)
- Take a deep breath--acting as if you are calm, will help to calm you
- Force yourself to talk slow, move slow, be deliberate
- Direct your attention to the patient's most immediate concern
- Once you are past your initial emotional response, you are usually home free
- Ask for help if you need it.
Hopefully, your colleagues have an acceptance of emotions and are there for each other when they are needed. There is nothing more difficult (and more dangerous) than working with a "macho" group who won't admit to ever being unsure or scared. This is one of the great advantages of having a steady partner; you have a chance to develop trust and get to know and accept each other strengths and areas of vulnerability. When it comes to your own emotional care, follow the simple rule of react, act, distract:
- React: Allow yourself to have feelings after a stressful event.
- Act: Do something to help you feel more in control, talk to a colleague, read an article on the issue, obtain a consult.
- Distract: Try not to dwell on the incident, engage yourself in positive activities.
Unfortunately burnout is not uncommon in rescue workers. Burnout is physical and emotional depletion caused by an intense involvement in a particular type of stressful situation over a period of time. Causes of burnout include:
- When one experiences little positive effect from their efforts
- Ignoring ones' own emotions and needs
- Unrealistic goals
- Multiple demands/unrealistic expectations
- High intensity careers
Watch for these symptoms of burnout:
- Feeling trapped
- Tiring easily, trouble sleeping
- Loss of enthusiasm
- Avoiding or rushing
- Rigidity, "by the book"
- Dehumanizing patients
- Bickering and conflict at work/home
- Angry and emotional outbursts
- Cynical attitude
- Physical complaints (headache, GI distress, body aches)
- Increased use of alcohol / drugs
- Loss of sense of humor
- Work stress interfering in other areas of life
Following are some suggestions for burnout prevention:
- Increase self-awareness
- Practice self-empathy
- Use relaxation techniques
- Keep your mind active, learn something new & fun (not in a rescuers role)
- Take breaks & vacations
- Ask for help
- Accept help
- Offer help only if you really want to
- Learn to say no
- Develop assertiveness skills
- Spend time alone, with nature, with children and animals
- Burnout can not always be prevented
- Manage conflicts directly, and as soon as possible
If you feel you are burned out and it is affecting you personal life and your work, it may be time for a change. Please remember, we all are human, with our own feelings and needs, and that is ok! This is what makes us empathic and caring individuals. In order to help others, we must be well and help ourselves.
Ed's Note: You can find further reading about this topic including specific situations and suggestions in Dr. Duffy's book Behavioral First Aid: Managing Emotions During Emergencies. Find it at www.PsychSense.com.
Eagan G. The Skilled Helper 7th ed. Brooks/ Cole, Thompson Learning, 2002.
Duffy, V. Behavioral First Aid: Managing Emotions During Emergencies 2nd ed, New York.
Virginia J. Duffy, PhD, is a psychiatric NP with over 30 years of experience working in the mental health field. She has specialized in crisis intervention, women's interests, depression, anxiety and mental illness. Dr. Duffy has worked in psychiatric emergency department, inpatient and outpatient psychiatric facilities, mental health clinics, nursing homes, college counseling centers, developmental disability clinics and more. Dr. Duffy is an educator who has taught crisis intervention, communication skills and other mental health content to graduate and undergraduate students at the University of Rochester in New York.